Ryomoto Masaaki, Tanaka Hiroe, Mitsuno Masataka, Yamamura Mitsuhiro, Sekiya Naosumi, Uemura Hisashi, Sato Ayaka, Ueda Daisuke
Department of Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
Department of Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
Ann Vasc Surg. 2019 Aug;59:143-149. doi: 10.1016/j.avsg.2018.09.036. Epub 2019 Apr 5.
Perioperative stroke is a major complication after debranching thoracic endovascular aortic repair (TEVAR), with a reported incidence of 7.0-26.9%. Subsequent functional recovery is difficult in most cases. This study was performed to evaluate the efficacy of mini-cardiopulmonary bypass (mini-CPB) support in debranching TEVAR to prevent perioperative stroke.
From December 2010 to July 2017, 32 patients with a shaggy aorta or intimal irregularity in the aortic arch identified on preoperative computed tomography underwent debranching TEVAR. Nineteen patients underwent debranching TEVAR without mini-CPB, and 13 patients underwent debranching TEVAR with a mini-CPB support. Mini-CPB support had been used in November 2014 to treat perioperative stroke, which had occurred in 8 (42%) patients at that time. The form of the debranching arch vessels was not changed; bypass from the right axillary artery to the left axillary artery was performed for one debranching, and bypass from the right axillary artery to the left common carotid artery and left axillary artery was performed for two debranchings. After establishment of mini-CPB support through this debranching graft and right femoral vein cannulation, all endovascular manipulations were initiated. The left subclavian artery was occluded with a plug at the end of the procedure.
The proximal landing zones of the endoprosthesis were as follows: zone 0 in 9 patients, zone 1 in 5 patients, and zone 2 in 5 patients in the no-CPB era and zone 1 in 3 patients and zone 2 in 10 patients in the CPB era. The mean mini-CPB support period was 51 minutes. Postoperative respiratory support and hospitalization were not prolonged with mini-CPB support. The incidence of perioperative stroke was 42% in the no-CPB era and 8% in the CPB era. No operative mortality was observed in the CPB era, although 5 (26%) patients died in the no-CPB era. The cause of operative mortality in the no-CPB era was perioperative stroke in 4 patients and acute myocardial infarction in 1 patient. No significant difference in the cumulative survival rate was found between patients with and without mini-CPB support.
Our mini-CPB system may have the potential to prevent perioperative stroke during debranching TEVAR for treatment of aortic arch pathologies.
围手术期卒中是去分支胸主动脉腔内修复术（TEVAR）后的主要并发症，报道的发生率为7.0%-26.9%。在大多数情况下，随后的功能恢复很困难。本研究旨在评估在去分支TEVAR中使用体外循环（mini-CPB）支持以预防围手术期卒中的疗效。
2010年12月至2017年7月，32例术前计算机断层扫描显示主动脉弓有毛糙或内膜不规则的患者接受了去分支TEVAR。19例患者在无mini-CPB支持的情况下接受了去分支TEVAR，13例患者在mini-CPB支持下接受了去分支TEVAR。mini-CPB支持于2014年11月开始用于治疗围手术期卒中，当时有8例（42%）患者发生了围手术期卒中。去分支弓血管的形式未改变；一次去分支时，从右腋动脉至左腋动脉进行旁路搭桥，两次去分支时，从右腋动脉至左颈总动脉和左腋动脉进行旁路搭桥。通过该去分支移植物和右股静脉插管建立mini-CPB支持后，开始所有血管腔内操作。手术结束时用封堵器闭塞左锁骨下动脉。
在无CPB时代，腔内移植物的近端锚定区如下：9例患者为0区，5例患者为1区，5例患者为2区；在CPB时代，3例患者为1区，10例患者为2区。mini-CPB的平均支持时间为51分钟。mini-CPB支持并未延长术后呼吸支持时间和住院时间。围手术期卒中的发生率在无CPB时代为42%，在CPB时代为8%。在CPB时代未观察到手术死亡，尽管在无CPB时代有5例（26%）患者死亡。无CPB时代手术死亡的原因是4例患者发生围手术期卒中，1例患者发生急性心肌梗死。有无mini-CPB支持的患者累积生存率无显著差异。
我们的mini-CPB系统可能有潜力在去分支TEVAR治疗主动脉弓病变期间预防围手术期卒中。
