Goldstein L J, Davies R R, Rizzo J A, Davila J J, Cooperberg M R, Shaw R K, Kopf G S, Elefteriades J A
Department of Surgery, Section of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, CT 06510, USA.
J Thorac Cardiovasc Surg. 2001 Nov;122(5):935-45. doi: 10.1067/mtc.2001.117276.
To determine the incidence, impact, etiology, and methods for prevention of stroke after surgery of the thoracic aorta.
A total of 317 thoracic aortic operations on 303 patients (194 male, 109 female) aged 13 to 87 years (mean 61 years) were reviewed. There were 218 procedures on the ascending aorta and arch and 99 on the descending aorta. Of the 218 procedures on the ascending aorta and arch, 86 involved cardiopulmonary bypass, 122 involved deep hypothermic circulatory arrest, 2 involved antegrade cerebral perfusion, and 8 involved "clamp and sew" or left heart bypass. Of the 99 procedures on the descending aorta, 20 involved "clamp and sew," 69 involved left heart or full bypass, and 10 involved deep hypothermic circulatory arrest. A total of 206 cases were elective and 97 were emergency operations.
Twenty-three (7.3%) of 317 patients had a stroke. Fifteen strokes occurred in operations on the ascending aorta and 8 in operations on the descending aorta (6.9% vs 8.1%; P =.703). Stroke occurred in 16 (16.5%) of 97 emergency operations and 7 (3.4%) of 206 elective operations (P =.001). In the 300 patients surviving the operation, stroke was a significant predictor of postoperative death (9/23 [39.1%] vs 23/277 [8.3%]; P =.001). Analysis of operative reports, brain images, and neurologic consultations revealed 15 of the 23 strokes were embolic, 3 were ischemic, 3 hemorrhagic, and 2 indeterminate. Patients with stroke had longer intensive care unit stays (18.4 vs 6.8 days; P =.0001), longer times to extubation (12.7 vs 3.8 days; P <.0012), longer postoperative stays (31.4 vs 14.3 days; P =.001), and decreased age-adjusted survival (relative risk 2.775; P =.0013). After implementation of a rigorous antiembolic regimen, both strokes and mortality trended downward.
(1) Stroke complicates surgery of both the ascending and descending thoracic aorta and warrants consideration in decision making. (2) Strokes are largely embolic. (3) Antiembolic measures for particles and air are essential, including gentle aortic manipulation, thorough debridement, transesophageal echocardiography to identify aortic atheromas, carbon dioxide flooding of the field, and (in descending cases) proximal clamp application before initiating femoral perfusion.
确定胸主动脉手术后中风的发生率、影响、病因及预防方法。
回顾了303例患者（194例男性，109例女性）的317例胸主动脉手术，患者年龄13至87岁（平均61岁）。升主动脉和主动脉弓手术218例，降主动脉手术99例。在218例升主动脉和主动脉弓手术中，86例涉及心肺转流，122例涉及深低温循环停搏，2例涉及顺行性脑灌注，8例涉及“钳夹缝合”或左心转流。在99例降主动脉手术中，20例涉及“钳夹缝合”，69例涉及左心或全转流，10例涉及深低温循环停搏。共206例为择期手术，97例为急诊手术。
317例患者中有23例（7.3%）发生中风。升主动脉手术中有15例中风，降主动脉手术中有8例中风（6.9%对8.1%；P = 0.703）。97例急诊手术中有16例（16.5%）发生中风，206例择期手术中有7例（3.4%）发生中风（P = 0.001）。在手术存活的300例患者中，中风是术后死亡的重要预测因素（9/23 [39.1%]对23/277 [8.3%]；P = 0.001）。对手术报告、脑部影像和神经科会诊的分析显示，23例中风中有15例为栓塞性，3例为缺血性，3例为出血性，2例不确定。中风患者的重症监护病房住院时间更长（18.4天对6.8天；P = 0.0001），拔管时间更长（12.7天对3.8天；P < 0.0012），术后住院时间更长（31.4天对14.3天；P = 0.001），年龄调整后的生存率降低（相对风险2.775；P = 0.0013）。实施严格的抗栓方案后，中风和死亡率均呈下降趋势。
（1）中风使升主动脉和降主动脉手术复杂化，在决策时应予以考虑。（2）中风主要为栓塞性。（3）针对颗粒和空气的抗栓措施至关重要，包括轻柔的主动脉操作、彻底清创、经食管超声心动图检查以识别主动脉粥样硬化斑块、术野二氧化碳冲洗以及（降主动脉手术时）在开始股动脉灌注前应用近端阻断钳。
