Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA; ; Cardiovascular Surgery Service, The Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, Texas, USA.
Ann Cardiothorac Surg. 2013 May;2(3):347-52. doi: 10.3978/j.issn.2225-319X.2013.05.02.
Since the pioneering work of DeBakey, Cooley, and colleagues more than 50 years ago, surgical treatment of aneurysms involving the transverse aortic arch has been associated with substantial morbidity and mortality. Over the past 15 years, techniques for replacing the diseased aortic arch have evolved substantially. Previously, our approach to these operations involved femoral cannulation, profound-to-deep hypothermic circulatory arrest and retrograde cerebral perfusion, and the island technique for reattaching the brachiocephalic vessels. In contrast, we currently use innominate artery cannulation, deep-to-moderate hypothermic circulatory arrest with antegrade cerebral perfusion, bilateral cerebral monitoring with near-infrared spectroscopy, and the trifurcated graft (Y-graft) technique for reattaching the arch branches. Cannulating the innominate artery to provide an inflow site for cardiopulmonary bypass has facilitated the use of antegrade cerebral perfusion as a cerebral protection strategy; the left common carotid artery is additionally perfused to provide bilateral cerebral perfusion. Despite having a systemic circulatory arrest time that often exceeds 60 minutes, these improved perfusion strategies make it possible to consistently avoid cerebral circulatory arrest all together. A moderate temperature target of between 18 and 23 °C is now used; this appears to reduce the risk of hypothermic coagulopathy and improve hemostasis. Y-graft techniques, such as the trifurcated graft approach, have the advantages of eliminating residual aortic arch tissue and being easily tailored to the needs of the individual patient. This report describes total aortic arch replacement in patients with aneurysms that are confined to the ascending aorta and transverse aortic arch.
自 50 多年前 DeBakey、Cooley 和同事们的开创性工作以来，涉及升主动脉弓的动脉瘤的手术治疗与较高的发病率和死亡率相关。在过去的 15 年中，置换病变主动脉弓的技术有了实质性的发展。以前，我们对这些手术的方法涉及股动脉插管、深低温停循环和逆行脑灌注，以及重新连接头臂血管的岛状技术。相比之下，我们目前使用无名动脉插管、深低温中度停循环伴顺行脑灌注、双侧脑监测近红外光谱和分叉移植物（Y 型移植物）技术重新连接弓分支。无名动脉插管为体外循环提供流入部位，便于使用顺行脑灌注作为脑保护策略；左颈总动脉也被灌注，以提供双侧脑灌注。尽管全身循环停止时间通常超过 60 分钟，但这些改进的灌注策略使得完全避免脑循环停止成为可能。目前使用的中温目标在 18 到 23°C 之间；这似乎降低了低温凝血障碍的风险并改善了止血效果。Y 型移植物技术，如分叉移植物方法，具有消除残余主动脉弓组织的优点，并且易于根据患者的个体需求进行定制。本报告描述了升主动脉和主动脉弓的动脉瘤患者的全主动脉弓置换术。
