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主动脉腔内修复术的麻醉

Author
E. Andrew Ochroch, MD, MSCE
Section Editor
Peter D Slinger, MD, FRCPC
Deputy Editor
Nancy A Nussmeier, MD, FAHA
Translators
王彬, 副主任医师，副教授

引言

主动脉腔内修复术(endovascular aortic repair, EVAR)已经成为胸主动脉瘤和腹主动脉瘤的标准治疗方法，有一大半本应行开放手术修复的患者都可采用本法。EVAR不需要胸腔内或腹腔内暴露主动脉，也不需要主动脉横断钳闭，因此围术期并发症发病率和死亡率都低于开放修复术。而且，EVAR使一些因共存疾病而不适合其他主动脉修复方法的患者有了治疗的可能。

EVAR的血管通路为经皮股动脉通路或利用股动脉小切口建立的开放性通路，因此该过程可在采用麻醉性监护(monitored anesthesia care, MAC)的局部麻醉、椎管内区域麻醉或全身麻醉下完成。本专题将为胸/腹主动脉瘤EVAR总结术前麻醉问题及各种麻醉方式。EVAR的手术技术及血管内装置，以及该操作的并发症将在别处详细讨论。 (参见“胸主动脉腔内修复术”和“Endovascular devices for thoracic aortic repair”和“腹主动脉瘤腔内修复术”和“腹主动脉修复术的腔内装置”和“腹主动脉腔内修复的并发症”)

术前评估

绝大多数胸和/或腹主动脉瘤患者都年龄较大，而且存在重大心脏病及其他共存疾病(如冠状动脉疾病、高血压、肥胖、糖尿病、高脂血症、吸烟和慢性阻塞性肺疾病)。尽管EVAR的围术期并发症发病率和死亡率都低于开放修复术，但有需要中转开放手术(胸腔内或腹腔内)的风险[1,2]。因此，EVAR患者应进行和开放修复术患者一样全面的术前评估。 (参见“胸主动脉腔内修复术”，关于‘内科风险评估’一节和“胸主动脉腔内修复术”，关于‘术前准备’一节和“腹主动脉瘤腔内修复术”，关于‘术前风险评估’一节)

心血管评估 — 胸主动脉瘤EVAR和腹主动脉瘤EVAR都有中等程度的围术期心血管事件风险(至少1%)[1,2]。2014年美国心脏病学会/美国心脏协会指南和欧洲心脏病协会/欧洲麻醉协会指南为行中等风险非心脏手术的患者做出了有关心脏风险评估与处理的推荐，我们赞同这些推荐意见[1,3,4]。

我们会进行术前心电图(electrocardiogram, ECG)，因为基线心电图有助于术后心电图异常的考量。评估术前心电图有无Q波、明显的ST段抬高或压低(提示可能有心肌缺血或梗死)、左心室肥厚、校正QT间期延长、束支阻滞或心律失常。

                                   

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Literature review current through: 2017-07 . | This topic last updated: 2017-06-30.
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