单侧和双侧脑灌注应用于头臂动脉受累的急性A型主动脉夹层手术效果对比

Bilateral and unilateral antegrade cerebral perfusion in acute Stanford A aortic dissection with innominate artery involved:a randomized controlled study

目的:施行全主动脉弓替换联合支架“象鼻”术(TAR&SET)治疗急性Stanford A型主动脉夹层(aTAAD)需在停循环期间通过灌注一侧或双侧颈动脉维持脑血供与代谢。头臂动脉受累的情况下,双侧颈动脉顺行脑灌注是否比目前通行的经右腋动脉单侧顺行脑灌注更有优势尚存争议。我们采用随机对照研究,旨在比较此类患者停循环期间、核心温度28 t双侧脑灌注与24 t单侧脑灌注的手术效果。方法:选取安徽医科大学第一附属医院自2018年1月至2020年9月间,接受急诊TAR&SET术的急性Stanford A型主脉夹层患者。符合条件的62例患者以掷币法随机分入单侧脑灌注(对照组,24 t经右腋动脉单侧脑灌注)和双侧脑灌注组(改良组,28 t,经右腋动脉、左颈总动脉双侧脑灌注)。比较其术前资料、手术情况、并发症及预后。结果:改良组34例,对照组28例。两组性别构成、年龄、合并症等差异无统计学意义。两组患者住院死亡率(2.9%vs.3.5%,P=0.88)、院外死亡率(零vs.10.7%,P=0.09)、持续性神经功能障碍(零vs.7.1%,P=0.11)无统计学差异。改良组的不良事件发生率低于对照组(9.0%vs.35.7%,P=0.01);改良组缩短了手术时长[(7.6±1.1)vs.(8.6±0.7)h,P<0.01]和体外循环时长[(194.0±24,7)vs.(225.1±32.4)min,P<0.01]。改良组术后发生短暂性神经功能障碍(5.9%vs.28.6%,P<0.05)、辅助通气时间[5.5(10.4,19.0)vs.18.4(7.9,13.5),P<0.01]、ICU停留时间、住院天数及出血事件低于对照组。结论:28 t双侧脑灌注可为头臂动脉受累的aTAAD患者接受急诊TAR&SET术提供安全灌注。

Objective:Deep hypothermic circulatory arrest and selective antegraed cerebral perfusion are employed to protect the ischaemic cerebral during total aortic arch replacement(TAR)combined with stent elephant trunk(SET)implantation for acute Stanford type A aortic dissection(aTAAD).However,there is no standard protocol for choosing unilateral or bilateral cerebral perfusion when the innominate artery is involved.Therefore,we conducted this randomized controlled study to evaluated the outcome of hypothermic circulatory arrest with 28 t and bilateral antegrade cerebral perfusion(bSACP)vs hypothermic circulatory arrest with 24t and unilateral antegrade cerebral perfusion(uSACP)for these patients treated by TAR with SET.Methods:Between January 2018 and July 2019,aTAAD patients met the inclusion criteria were randomly divided into control group(24℃,uSACP)and modified groups(28℃,bSACP).All the patients were treated by the TAR with SET procedure by same team.The preoperative clinical profiles,operative outcomes and postoperative result were compared.Results:There were 34 patients in modified group and 28 patients in control group.There were not statistically significant in terms of sex,age and comorbidities.There were no significant differences in in-hospital mortality(2.9%vs.3.5%,P=0.88)and permanent neurologic deficit(modified 0 vs.10.7%,P=0.09).However,the incidence of overall major adverse events was significant lower in modified group(9.0%vs.35.7%,P=0.01);The rate of temporary neurological deficit was lower in modified group(5.9%vs.28.6%,P<0.05).Shorter operative duration,ventilation time and hospital stay as well as a reduced volume of drainage was identified in modified group.Conclusions:The study shows that hypothermic circulatory arrest with 28℃ and bSACP is a safer than hypothermic circulatory arrest with 24℃ and uSACP for aTAAD patients with innominate artery involed.