急性A型主动脉夹层术前合并脑缺血患者的手术治疗效果分析

Analysis of the effect of surgical treatment in patients with acute type A aortic dissection complicated with cerebral ischemia before operation

目的探讨急性A型主动脉夹层(AAAD)术前合并脑缺血的临床特征、脑缺血分型和手术干预的效果和预后及体外循环的管理。方法回顾分析2011年1月至2019年10月本中心急性A型夹层手术患者1040名,其中105(10.09%)名合并术前脑缺血患者。根据术前脑缺血类型分为一过性脑损伤(TND)组89名(84.8%)和永久性脑损伤(PND)组16名(15.2%)。收集全部105名AAAD术前合并脑缺血患者的术前基本资料:脑卒中病史、肢体肠道心肌缺血病史、发病到手术时间、术中手术方式、动脉插管部位、脑保护方法、手术时间、心脏停搏时间、体外循环时间、选择性顺行脑灌注时间、院内死亡例数、肾功能不全血液过滤治疗例数、再次开胸止血例数、长期机械通气例数以及ICU时间、术后麻醉清醒时间、脑部并发症以及近期(30 d内)、远期(1~60个月)的生存率统计。结果105名术前合并脑缺血的急性A型主动脉夹层患者全部接受深低温停循环体外循环手术治疗,PND组术前资料除术前脑卒中病史及肢体缺血病史外与TND组无明显差异。两组患者术中体外循环资料、脑保护方式、停循环时间均没有显著差异。术后住院时间TND组较PND组住院时间长(P=0.003);30 d死亡率TND组较PND组死亡率较低(P=0.010)。绘制近远期生存曲线,近期生存率TND组较PND组高(P=0.0016)。结论尽管急性A型主动脉夹层术前合并脑缺血患者的手术风险大、死亡率较高,但是仍有大部分患者得以术后存活,所以积极手术治疗是有意义的,术中有效的脑保护措施和体外循环管理是AAAD手术成功的保障。

Objective To investigate the clinical characteristics,classification of cerebral ischemia,effect and prognosis of surgical intervention and management of cardiopulmonary bypass(CPB)in patients with acute type A aortic dissection(AAAD)complicated with cerebral ischemia before operation.Methods A total of 1040 patients with AAAD in our center from January 2011 to October 2019 were analyzed retrospectively,of which 105(10.09%)were complicated with preoperative cerebral ischemia.According to the type of cerebral ischemia before operation,they were divided into transient brain injury(TND)group(89 cases,84.8%)and permanent brain injury(PND)group(16 cases,15.2%).The perioperative basic data of all the patients with cerebral ischemia were collected,including stroke history,ischemia history of limb,intestine or myocardium,onset to operation time,intraoperative operation method,arterial intubation site,brain protection method,operation time,cardiac arrest time,CPB time,selective antegrade cerebral perfusion time,in-hospital death,renal insufficiency treated by hemofiltration,re-operation for hemostasis,long-term mechanical ventilation,the time of ICU stay,the postoperative recovery time after anesthesia,the brain complications and the short-term(within 30 days)and long-term survival rates(1-60 months).Results All patients with AAAD complicated with cerebral ischemia received deep hypothermic circulatory arrest and CPB.There was no significant difference in the preoperative clinical data between PND group and TND group except for the history of stroke and limb ischemia.There was no significant difference in the intraoperative data of extracorporeal circulation,the mode of brain protection and the time of circulatory arrest between the two groups.The postoperative hospital stay(P<0.003)and the 30-day mortality(P<0.010)in TND group were significantly different from those in PND group.The short-term survival rate was statistically different between the two groups.Conclusion Although patients with AAAD complicated with cerebral ischemia have high surgical risk and high mortality,most of them still survive,so aggressive surgical treatment is meaningful.Effective brain protection measures and CPB management during operation are the guarantee for the success of AAAD operation.