Kouchoukos N T, Daily B B, Rokkas C K, Murphy S F, Bauer S, Abboud N
Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
Ann Thorac Surg. 1995 Jul;60(1):67-76; discussion 76-7.
Hypothermic cardiopulmonary bypass with intervals of circulatory arrest is a useful adjunct during operations on the descending thoracic aorta and distal aortic arch when severe aortic disease precludes placement of clamps on the aorta. Hypothermia also has a marked protective effect on spinal cord function during periods of aortic occlusion.
Fifty-one patients (age range, 22 to 79 years) with descending thoracic or thoracoabdominal aortic disease had resection and graft replacement of the diseased aortic segments using hypothermic cardiopulmonary bypass and intervals of circulatory arrest in situations where the location, extent, or severity of disease precluded placement of clamps on the proximal aorta (8 patients) or (in 43 patients) when extensive thoracic (11) or thoracoabdominal (32) aortic disease was present and the risk for development of spinal cord ischemic injury and renal failure was judged to be increased. Patent intercostal (below T-6) and upper lumbar arteries were attached to the graft whenever possible.
Thirty-day mortality was 9.8% (5 patients). Paraplegia occurred in 2 and paraparesis in 1 of the 46 30-day survivors (6.5%). Among the 27 operative survivors with thoracoabdominal aneurysms, paraplegia occurred in 1 of 12 with Crawford type I (8%), 0 of 10 with type II, and 1 of 5 with type III aneurysms (20%). Paraplegia occurred in none of the 12 patients with aortic dissection and in 2 of the 15 patients with degenerative aneurysms. Renal failure requiring dialysis occurred in 1 (2.2%) of the 46 30-day survivors.
Hypothermic circulatory arrest is a valuable adjunct for the treatment of complex aortic disease involving the aortic arch and thoracoabdominal aorta. In patients with thoracoabdominal aneurysms, its use has been associated with a low incidence of renal failure and an incidence of paraplegia/paraparesis in traditionally high-risk subsets (type I and II aneurysms, aortic dissection), which may be less than that observed with other surgical techniques.
在降主动脉和主动脉弓远端手术中，当严重的主动脉疾病妨碍在主动脉上放置血管夹时，伴有循环阻断间隔的低温体外循环是一种有用的辅助手段。低温对主动脉阻断期间的脊髓功能也有显著的保护作用。
51例（年龄范围22至79岁）降主动脉或胸腹主动脉疾病患者，在疾病的位置、范围或严重程度妨碍在近端主动脉放置血管夹（8例）的情况下，或（在43例患者中）当存在广泛的胸主动脉（11例）或胸腹主动脉（32例）疾病且判断脊髓缺血性损伤和肾衰竭的发生风险增加时，采用低温体外循环和循环阻断间隔进行病变主动脉段的切除和移植物置换。尽可能将通畅的肋间动脉（T-6以下）和上腰动脉与移植物相连。
30天死亡率为9.8%（5例）。46例30天存活者中有2例发生截瘫，1例发生轻瘫（6.5%）。在27例胸腹主动脉瘤手术存活者中，12例Crawford I型中有1例发生截瘫（8%），10例II型中无1例发生，5例III型动脉瘤中有1例发生（20%）。12例主动脉夹层患者均未发生截瘫，15例退行性动脉瘤患者中有2例发生截瘫。46例30天存活者中有1例（2.2%）发生需要透析的肾衰竭。
低温循环阻断是治疗累及主动脉弓和胸腹主动脉的复杂主动脉疾病的一种有价值的辅助手段。在胸腹主动脉瘤患者中，其应用与肾衰竭发生率低以及传统高危亚组（I型和II型动脉瘤、主动脉夹层）中截瘫/轻瘫发生率低相关，这一发生率可能低于其他手术技术所观察到的。
