Cheung Albert T, Pochettino Alberto, Guvakov Dmitri V, Weiss Stuart J, Shanmugan Skandan, Bavaria Joseph E
Department of Anesthesiology, University of Pennsylvania, Philadelphia, PA 19104-4283, USA.
Ann Thorac Surg. 2003 Oct;76(4):1190-6; discussion 1196-7. doi: 10.1016/s0003-4975(03)00881-6.
The safety of cerebrospinal fluid (CSF) drainage in thoracic aortic surgery using extracorporeal circulation (ECC) with systemic heparinization has not been established.
Four hundred thirty-two patients had descending thoracic or thoracoabdominal aortic repair between 1993 and 2002. One hundred sixty-two of those patients (age range, 67 +/- 13 years) had repairs performed with ECC, systemic anticoagulation, and lumbar CSF drainage. Repairs performed without CSF drainage, without ECC, or by stent graft (n = 53) were excluded. The CSF catheters were inserted at L3 to L5. Cerebrospinal fluid was drained to maintain pressures of 10 to 12 mm Hg. In the absence of neurologic deficit or coagulopathy, the catheters were capped at 24 hours and removed at 48 hours. Cerebrospinal fluid drainage was continued beyond 24 hours for delayed onset paraparesis.
Cerebrospinal fluid drains were used in 135 thoracoabdominal aortic aneurysms (extent I, n = 63; extent II, n = 25; extent III, n = 39; extent IV, n = 8) and 27 descending thoracic aortic repairs (aneurysm, n = 24; traumatic aortic injury, n = 2; aortic coarctation, n = 1). Partial left heart bypass was used in 132 patients, full cardiopulmonary bypass without deep hypothermic circulatory arrest in 5, and cardiopulmonary bypass with adjunctive deep hypothermic circulatory arrest in 25. Time between catheter insertion and anticoagulation was 153 +/- 60 minutes. Heparin achieved an average maximum activated clotting time of 528 +/- 192 seconds. Average ECC time was 114 +/- 77 minutes. Average deep hypothermic circulatory arrest time was 40 +/- 12 minutes. Mortality was 14.1% (23 of 162), and permanent paraplegia was 4.9% (8 of 162). No epidural or spinal hematoma was observed. Six (3.7%) patients had catheter-related complications (temporary abducens nerve palsy [n = 1]; retained catheter fragments [n = 2]; retained catheter fragment and meningitis [n = 1]; isolated meningitis [n = 1]; and spinal headache [n = 1]).
The CSF drainage in thoracic aortic surgery using ECC with full anticoagulation did not result in hemorrhagic complications. The permanent paraplegia rate in this complex patient population consisting of combined distal arch, thoracoabdominal aortic procedures were low, and lumbar CSF catheter-related complications had no permanent sequelae.
在使用体外循环（ECC）并全身肝素化的胸主动脉手术中，脑脊液（CSF）引流的安全性尚未确立。
1993年至2002年间，432例患者接受了降胸段或胸腹主动脉修复术。其中162例患者（年龄范围67±13岁）在ECC、全身抗凝及腰椎CSF引流下进行修复。排除未行CSF引流、未行ECC或采用支架植入术的修复患者（n = 53）。CSF导管插入L3至L5。引流脑脊液以维持压力在10至12 mmHg。若无神经功能缺损或凝血障碍，导管在24小时时夹闭，并在48小时时拔除。若出现迟发性截瘫，则CSF引流持续超过24小时。
135例胸腹主动脉瘤（I型，n = 63；II型，n = 25；III型，n = 39；IV型，n = 8）和27例降胸段主动脉修复术（动脉瘤，n = 24；创伤性主动脉损伤，n = 2；主动脉缩窄，n = 1）使用了CSF引流。132例患者采用部分左心转流，5例采用非深低温停循环的全心肺转流，25例采用辅助深低温停循环的心肺转流。导管插入至抗凝的时间为153±60分钟。肝素平均最大活化凝血时间为528±192秒。平均ECC时间为114±77分钟。平均深低温停循环时间为40±12分钟。死亡率为14.1%（162例中的23例），永久性截瘫率为4.9%（162例中的8例）。未观察到硬膜外或脊髓血肿。6例（3.7%）患者出现导管相关并发症（暂时性展神经麻痹[n = 1]；残留导管碎片[n = 2]；残留导管碎片合并脑膜炎[n = 1]；孤立性脑膜炎[n = 1]；以及脊柱头痛[n = 1]）。
在使用ECC并充分抗凝的胸主动脉手术中，CSF引流未导致出血并发症。在由远端主动脉弓、胸腹主动脉联合手术组成的这一复杂患者群体中，永久性截瘫率较低，且腰椎CSF导管相关并发症无永久性后遗症。
