Bachet J, Teodori G, Goudot B, Diaz F, el Kerdany A, Dubois C, Brodaty D, de Lentdecker P, Guilmet D
Service de Chirurgie Cardio-vascularire, Hopital Foch, Universite Paris-Ouest, Suresnes, France.
J Thorac Cardiovasc Surg. 1988 Dec;96(6):878-86.
In type A aortic dissection, the intimal disruption is located on or extends to the transverse arch in about 20% of patients. Replacement of the arch may then be necessary to avoid leaving an unresected, acutely dissected aorta and to prevent bleeding, progression of aneurysm, rupture, and ultimately reoperation or death. From 1970 to September 1987, 119 patients were operated on for type A acute dissection. Starting in January 1977, gelatin-resorcin-formaldehyde biologic glue was used in 91 patients to reinforce the dissected tissues at the suture sites. Among these 119 patients, 26 (ages 32 to 76 years) underwent replacement of the transverse aortic arch in addition to replacement of the ascending aorta. In 20 patients cerebral protection was achieved by profound hypothermia (16 degrees to 20 degrees C) associated with circulatory arrest (15 to 40 minutes, mean 27 minutes) during the distal anastomosis. In six patients the carotid arteries were selectively perfused with cold blood (6 degrees C) during moderate core hypothermia (28 degrees C) while cardiopulmonary bypass was discontinued (19 to 34 minutes, mean 25 minutes) to allow the prosthesis to be sutured without the distal aorta being cross-clamped. Moderate hypothermia avoided the long rewarming time necessitated by profound hypothermia. The hospital mortality rate was 34% (9/26). Two of the 20 patients subjected to profound hypothermia and circulatory arrest died during the operation and seven patients died of postoperative complications. No deaths or major complication were observed in the other six patients. Follow-up of the 17 survivors ranges from 3 to 90 months (mean 39). One patient died 6 months after the operation of cerebral hemorrhage. One patient is disabled by neurologic sequelae. Fifteen patients are in good clinical condition (New York Heart Association class I or II). Postoperative aortograms in 12 patients, and computed tomographic scans in all, have shown a stable repair of the transverse arch in all survivors but a persisting dissection of the descending aorta in 11 (70%). Growing experience and improving results in emergency operations for type A aortic dissection have led us to extend the replacement of the aorta to the transverse arch whenever necessary. The gelatin-resorcin-formaldehyde glue has proved to be an efficient adjunct. The best cerebral protection was obtained in our experience by carotid perfusion with cold blood during circulatory arrest at moderate core hypothermia.
在A型主动脉夹层中，约20%的患者内膜破裂位于或延伸至主动脉弓横部。此时可能需要进行主动脉弓置换，以避免留下未切除的急性夹层主动脉，防止出血、动脉瘤进展、破裂，并最终避免再次手术或死亡。1970年至1987年9月，119例患者接受了A型急性夹层手术。从1977年1月开始，91例患者使用明胶-间苯二酚-甲醛生物胶加固缝合部位的夹层组织。在这119例患者中，26例（年龄32至76岁）除了升主动脉置换外，还接受了主动脉弓横部置换。20例患者在远端吻合期间通过深度低温（16℃至20℃）联合循环停止（15至40分钟，平均27分钟）实现了脑保护。6例患者在中度体温过低（28℃）时，在体外循环停止期间（19至34分钟，平均25分钟），通过冷血（6℃）选择性灌注颈动脉，以便在不夹闭远端主动脉的情况下缝合人工血管。中度低温避免了深度低温所需的长时间复温。医院死亡率为34%（9/26）。20例接受深度低温和循环停止的患者中有2例在手术期间死亡，7例死于术后并发症。其他6例患者未观察到死亡或重大并发症。17例幸存者的随访时间为3至90个月（平均39个月）。1例患者术后6个月死于脑出血。1例患者因神经后遗症致残。15例患者临床状况良好（纽约心脏协会I级或II级）。12例患者的术后主动脉造影以及所有患者的计算机断层扫描显示，所有幸存者的主动脉弓修复稳定，但11例（70%）降主动脉夹层持续存在。在A型主动脉夹层急诊手术方面经验的不断积累和结果的改善，使我们在必要时将主动脉置换扩展至主动脉弓横部。明胶-间苯二酚-甲醛胶已被证明是一种有效的辅助材料。根据我们的经验，在中度体温过低时循环停止期间通过颈动脉灌注冷血可获得最佳脑保护。
