全主动脉弓替换术中顺行性脑灌注时血流变化观察

Orbital Ultrasound and S100 Protein Monitoring during Unilateral and Bilateral Antegrade Selective Cerebral Perfusion in Total Aortic Arch Replacement

目的 利用前瞻性随机对照方法比较全主动脉弓替换术中单侧顺行性脑灌注 (ASCP)和双侧ASCP时视网膜中央动脉、球后血管血流变化和血S1 0 0蛋白浓度变化。方法 1 6例全主动脉弓替换术患者随机分为单侧AS CP和双侧ASCP组 ,每组各 8例。两组均行术前术后颅脑计算机体层摄影 (CT)。术中采用经眼球超声监测视网膜中央动脉及球后血管血流。术中术后动态测定血S1 0 0蛋白浓度。结果 两组各有 1例出现短暂性神经功能异常。ASCP过程中单侧组右侧视网膜中央动脉可探及血流 ,左侧视网膜中央动脉不可探及 ,双侧组两侧视网膜中央动脉均可探及血流。所有患者球后动脉均可探及血流。两组间各阶段血S1 0 0蛋白浓度无显著性差异 (P >0 .0 5 )。结论 在基底动脉环完整 ,存在有效侧支循环条件下 ,单侧灌注操作较为简便 ,双侧灌注在ASCP期间两侧脑灌注较为均衡 ,但两种灌注方法对S1 0 0蛋白浓度的影响无显著性差异。

OBJECTIVE To compare the serum S100 protein concentration and blood flow in the central retinal artery and retrobular vessels between unilateral and bilateral antegrade selective cerebral perfusion during total aortic arch replacement.METHODS From June 2003 to March 2004, 16 patients who underwent total arch replacement were randomly allocated to one of two methods of brain protection: unilateral antegrade selective cerebral perfusion (unilateral group, n=8 ) or bilateral antegrade cerebral perfusion (bilateral group, n=8). Preoperative and postoperative brain CT scans were performed. During the operation, the blood flow in the central retinal artery and retrobular vessels was monitored with orbital ultrasound. Serum S100 protein was assayed before skin incision, immediately after thoracotomy, 30 minutes after the cardiopulmonary bypass, as well as 6 hours, 24 hours and 48 hours post-operatively. RESULTS All patients survived and were discharged from hospital. No new brain infarction occurred. Transient neurologic dysfunction occurred in 1 patient from each group. During antegrade selective cerebral perfusion, blood flow in the right central retinal artery was detectable in the unilateral group, butnot detectable in the left central retinal artery. In the bilateral group, the blood flow on both sides was detectable during antegrade selective cerebral perfusion. The blood flow in the retrobular vessels was detectable in all of the patients during antegrade selective cerebral perfusion. There were no intergroup differences in serum S100 protein concentration in all phases (P>0.05). CONCLUSION Both methods of brain protection had a similar effect upon S100 protein concentration providing the circle of Willis was patent and collateral flow was adequate. Blood flow in bilateral antegrade selective cerebral perfusion was more uniform, whilst unilateral antegrade selective cerebral perfusion has the advantage of simplicity.