AIM: To compare a modified technique preserving brain circulation during cardiopulmonary by-pass(CPB) for radical nephrectomy and caval thrombectomy, to the standard technique.METHODS: Retrospective evaluation of an i...AIM: To compare a modified technique preserving brain circulation during cardiopulmonary by-pass(CPB) for radical nephrectomy and caval thrombectomy, to the standard technique.METHODS: Retrospective evaluation of an institutional database that collects the data of patients submitted to nephrectomy and removal of caval thrombosis with CPB since 1998. In period between 1998 and 2007, CPB followed a standard technique(group s CPB); then, since 2008, a variation in the perfusional technique was introduced, allowing the anterograde perfusion of brain circulation during circulatory arrest(group CPB + BP) with the aim to reduce the risk of ischemic damage to the brain and also the need of deeper hypothermia. Patients(age, gender, comorbidity) and tumor characteristics(side, histology, staging, level of thrombosis), as well as parameters of CPB(times of CPB, aortic clamping andcirculatory arrest, minimum temperature reached during hypothermia), intra- and perioperative morbidity(complications in general, bleeding, renal and hepatic failure) and mortality were analyzed and compared between 2 groups(s CPB vs CPB + BP)RESULTS: The data of 24 patients, respectively 9 in s CPB group and 15 in CPB + BP group, have been reviewed. No differences in the characteristics of patients and tumors were observed. Only 1(11.1%) and 4(26.0%) of s CPB and CPB + BP patients, respectively, didn't experience any event of complication. In s CPB group were observed 15 events of complication(5 of which Clavien ≥ 3, 33% of the events), for a mean of 1.66 events/patient; 29 events(10 Clavien ≥ 3, 30.3%), in the CPB + BP group, for a mean of 2.1 events/patient. 1(11.1%) and 2(14.2%) deaths occurred, respectively. For patients submitted to CPB + BP, the minimum temperature reached was significantly higher(29.9 ℃ vs 26.4 ℃, P = 0.001), the time of circulatory arrest was longer(17.4 min vs 13.7 min, NS), but the overall time of CPB shorter(76.1 min vs 92.5 min, NS), albeit these latter differences were not statistically significant. No differences in terms of bleeding, impairment of renal function(post-operative Cr > 2.0 mg/d L respectively in 44.4% vs 35.7% of cases, in the two groups, NS) or hepatic insufficiency(post-operative GOT or GPT > 50 U/L respectively in 44.4% and 66.7% of patients, NS) were noted. Average follow-up was 51 mo in patients undergoing a s CPB and 12 mo in the CPB + BP group of patients; at the last follow-up, 7 patients had died of progression of the condition(4 in the first group and 3 in the second group, respectively), 7 were alive in progression and 10 had no evidence of the disease. CONCLUSION: The perfusional technique that maintains brain perfusion during circulatory arrest limits hypothermia and lowers time of CPB, without rising the risk of renal and hepatic injury.展开更多
Background:Renal artery stenosis (RAS) is always associated with abnormalities in renal microvascular perfusion (RMP).However,few imaging methods can simultaneously evaluate the degree of luminal stenosis and RMP.Thus...Background:Renal artery stenosis (RAS) is always associated with abnormalities in renal microvascular perfusion (RMP).However,few imaging methods can simultaneously evaluate the degree of luminal stenosis and RMP.Thus,this study will aim to evaluate the feasibility of using contrast-enhanced ultrasound (CEUS) for assessing both RAS and RMP to achieve a one-stop assessment of patients with suspected renovascular hypertension. Methods:This will be a single-center diagnostic study with a sample size of 440.Patients with chronic kidney disease (CKD) and suspected of having resistant hypertension will be eligible.Patients with Stages 1–3 CKD will undergo CEUS and computed tomography (CT) angiography (CTA).Values obtained by CEUS and CTA for diagnosing low-grade (lumen reduced by <60%) and high-grade (lumen reduced by ≥60%) RAS will be compared.Moreover,all patients