单侧与双侧选择性顺行脑灌注对DeBakeyⅠ型主动脉夹层分离杂交手术患者神经功能的影响——前瞻性随机对照研究

Impact of unilateral and bilateral antegrade selective cerebral perfusion on neurological function in patients undergoing a hybrid approach for DeBakey type Ⅰ aortic dissection A prospective randomized controlled study

目的 比较DeBakey Ⅰ型主动脉夹层分离杂交手术时单侧选择性顺行脑灌注（antegrade selective cerebral perfusion,ASCP）和双侧ASCP的脑保护效果,为主动脉夹层手术脑灌注方式的选择提供临床依据.方法 自2009年1月至2011年6月,56例行杂交手术的DeBakey Ⅰ型主动脉夹层患者中,24例纳入本研究,随机分为单侧ASCP组（11例）和双侧ASCP组（13例）.两组患者手术前后均行认知能力测验、脑CT、脑血管和主动脉CT血管造影检查.比较两组患者一般资料、术中情况和神经功能.结果 单侧与双侧ASCP组一般资料无差异,术中体外循环时间[（125.2±34.4）min对（132.1±45.4）min；t=-0.278,P=0.784 ]、主动脉阻断时间[（54.5±23.6）min对（61.6 ±27.5）min；t=-0.149,P=0.883]、脑灌注时间[（30.9± 13.2）min对（31.7± 14.5）min;t=-1.283,P=0.213]、右侧桡动脉压[（57.6± 15.5）mmHg（1 mm Hg=0.133 kPa）对（60.7±14.3）mm Hg;t =0.758,P=0.457]、动脉血氧分压[（465.6±62.4）mm Hg对（488.4±72.5）mm Hg;t=-1.894,P=0.071]均无显著差异.单侧与双侧ASCP组无手术及近期死亡,机械通气时间[ （33.5±14.6）h对（37.8±12.3）h；t=-1.009,P=0.162]、术后清醒时间[（5.2±2.4）h对（5.5±3.1）h；t=0.876,P=0.195]和重症监护病房停留时间[（7.5±3.1）d对（8.2±3.5）d；t=-0.186,P=0.427]均无显著差异.两组均无新发永久性神经功能障碍,各有1例出现暂时性神经功能障碍.单侧ASCP组[（50.1±14.8）分对（47.3±15.2）分；t=1.005,P=0.126]和双侧ASCP组[（52.1±13.7）分对（48.6±16.5）分；t=0.576,P=0.254]术后认知能力评分均较术前略有下降,但无统计学差异；单侧与双侧ASCP组术前（t=-0.887,P=0.385）以及术后（t=- 0.953,P=0.351）亦无显著差异.结论 在Willis环完整情况下,单侧与双侧ASCP对DeBakey Ⅰ型主动脉夹层分离杂交手术患者的脑保护效果无显著差异,可使用操作较为简便的单侧ASCP.

Objective To compare the effect of brain unilateral and bilateral antegrade selective cerebral perfusion （ASCP） during a hybrid approach to DeBakey type Ⅰ aortic dissection and to provide the clinical evidence for the selection of cerebral perfusion methods of aortic dissection surgery.Methods Among the 56 patients undergoing a hybrid approach to DeBakey type Ⅰ aortic dissection from January 2009 to June 2011,24 were enrolled in the study.They were randomly divided into a unilateral ASCP group （n =11） and a bilateral ASCP group （n =13）.The patients in both groups underwent cognitive ability test,brain CT scan,cerebrovascular and aortic CTA examinations before and after procedure.The general information,intraoperative conditions and neurological function in the patients of both groups were compared.Results There was no difference in the general data between the unilateral and bilateral ASCP groups.There were no significant differences among the intraoperative cardiopulmonary bypass time （125.2 ± 34.4 min vs.132.1 ± 45.4 min; t =- 0.278,P =0.784）,aortic cross-clamping time （54.5 ± 23.6 min vs.61.6 ± 27.5 min; t =-0.149,P =0.883）,cerebral perfusion time （30.9 ± 13.2 min vs.31.7 ± 14.5 min; t =- 1.283,P =0.213）,right radial artery pressure （57.6 ± 15.5 mm Hg vs.60.7 ± 14.3 mm Hg; t =0.758,P =0.457）,and arterial oxygen pressure （465.6 ± 62.4 mm Hg vs.488.4 ± 72.5 mm Hg; t =- 1.894,P =0.071 ）.There were no surgery and recent death in both groups.There were no significant differences among the mechanical ventilation time （33.5 ± 14.6 h vs.37.8 ± 12.3; t =- 1.009,P =0.162）,time awake after surgery （5.2 ± 2.4 h vs.5.5 ± 3.1 h; t =0.876,P =0.195）,and intensive care unit stay time （7.5 ± 3.1 d vs.8.2 ± 3.5 d; t =-0.186,P =0.427）.There was no new permanent neurological dysfunction in both groups.One patient had transient neurological impairment in each group.The cognitive function scores after surgery in the unilateral ASCP group （50.1 ± 14.8 vs.47.3 ± 15.2; t =1.005,P =0.126） and in the bilateral ASCP group （52.1 ± 13.7 vs.48.6 ± 16.5; t =0.576,P =0.254） were slightly lower than those before procedure,however,there was no significant difference; there was also no significant difference in the unilateral and bilateral ASCP groups before （t =-0.887,P =0.385） and after procedure （t =-0.953,P =0.351）.Conclusions Under the circumstance of complete circle of Willis,the brain protective effect of the unilateral and bilateral ASCP in patients undergoing a hybrid approach for DeBakey type Ⅰ aortic dissection had no significant difference,and more simple and convenient unilateral ASCP can be used.