弓上分流术对Stanford B型主动脉夹层患者脑氧饱和度及颈动脉血流动力学影响的分析

Assessment of supra-arch branches bypass on cerebral oxygen saturation and carotid hemodynamics in patients with Stanford type B aortic dissection

目的评估Stanford B型主动脉夹层患者弓上分流术对脑氧饱和度和血流动力学的影响。方法2018年1月至12月,连续27例Stanford B型主动脉夹层患者纳入研究,患者均接受Hybrid治疗,包括弓上分流(右腋动脉-左颈总动脉-左锁骨下动脉)+主动脉腔内修复(TEVAR)手术,其中弓上分流术由单一术者完成。分别测定麻醉后(T1)、左颈总动脉阻断时(T2)、弓上分流术后(T3)3个时间点左、右脑氧饱和度(rScO2);测定术前(t1)、术后(t2)左、右颈总动脉收缩期峰值血流速度(peak systolic velocity,PSV)及阻力指数(RI)。结果左侧脑氧饱和度在T1、T2、T3时间点分别为0.62±0.01、0.54±0.01和0.62±0.01,T2和T1、T3时间点比较差异有统计学意义(P=0.002,P=0.001),T1与T3比较差异无统计学意义。左颈总动脉PSV在t1、t2时间点为(0.91±0.11)m/s、(0.76±0.09)m/s,差异无统计学意义(P=0.191)。左颈总动脉RI在t1、t2时间点为0.83±0.06、0.93±0.13,差异无统计学意义(P=0.575)。结论弓上分流术中短时间阻断一侧颈总动脉,术侧脑氧饱和度会发生一过性降低,术后脑氧代谢变化能够完全恢复。弓上分流术改变了主动脉弓部分支血管原有解剖结构,但是颈动脉血流动力学不会发生显著改变。在Stanford B型主动脉夹层患者Hybrid治疗策略中,采用右腋动脉-左颈总动脉-左锁骨下动脉分流术式,能够避免阻断双侧颈总动脉,是一种安全、有效的选择。

Objective To evaluate the effects of supra-arch branches bypass on cerebral oxygen saturation and hemodynamics in patients with Stanford type B aortic dissection.Methods From January to December 2018,consecutive 27 patients with Stanford type B aortic dissection were enrolled in the study.All patients received hybrid treatment,including supra-arch branches bypass(right axillary artery-left common carotid artery-left subclavian artery)and thoracic endovascular aortic repaire(TEVAR).All the operations were performed by the same surgical team.The left and right cerebral oxygen saturation were measured after anesthesia(T1),left carotid artery occlusion(T2)and after operation(T3);peak systolic velocity(PSV)and resistance index(RI)of left and right carotid arteries were measured before(t1)and after operation(t2).Results The left cerebral oxygen saturation was 0.62±0.01,0.54±0.01 and 0.62±0.01 at T1,T2 and T3,respectively.There was significant difference between T2 and T1 and T3(P=0.002,P=0.001),but there was no significant difference between T1 and T3.The PSV of left carotid artery at t1 and t2 were(0.91±0.11)m/s and(0.76±0.09)m/s respectively,with no significant difference(P=0.191).The RI of left carotid artery at t1 and t2 were 0.83±0.06 and 0.93±0.13 respectively,with no significant difference(P=0.575).Conclusion If one side of carotid artery was blocked for a short time during supra-arch branches bypass,the cerebral oxygen saturation would be decreased temporarily,but the changes of cerebral oxygen metabolism could be completely restored after operation.However,the hemodynamics of carotid artery would not change significantly.In the hybrid treatment strategy for the patients with aortic dissection Stanford type B,blocking bilateral carotid arteries can be avoided.Making the right axillary artery-left common carotid artery-left subclavian artery shunt is a safe and effective choice.