will also undergo radionuclide imaging.The diagnostic value for RAS will be assessed by the receiver operating characteristic curve,including the accuracy,sensitivity,specificity,positive predictive values,negative predictive values,and area under the ROC.Pearson correlation analysis will be performed to assess the association between CEUS findings for RMP and glomerular filtration rate measured by a radionuclide imaging method. Conclusion:The data gathered from this study will be used to evaluate the feasibility of expanding clinical applications of CEUS for evaluation of patients with suspected renovascular hypertension.展开更多
Background:This study aims to observe the dynamic changes of renal artery(RA)disease and cortical blood perfusion(CBP)evaluated by contrast-enhanced ultrasound(CEUS)after percutaneous transluminal renal artery stentin...Background:This study aims to observe the dynamic changes of renal artery(RA)disease and cortical blood perfusion(CBP)evaluated by contrast-enhanced ultrasound(CEUS)after percutaneous transluminal renal artery stenting(PTRAS)in patients with severe atherosclerotic renal artery stenosis(ARAS)and to analyze the relationship between CBP and prognosis.Methods:This was a single-center retrospective cohort study.A total of 98 patients with unilateral severe ARAS after successful PTRAS in Beijing Hospital from September 2017 to September 2020 were included.According to renal glomerular filtration rate(GFR)detected by radionuclide imaging at 12 months after PTRAS,all patients were divided into the poor prognosis group(n=21,GFR decreased by≥20%compared with baseline)and the control group(n=77,GFR decreased by<20%or improved compared with baseline).Renal artery stenosis was diagnosed by digital subtraction angiography,and renal CBP was evaluated by CEUS using TomTec Imaging Systems(Germany)before PTRAS,at 6 months and 12 months after discharge.The receiver operating characteristic(ROC)curve with area under the curve(AUC)was used to analyze the predictive value of CBP parameters,including area under ascending curve(AUC1),area under the descending curve(AUC2),rising time(RT),time to peak intensity(TTP),maximum intensity(IMAX),and mean transit time(MTT)for poor prognosis.Results:Among the 98 patients,there were 52 males(53.1%),aged 55–74 years old,with an average age of 62.1±8.7 years,and an average artery stenosis of 82.3±12.9%.The poor prognosis group was associated with significantly increased incidence of diabetes(76.2%vs.41.6%),and lower levels of GFR of the stenotic kidney(21.8 mL/min vs.25.0 mL/min)and total GFR(57.6 mL/min vs.63.7 mL/min)(all P<0.05),compared with the control group(P<0.05).In addition,the rate of RA restenosis was significantly higher in the poor prognosis group than in the control group(9.5%vs.0,χ^(2)=9.462,P=0.002).Compared with the control group,the poor prognosis group was associated with significantly decreased baseline AUC1 and AUC2,and extended duration of TTP and MTT(P<0.05).At 6 months and 12 months of follow-up,patients in the control group were associated with markedly increased AUC1,AUC2,and IMAX,and shorter duration of RT and MTT(P<0.05).The ROC curve showed that the predictive values of AUC1,AUC2,RT,TTP,IMAX,and MTT for poor prognosis were 0.812(95%CI:0.698–0.945),0.752(95%CI:0.591–0.957),0.724(95%CI:0.569–0.961),0.720(95%CI:0.522–0.993),0.693(95%CI:0.507–0.947),and 0.786(95%CI:0.631–0.979),respectively.Conclusions:Preoperative renal CBP in severe ARAS patients with poor prognosis is significantly reduced,and does not show significant improvement after stent treatment over the first year of follow-up.The parameter AUC1 may be a good predictor for renal dysfunction after PTRAS in severe ARAS patients.Trial Registration:ChiCTR.org.cn,ChiCTR1800016252.展开更多
