Schneider J R, Gottner R J, Golan J F
Division of Cardiovascular and Thoracic Surgery, Evanston Hospital, Illinois, USA.
Cardiovasc Surg. 1997 Jun;5(3):279-85. doi: 10.1016/s0967-2109(97)00021-5.
Repair of abdominal aortic aneurysms may require aortic occlusion above the renal arteries. Despite fears of renal, hepatic and intestinal ischemia, recent publications have suggested that when repair would be difficult or impossible with infrarenal aortic clamping, supraceliac clamping may not be associated with significantly increased morbidity. Between February 1985 and January 1994, 169 patients underwent elective or urgent (symptomatic but not ruptured) repair of infra- or juxtarenal abdominal aortic aneurysm. Twenty-three patients (14%) required supraceliac clamping for juxtarenal abdominal aortic aneurysm, inflammatory abdominal aortic aneurysm, or other difficult exposure problems. Supraceliac clamping and infrarenal aortic clamping patients were indistinguishable with respect to age, gender, abdominal aortic aneurysm diameter, and other co-morbidities. There was a trend toward more frequent use of supraceliac clamping in urgent operations. Preoperative angiography was used selectively and was obtained more often in supraceliac clamping patients, reflecting suspected juxtarenal or renal involvement based on computed tomography findings, but the decision to employ supraceliac clamping was made at surgery. Mean (s.d.) supraceliac clamping clamp time was 22(5) (range 12-30) min. Similar numbers of supraceliac clamping and infrarenal aortic clamping patients required bifurcated grafts, operative times were comparable, and numbers of early complications were similar in the two groups. Transfusion requirements were slightly greater and length of stay was insignificantly shorter in supraceliac clamping patients (due to a few prolonged hospital stays in infrarenal aortic clamping patients). No supraceliac clamping patient required dialysis or suffered clinically apparent hepatic failure, coagulopathy, or intestinal ischemia. There were no operative deaths and all patients were discharged from the hospital. Supraceliac clamping was not associated with greater perioperative morbidity and may have contributed to a lack of mortality by facilitating repair of difficult abdominal aortic aneurysm. Supraceliac clamping should be considered for elective and urgent abdominal aortic aneurysm repair when there is inadequate length or quality of infrarenal aorta for anastomosis, severe associated pararenal atherosclerosis, inflammatory aneurysm, or previous aortic surgery. It is concluded that selective supraceliac clamping is safe and facilitates repair of difficult aortic problems.
腹主动脉瘤修复术可能需要在肾动脉上方阻断主动脉。尽管担心会出现肾、肝和肠道缺血,但最近的出版物表明,当采用肾下主动脉钳夹难以或无法进行修复时,腹腔动脉上钳夹可能不会显著增加发病率。1985年2月至1994年1月期间,169例患者接受了择期或急诊(有症状但未破裂)的肾下或近肾腹主动脉瘤修复术。23例患者(14%)因近肾腹主动脉瘤、炎性腹主动脉瘤或其他暴露困难问题而需要进行腹腔动脉上钳夹。在年龄、性别、腹主动脉瘤直径和其他合并症方面,腹腔动脉上钳夹患者和肾下主动脉钳夹患者并无差异。在急诊手术中,腹腔动脉上钳夹的使用频率有增加的趋势。术前血管造影术为选择性使用,腹腔动脉上钳夹患者中更常进行此项检查,这反映了基于计算机断层扫描结果怀疑近肾或肾受累,但腹腔动脉上钳夹的决定是在手术时做出的。腹腔动脉上钳夹的平均(标准差)钳夹时间为22(5)分钟(范围12 - 30分钟)。腹腔动脉上钳夹患者和肾下主动脉钳夹患者中需要分叉移植物的人数相似,手术时间相当,两组早期并发症的数量也相似。腹腔动脉上钳夹患者的输血需求略高,住院时间略短(原因是肾下主动脉钳夹患者中有少数住院时间延长)。没有腹腔动脉上钳夹患者需要透析或出现临床明显的肝衰竭、凝血病或肠道缺血。没有手术死亡病例,所有患者均出院。腹腔动脉上钳夹与围手术期更高的发病率无关,并且可能通过促进困难腹主动脉瘤的修复而有助于避免死亡。当肾下主动脉的长度或质量不足以进行吻合、存在严重的肾旁动脉粥样硬化、炎性动脉瘤或既往有主动脉手术史时,对于择期和急诊腹主动脉瘤修复术应考虑使用腹腔动脉上钳夹。结论是选择性腹腔动脉上钳夹是安全的,并且有助于修复困难的主动脉问题。