单侧脑顺行灌注保护在主动脉全弓置换术中的应用

Unilateral antegrade cerebral perfusion in total aortic arch replacement surgery

目的观察在主动脉全弓置换术中应用单侧脑顺行灌注保护的效果。方法收集2010年1月至2012年3月连续53例主动脉全弓置换术患者资料,按术中脑保护方法分为单纯深低温停循环组(DHCA)和经右锁骨下动脉插管于停循环中行单侧脑顺行灌注组(UACP),比较两组患者体外循环时间、停循环时间、停循环温度、变温时间、术后气管插管时间、监护室滞留时间、住院时间、死亡及神经系统并发症的发生率。结果较DHCA组比,UACP组停循环时间较长(P=0.007),停循环时鼻咽温度、直肠温度均较高(P=0.000),体外循环时间(P=0.011)、降温时间(P=0.000)、升温时间(P=0.000)则缩短,术后气管插管时间(P=0.011)、监护室滞留时间(P=0.015)明显缩短,住院时间无差异(P=0.146)。术后DHCA组死亡2例,UACP组无死亡,死亡率无差异(P=0.495)。术后DHCA组偏瘫1例,UACP组截瘫1例,比较无差异(P=0.705)。结论主动脉全弓置换术中,经右锁骨下动脉插管于停循环中行UACP保护简便、安全、有效,能缩短体外循环时间、减少体外循环本身和过度低温损伤,在需要停循环时间较长的手术中,其优势可能更为明显。

Objective To evaluate the effect of cerebral protection with unilateral antegrade cerebral perfusion technique in to- tal aortic arch replacement surgery. Methods Fifty three consecutive patients received total aortic arch replacement surgery from Jan. 2010 to Mar. 2012. Based on the intraoperative cerebral protection methods, all these patients were divided into simple deep hypothermia circulatory arrest group （DHCA group） and unilateral antegrade cerebral perfusion group （UACP group） with the right subclavian artery cannulization. The clinical data of both groups were analyzed, including extraeorporeal circulation time, circulatory arrest time, tempera- ture of circulatory arrest, heterotherm time, postoperative intubation time, ICU retention time, hospitalization time, and incidence of death and complications of nervous system. Results UACP group had longer circulatory arrest time （40.6 ± 7.3 min vs 35.3 ± 6.2 min, P = 0.007 ）, higher nasopharyngeal temperature （22.6 ± 1.1 ℃ vs 16.9 ± 1.9℃, P = 0.000） and rectal temperature （24.4 ± 1.2℃ vs 20.0 ± 1.6℃, P =0. 000） during circulatory arrest. This group also had shorter extracorporeal circulation time （ 182. 1 ± 19.9 min vs 208.1 248.0 min, P =0.011）, cooling time （37.6 ±4.3 min vs 54.2 ±11 min, P =0.000）, and rewarming time （54. 1 ±5.5 min vs 88.6 ± 10.3 min, P = 0. 000）. Postoperative intubation time （37.5 ± 16.8 h vs 54.8 ± 29.5 h, P = 0.011 ） and ICU retention time （ 3.2 ± 1.0 d vs 4.3 ± 2.1 d, P = 0. 015 ） were obviously shorter in UACP group. There was no difference in hospitalization time（ 19.5 ± 5.2 d vs 21.5 ± 4.6 d, P = 0. 146） and mortality （2 patients died in DHCA group, none in UACP group, P = 0. 495 ） between UACP group and DHCA group. Also there was no significant difference in the incidence of nervous system complications be- tween two groups （1 hemiplegia in DHCA group, 1 paraplegia in UACP group, P = 0.705 ）. Conclusion Unilateral antegrade cere- bral perfusion technique with the right subclavian artery eannulization in total aortic arch replacement surgery is simple, safe and effec- tive. This technique can shorten the total extracorporeal circulation time; reduce the perfusion and excessive hypothermia injury. These advantages are likely to be more pronounced in procedures that need longer circulatory arrest time.