目的:应用多普勒超声观察体外循环(cardiopulmonary bypass,CPB)不同灌注流量对颈动脉血流的影响。方法:选择2014年12月至2015年1月在湘雅医院择期行瓣膜置换术或室间隔缺损修补术的患者共45例。分为G1,G2,G3组,灌注流量分别为(62±...目的:应用多普勒超声观察体外循环(cardiopulmonary bypass,CPB)不同灌注流量对颈动脉血流的影响。方法:选择2014年12月至2015年1月在湘雅医院择期行瓣膜置换术或室间隔缺损修补术的患者共45例。分为G1,G2,G3组,灌注流量分别为(62±2),(72±2),(82±2)mL/(kg·min)。在麻醉前(T1),麻醉后(T2),CPB开始后10 min(T3),20 min(T4),40 min(T5),60 min(T6)及CPB结束后20 min(T7),利用便携式多普勒超声诊断仪行颈总动脉(common carotid artery,CCA)和颈内动脉(internal carotid artery,ICA)测量,并记录灌注流量、颈总动脉管径(diameter of common carotid artery,CCAD)、颈总动脉峰值流速(peak velocity of common carotid artery,CCAV)、颈总动脉血流量(flow of common carotid artery,CCAF)、颈内动脉管径(diameter of internal carotid artery,ICAD)、颈内动脉峰值流速(peak velocity of internal carotid artery,ICAV)和颈内动脉血流量(flow of internal carotid artery,ICAF)。用α稳态法在CPB期间转机前(P1)、CPB期间体温降至最低(P2)、CPB复温至35℃(P3)、CPB停止后20 min(P4)和2 h(P5)行血气分析,对比血红蛋白(hemoglobin,Hb)和乳酸水平。记录手术时间、CPB时间、主动脉阻断时间,术后患者拔管时间、ICU时间、术后住院时间及术后并发症的情况。结果:3组患者Hb和乳酸的差异无统计学意义(均P>0.05)。组内比较:P2~P5各时间点的Hb水平均比P1的低,差异均有统计学意义(均P<0.05),在P2和P3时Hb水平最低。P3~P5各时间点的乳酸水平均比P1的高,差异均有统计学意义(均P<0.05)。麻醉前患者左右两侧CCAD,CCAV,CCAF,ICAD,ICAV,ICAF比较差异均无统计学意义(均P>0.05)。3组患者间CCAV和CCAF差异无统计学意义(均P>0.05)。组内比较:T2~T6的CCAV较T1明显下降(P<0.05);T7的CCAV较T3~T6明显回升(均P<0.05),但仍然明显低于T1(P<0.05)。T2~T5的CCAF与T1比较差异有统计学意义(均P<0.05)。在T3时,G1组的ICAV低于G3组(P<0.05);在T4时,G1组的ICAV低于G2组,G2组的ICAV低于G3组(均P<0.05);在T6时,G1组的ICAV低于G2组(P<0.05)。组内比较:T2的ICAV明显低于T1(P<0.05),T3~T6的ICAV明显低于T1和T2(均P<0.05)。在T3~T6时,G1组ICAF低于G3组(均P<0.05);在组内比较,T2~T6的ICAF较T1明显下降(均P<0.05)。在T4时,灌注流量与CCAF,ICAV,ICAV呈正相关(均P<0.05)。患者术后均无明显的运动、感觉或意识障碍,且无神经系统并发症。3组患者的术后住院时间、术后ICU时间及术后拔管时间差异无统计学意义(均P>0.05)。结论:体外循环不同灌注流量对颈动脉血流的影响有一定的差异,颈动脉血流参数与灌注流量有一定相关性,颈动脉超声检测可以用于评估心输出量。展开更多
文摘AIM: To compare a modified technique preserving brain circulation during cardiopulmonary by-pass(CPB) for radical nephrectomy and caval thrombectomy, to the standard technique.METHODS: Retrospective evaluation of an institutional database that collects the data of patients submitted to nephrectomy and removal of caval thrombosis with CPB since 1998. In period between 1998 and 2007, CPB followed a standard technique(group s CPB); then, since 2008, a variation in the perfusional technique was introduced, allowing the anterograde perfusion of brain circulation during circulatory arrest(group CPB + BP) with the aim to reduce the risk of ischemic damage to the brain and also the need of deeper hypothermia. Patients(age, gender, comorbidity) and tumor characteristics(side, histology, staging, level of thrombosis), as well as parameters of CPB(times of CPB, aortic clamping andcirculatory arrest, minimum temperature reached during hypothermia), intra- and perioperative morbidity(complications in general, bleeding, renal and hepatic failure) and mortality were analyzed and compared between 2 groups(s CPB vs CPB + BP)RESULTS: The data of 24 patients, respectively 9 in s CPB group and 15 in CPB + BP group, have been reviewed. No differences in the characteristics of patients and tumors were observed. Only 1(11.1%) and 4(26.0%) of s CPB and CPB + BP patients, respectively, didn't experience any event of complication. In s CPB group were observed 15 events of complication(5 of which Clavien ≥ 3, 33% of the events), for a mean of 1.66 events/patient; 29 events(10 Clavien ≥ 3, 30.3%), in the CPB + BP group, for a mean of 2.1 events/patient. 1(11.1%) and 2(14.2%) deaths occurred, respectively. For patients submitted to CPB + BP, the minimum temperature reached was significantly higher(29.9 ℃ vs 26.4 ℃, P = 0.001), the time of circulatory arrest was longer(17.4 min vs 13.7 min, NS), but the overall time of CPB shorter(76.1 min vs 92.5 min, NS), albeit these latter differences were not statistically significant. No differences in terms of bleeding, impairment of renal function(post-operative Cr > 2.0 mg/d L respectively in 44.4% vs 35.7% of cases, in the two groups, NS) or hepatic insufficiency(post-operative GOT or GPT > 50 U/L respectively in 44.4% and 66.7% of patients, NS) were noted. Average follow-up was 51 mo in patients undergoing a s CPB and 12 mo in the CPB + BP group of patients; at the last follow-up, 7 patients had died of progression of the condition(4 in the first group and 3 in the second group, respectively), 7 were alive in progression and 10 had no evidence of the disease. CONCLUSION: The perfusional technique that maintains brain perfusion during circulatory arrest limits hypothermia and lowers time of CPB, without rising the risk of renal and hepatic injury.
