ascending aorta-innominate artery bypass graft

Aortic arch syndrome belongs to type I aortitis according to classification. Clinical symptoms are a series of manifestations of ischemia in the brain and upper limbs, and their severity is related to the location, extent, and collateral circulation. According to statistics, the incidence of left subclavian artery is the highest, accounting for 49%, followed by the innominate artery (16%), the left common carotid artery (14.8%), the right subclavian artery (14.3%) and the right carotid artery (5.8%). Some authors divide this type into four subtypes according to brain symptoms: 1 asymptomatic; 2 cerebral blood circulation temporary disorder; 3 chronic vascular brain insufficiency; 4 ischemic stroke. In 1956, Davis first performed an invasive arterial thrombectomy with this type of lesion. In 1957, Lyons et al further introduced the transection of the subclavian artery and carotid artery through the neck to treat the common carotid artery occlusion. Grawford's case-to-thoracic and intrathoracic bypass methods had a mortality rate of 2.2% and 5.2%, respectively. Treatment of diseases: ascending aortic aneurysm Indication Ascending aorta-invasive arterial bypass grafting is suitable for: Stenosis or occlusion of the brachiocephalic cerebral ischemic disorder has a high mortality rate. For such patients, even if the symptoms are less than 50%, the stenosis should be reconstructed. Contraindications 1, the lesion is still in the early stage of instability, the lumen has not been significantly narrowed, and should be actively treated with drugs to control the development of the disease. 2, for severe tubular stenosis, the lesion has been extended to the intracranial, it is not suitable for surgery. 3, the occurrence of stroke and the formation of permanent damage in patients with poor efficacy, surgery should be cautious. Preoperative preparation 1, before surgery to fully understand the condition of the lesion, do two-dimensional echocardiography and retrograde ascending aorta angiography, percussion of carotid pulsation, limb pulse and blood pressure. Understand brain function including vision and fundus examination. 2. There are many ways to bypass the transplant. According to the location, extent and extent of the disease, the number of grafts and the transplantation method should be designed before operation. Surgical procedure 1. The upper chest is incision, the sternum is transversely cut from the fourth intercostal space, the upper part is extended to the base of the neck, or another incision is made in the neck. 2, retract the chest incision, revealing the ascending aorta, aortic arch and its branches, pay attention to protect the left unnamed vein. 3. Apply non-invasive vascular clamp to clamp the front side wall of the aorta, make a longitudinal incision in the clamp part, select 10mm diameter for the innominate artery, use 8mm diameter artificial blood vessel under the subclavian or common carotid artery, and treat the branch of the aortic arch as a lesion. Single artificial blood vessel or branch artificial blood vessel transplantation. The artificial blood vessel is end-to-side anastomosis with the lesion-free area of the ascending main vein. 4. The other end is delivered to the distal end of the neck through the mediastinum and the distal end of the vascular occlusion of the neck for end-to-side anastomosis. 5. If there are more than 2 lesions in the branch of the aortic arch, the distal bifurcation vessel or another artificial vessel can be grafted to the artificial vessel bridge and the distal end of the other vascular occlusion segment, and the end-to-side anastomosis is performed. Sew the vascular bridge connecting the ascending aorta. The branch distal anastomosis is performed one by one in the neck. The distal part of the subclavian artery can be released from the anterior scalene muscle to the beginning of the vertebral artery, and the common carotid artery can be exposed inside the vagus nerve. 6. After the artificial blood vessel is diverted, the blood is completely stopped, the wound is flushed, and the chest and neck incision is closed as usual. complication 1. Compression of artificial blood vessels Transplantation of multiple artificial blood vessels from the aortic arch to the neck must occupy the upper mediastinum and chest entrance space, plus postoperative reactive edema and congestion, often leading to airway compression and venous return obstruction, a small number of patients need emergency tracheotomy after surgery And artificial ventilation. This complication can cause swelling of the head and face and upper limbs, which significantly affects health. The prevention method generally advocates the use of a small-caliber artificial blood vessel with 2 or more grafts, one for the ascending aorta and its branch flow, and the other proximal end of the bypass vessel can be used at the neck and the first artificial vessel bridge - Side anastomosis. 2, vascular bridge occlusion It has been reported that there is no pulse after aortic-invasive artery bypass grafting. Further examination confirmed that the vascular bridge was occluded. The reoperation revealed that the artificial blood vessel was sent to the supraclavicular region through the chest tunnel, and the lumen was distorted. . 3, peripheral nerve injury The vagus nerve is located between the internal jugular vein and the carotid artery, often behind the carotid sheath, but 2% of cases are located in the anterolateral aspect of the common carotid artery. The recurrent laryngeal nerve is separated from the vagus nerve and bypassed from the subclavian artery on the right side. The side is bypassed from the arterial ligament. When separating such blood vessels, even if they are not directly disconnected, excessive neurite can cause neurological dysfunction and should be carefully protected. 4, lymphatic leakage The cervical lymphatic vessels, including the thoracic lymphatic vessels, are often encountered when separating the branches of the aortic arch or the supraclavicular region, and should be routinely ligated during surgery to prevent such complications.

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