Safi H J, Miller C C, Subramaniam M H, Campbell M P, Iliopoulos D C, O'Donnell J J, Reardon M J, Letsou G V, Espada R
Department of Surgery, Baylor College of Medicine, Houston, Tex 77030, USA.
J Vasc Surg. 1998 Oct;28(4):591-8. doi: 10.1016/s0741-5214(98)70081-3.
Although some authors advocate hypothermic circulatory arrest for spinal cord protection in descending thoracic and thoracoabdominal repair, this method has been associated with high morbidity and mortality rates in other studies. The safety and effectiveness of this surgical adjunct were evaluated.
Between February 1991 and April 1997, 409 patients underwent thoracic or thoracoabdominal aortic repair. Because of an inability to gain proximal aortic control because of anatomic or technical difficulty, hypothermic circulatory arrest was used in 21 patients (4.9%). Thirteen patients were men, 8 were women, and the median age was 57 (range, 21 to 81 years). Four patients (19%) had Marfan's syndrome, and 1 had aortitis. Seven patients (33%) had aortic dissection (4 chronic type A, 2 chronic type B, 1 acute B), and 1 had aortic laceration. All but 6 patients had hypertension. Fifteen patients (73%) were operated on for repair of the distal arch and descending thoracic aorta, 4 (19%) for repair of the distal arch and thoracoabdominal aorta, and 2 for repair of either the thoracoabdominal or descending thoracic aorta alone. Surgery for 9 patients (43%) also included bypass grafts to the subclavian or innominate arteries. Six operations (29%) were urgent.
The overall 30-day mortality rate was 29% (6 of 21 patients). Among urgent patients, the mortality rate was 50% (3 of 6 patients) versus 20% (3 of 15) for elective patients. Of the remaining 15 patients, renal failure occurred in 1 (7%) and heart failure in 2 (13%). Ten patients (67%) had pulmonary complications. Encephalopathy occurred in 5 patients (33%) and stroke in 2 (13%), and spinal cord neurologic deficit developed in 2 (13%). The median recovery was 28 days (range, 10 to 157 days).
Hypothermic circulatory arrest did not reduce the incidence of deaths and morbidity to a rate comparable with our conventional methods. We recommend the judicious application of this method in rare instances when proximal control is not feasible or catastrophic intraoperative bleeding leave the surgeon with no other option.
尽管一些作者主张在降胸段和胸腹段修复手术中采用低温循环停止以保护脊髓，但在其他研究中，这种方法与高发病率和死亡率相关。本研究评估了这种手术辅助手段的安全性和有效性。
1991年2月至1997年4月期间，409例患者接受了胸段或胸腹段主动脉修复手术。由于解剖或技术困难无法获得近端主动脉控制，21例患者（4.9%）采用了低温循环停止。13例为男性，8例为女性，中位年龄为57岁（范围21至81岁）。4例患者（19%）患有马凡综合征，1例患有主动脉炎。7例患者（33%）患有主动脉夹层（4例慢性A型，2例慢性B型，1例急性B型），1例患有主动脉撕裂伤。除6例患者外，其余均患有高血压。15例患者（73%）接受了远端主动脉弓和降胸段主动脉修复手术，4例（19%）接受了远端主动脉弓和胸腹段主动脉修复手术，2例仅接受了胸腹段或降胸段主动脉修复手术。9例患者（43%）的手术还包括锁骨下动脉或无名动脉旁路移植。6例手术（29%）为急诊手术。
30天总体死亡率为29%（21例患者中的6例）。急诊患者的死亡率为50%（6例患者中的3例），择期患者为20%（15例中的3例）。其余15例患者中，1例（7%）发生肾衰竭，2例（13%）发生心力衰竭。10例患者（67%）出现肺部并发症。5例患者（33%）发生脑病，2例（13%）发生中风，2例（13%）出现脊髓神经功能缺损。中位恢复时间为28天（范围10至157天）。
低温循环停止并未将死亡率和发病率降低到与我们传统方法相当的水平。我们建议在近端控制不可行或术中发生灾难性出血而外科医生别无选择的罕见情况下谨慎应用这种方法。