文摘Background:Renal artery stenosis (RAS) is always associated with abnormalities in renal microvascular perfusion (RMP).However,few imaging methods can simultaneously evaluate the degree of luminal stenosis and RMP.Thus,this study will aim to evaluate the feasibility of using contrast-enhanced ultrasound (CEUS) for assessing both RAS and RMP to achieve a one-stop assessment of patients with suspected renovascular hypertension. Methods:This will be a single-center diagnostic study with a sample size of 440.Patients with chronic kidney disease (CKD) and suspected of having resistant hypertension will be eligible.Patients with Stages 1–3 CKD will undergo CEUS and computed tomography (CT) angiography (CTA).Values obtained by CEUS and CTA for diagnosing low-grade (lumen reduced by <60%) and high-grade (lumen reduced by ≥60%) RAS will be compared.Moreover,all patients will also undergo radionuclide imaging.The diagnostic value for RAS will be assessed by the receiver operating characteristic curve,including the accuracy,sensitivity,specificity,positive predictive values,negative predictive values,and area under the ROC.Pearson correlation analysis will be performed to assess the association between CEUS findings for RMP and glomerular filtration rate measured by a radionuclide imaging method. Conclusion:The data gathered from this study will be used to evaluate the feasibility of expanding clinical applications of CEUS for evaluation of patients with suspected renovascular hypertension.
基金supported by grants from the National High Level Hospital Clinical Research Funding(No.BJ2018-198)Basic Research Project of the Central Academy of Medical Sciences of China(No.2019PT320012)+1 种基金Beijing Science and Technology Project(No.Z211100002921011)National Key R&D Program of China(No.2020YFC2008100).
文摘Background:This study aims to observe the dynamic changes of renal artery(RA)disease and cortical blood perfusion(CBP)evaluated by contrast-enhanced ultrasound(CEUS)after percutaneous transluminal renal artery stenting(PTRAS)in patients with severe atherosclerotic renal artery stenosis(ARAS)and to analyze the relationship between CBP and prognosis.Methods:This was a single-center retrospective cohort study.A total of 98 patients with unilateral severe ARAS after successful PTRAS in Beijing Hospital from September 2017 to September 2020 were included.According to renal glomerular filtration rate(GFR)detected by radionuclide imaging at 12 months after PTRAS,all patients were divided into the poor prognosis group(n=21,GFR decreased by≥20%compared with baseline)and the control group(n=77,GFR decreased by<20%or improved compared with baseline).Renal artery stenosis was diagnosed by digital subtraction angiography,and renal CBP was evaluated by CEUS using TomTec Imaging Systems(Germany)before PTRAS,at 6 months and 12 months after discharge.The receiver operating characteristic(ROC)curve with area under the curve(AUC)was used to analyze the predictive value of CBP parameters,including area under ascending curve(AUC1),area under the descending curve(AUC2),rising time(RT),time to peak intensity(TTP),maximum intensity(IMAX),and mean transit time(MTT)for poor prognosis.Results:Among the 98 patients,there were 52 males(53.1%),aged 55–74 years old,with an average age of 62.1±8.7 years,and an average artery stenosis of 82.3±12.9%.The poor prognosis group was associated with significantly increased incidence of diabetes(76.2%vs.41.6%),and lower levels of GFR of the stenotic kidney(21.8 mL/min vs.25.0 mL/min)and total GFR(57.6 mL/min vs.63.7 mL/min)(all P<0.05),compared with the control group(P<0.05).In addition,the rate of RA restenosis was significantly higher in the poor prognosis group than in the control group(9.5%vs.0,χ^(2)=9.462,P=0.002).Compared with the control group,the poor prognosis group was associated with significantly decreased baseline AUC1 and AUC2,and extended duration of TTP and MTT(P<0.05).At 6 months and 12 months of follow-up,patients in the control group were associated with markedly increased AUC1,AUC2,and IMAX,and shorter duration of RT and MTT(P<0.05).The ROC curve showed that the predictive values of AUC1,AUC2,RT,TTP,IMAX,and MTT for poor prognosis were 0.812(95%CI:0.698–0.945),0.752(95%CI:0.591–0.957),0.724(95%CI:0.569–0.961),0.720(95%CI:0.522–0.993),0.693(95%CI:0.507–0.947),and 0.786(95%CI:0.631–0.979),respectively.Conclusions:Preoperative renal CBP in severe ARAS patients with poor prognosis is significantly reduced,and does not show significant improvement after stent treatment over the first year of follow-up.The parameter AUC1 may be a good predictor for renal dysfunction after PTRAS in severe ARAS patients.Trial Registration:ChiCTR.org.cn,ChiCTR1800016252.
