Descending aortic rupture repair

Treatment of diseases: penetrating heart trauma penetrating cardiac trauma Indication The descending aortic rupture repair is applicable to: When suspected descending aortic rupture, it is necessary to take time to perform surgical exploration. Sometimes, even in the case of massive bleeding or even sudden cardiac arrest, there are cases of surviving cases of surgical rescue. Surgery is the only treatment option for this type of casualty. Preoperative preparation 1. Strengthen anti-shock treatment, with adequate blood supply and autologous blood transfusion preparation. 2. Pay attention to check whether there is a combined brain, spine and abdominal organ injury and deal with it accordingly. Surgical procedure Incision The standard posterolateral incision is opened by the fourth intercostal space, and the patient over 50 years old enters the chest through the fifth intercostal bed. 2. Exploring First look for the bleeding mouth, temporarily finger pressure to stop bleeding. 3. Repair method After the investigation and further identification of the injury, the following methods were used to repair the injury according to the injury. There are four basic methods for repairing the descending initiative: the purpose is to prevent spinal cord and visceral damage when the thoracic aorta is blocked. These four methods have their own advantages and disadvantages: 1 femoral-femoral artery bypass. The main disadvantage is that in patients with multiple blunt trauma, complete heparinized anticoagulation is required, which is likely to cause extensive bleeding. 2 using a centrifugal pump for partial reversal, without heparinization, according to the patient's condition from the left atrium or left superior pulmonary vein to the distal end of the tearing of the descending aorta or left femoral artery. 3 The inner wall of the heparinized plastic tube is used for partial bypass, namely Gott shunt, the proximal lumen is inserted into the ascending aorta or the left ventricular tip, and the distal end is inserted into the descending aorta or femoral artery. The main disadvantage is that Gott shunting does not control the flow. 4 clamp the aorta, suture the rupture, without the technique of circulation, the time of aortic obstruction is limited, and the ischemic time should not exceed 30 minutes. (1) Directly block the blood flow suture method: in an emergency, it is only suitable for small cracks, which can be directly repaired, and is expected to open the circulation within 20 to 30 minutes. On the proximal aorta of the left subclavian artery and the left subclavian artery, each of them is wound around a hemorrhage, and does not enter the hematoma, and then the aorta is wound around the hematoma. After preparing for bleeding control, the upper and lower aorta were dissected and the non-invasive arterial forceps were placed on the upper and lower sides of the left subclavian artery to temporarily block the descending aortic blood flow. The mediastinal hematoma was dissected, the aortic rupture was explored and trimmed, and the aortic rupture was sutured with a 4-0 non-invasive suture. (2) Intubation external shunt repair method: This method is suitable for those who have complete descending of the descending aorta or need to transplant artificial blood vessels. Before the left phrenic nerve, the happy bag was cut, the ascending aorta was revealed from the pericardium, the ascending aorta and the bow descending part were separated, and the distal end, the proximal thoracic aorta and the proximal left subclavian artery were dissociated, and the proximal hemostasis was temporarily stopped. Later, the two sides of the ascending aorta were sutured with a 3-0 non-invasive line of two layers of enveloping lines, respectively, into a thin rubber tube for tightening the cannula. The aortic cannula or the diverting tube is inserted into the purse coil, the purulent suture is tightened, the transfusion catheter is fixed, and the tube is prefilled with isotonic saline containing 1000 U of heparin; the same method is used for intubation on the distal side of the descending aorta. , to exclude gas accumulation in the pipeline. After open intubation and bypass, the proximal and distal aorta of the fracture were clamped to control wound bleeding. The mediastinal hematoma was dissected, the thoracic aortic rupture was explored, debridement and pruning were performed, and the aortic rupture was neat and defect-free. The 4-0 non-invasive suture was used for the anastomosis. In severe injury, when artificial blood vessel transplantation is required, non-invasive vascular clamps should be used to control wound hemorrhage under external bypass conditions. After debridement and trimming of the aortic stump, artificial blood vessels with appropriate caliber should be used to repair aortic defects. The 4-0 sutures are generally used for continuous proximal and distal-end anastomosis. Loosen the distal vascular clamp to remove gas from the vascular lumen, and then open the proximal obstruction forceps to reconstruct the descending aortic blood flow. After the aortic rupture was repaired, the external shunt was stopped, and the anastomosis and the wound were examined for bleeding. After the hemostasis, the bypass catheter was removed, the pleural pleura was sutured, and the closed pleural drainage tube was placed, and the chest was closed as usual. complication 1. Pneumonia, atelectasis and pulmonary insufficiency are common complications after operation. Intraoperative endotracheal intubation can help prevent such complications. Postoperative attention should be paid to monitoring and preventing pulmonary insufficiency. Mechanically assisted breathing time, if necessary, tracheotomy. 2. The most serious complication is lower limb paralysis caused by ischemic spinal cord injury, the incidence rate is about 4% to 20%, should be based on prevention. 3. Postoperative hypertension can last for several days, which is caused by stimulation of the cardiac plexus of the aortic isthmus. 4. Postoperative bleeding, especially when there is a mediastinal hematoma formation and progressive expansion after surgery, the chest should be re-opened to stop bleeding. 5. Arrhythmia, renal insufficiency and infection should also be closely observed and prevented.