文摘目的:应用多普勒超声观察体外循环(cardiopulmonary bypass,CPB)不同灌注流量对颈动脉血流的影响。方法:选择2014年12月至2015年1月在湘雅医院择期行瓣膜置换术或室间隔缺损修补术的患者共45例。分为G1,G2,G3组,灌注流量分别为(62±2),(72±2),(82±2)mL/(kg·min)。在麻醉前(T1),麻醉后(T2),CPB开始后10 min(T3),20 min(T4),40 min(T5),60 min(T6)及CPB结束后20 min(T7),利用便携式多普勒超声诊断仪行颈总动脉(common carotid artery,CCA)和颈内动脉(internal carotid artery,ICA)测量,并记录灌注流量、颈总动脉管径(diameter of common carotid artery,CCAD)、颈总动脉峰值流速(peak velocity of common carotid artery,CCAV)、颈总动脉血流量(flow of common carotid artery,CCAF)、颈内动脉管径(diameter of internal carotid artery,ICAD)、颈内动脉峰值流速(peak velocity of internal carotid artery,ICAV)和颈内动脉血流量(flow of internal carotid artery,ICAF)。用α稳态法在CPB期间转机前(P1)、CPB期间体温降至最低(P2)、CPB复温至35℃(P3)、CPB停止后20 min(P4)和2 h(P5)行血气分析,对比血红蛋白(hemoglobin,Hb)和乳酸水平。记录手术时间、CPB时间、主动脉阻断时间,术后患者拔管时间、ICU时间、术后住院时间及术后并发症的情况。结果:3组患者Hb和乳酸的差异无统计学意义(均P>0.05)。组内比较:P2~P5各时间点的Hb水平均比P1的低,差异均有统计学意义(均P<0.05),在P2和P3时Hb水平最低。P3~P5各时间点的乳酸水平均比P1的高,差异均有统计学意义(均P<0.05)。麻醉前患者左右两侧CCAD,CCAV,CCAF,ICAD,ICAV,ICAF比较差异均无统计学意义(均P>0.05)。3组患者间CCAV和CCAF差异无统计学意义(均P>0.05)。组内比较:T2~T6的CCAV较T1明显下降(P<0.05);T7的CCAV较T3~T6明显回升(均P<0.05),但仍然明显低于T1(P<0.05)。T2~T5的CCAF与T1比较差异有统计学意义(均P<0.05)。在T3时,G1组的ICAV低于G3组(P<0.05);在T4时,G1组的ICAV低于G2组,G2组的ICAV低于G3组(均P<0.05);在T6时,G1组的ICAV低于G2组(P<0.05)。组内比较:T2的ICAV明显低于T1(P<0.05),T3~T6的ICAV明显低于T1和T2(均P<0.05)。在T3~T6时,G1组ICAF低于G3组(均P<0.05);在组内比较,T2~T6的ICAF较T1明显下降(均P<0.05)。在T4时,灌注流量与CCAF,ICAV,ICAV呈正相关(均P<0.05)。患者术后均无明显的运动、感觉或意识障碍,且无神经系统并发症。3组患者的术后住院时间、术后ICU时间及术后拔管时间差异无统计学意义(均P>0.05)。结论:体外循环不同灌注流量对颈动脉血流的影响有一定的差异,颈动脉血流参数与灌注流量有一定相关性,颈动脉超声检测可以用于评估心输出量。
