Okada Tatsuji, Shimamoto Mitsuomi, Yamazaki Fumio, Nakai Masanao, Miura Yujiro, Itonaga Tatsuya, Takahashi Daisuke, Nomura Ryota, Abe Noriyuki, Terai Yasuhiko
Department of Cardiovascular Surgery, Shizuoka City Hospital, 10-93 Ohte-machi, Aoi-ku, Shizuoka, Shizuoka, 420-8630, Japan.
Gen Thorac Cardiovasc Surg. 2012 May;60(5):268-74. doi: 10.1007/s11748-011-0884-z. Epub 2012 Mar 28.
Although the outcomes of aortic arch surgery have improved, stroke remains one of the most devastating complications. Therefore, identification of true risk factors and understanding the pathogenesis of intraoperative stroke are necessary to decrease its occurrence.
From January 2002 to December 2010, a total of 251 consecutive patients underwent aortic arch surgery under deep hypothermic circulatory arrest and antegrade selective cerebral perfusion in our hospital. Hemiarch replacement cases were excluded. Of the remaining patients, 190 elective cases that could be reviewed with full perioperative clinical data were analyzed. Strokes were classified into three subtypes according to their distribution on imaging studies: multiple-embolism type, hypoperfusion type, and solitary-embolism type.
Operative death occurred in 1.1% of patients (2/190), and aortic arch surgery-related in-hospital death occurred in 5.3%. Among the 188 survivors, intraoperative strokes occurred in 5.9%. Multiple-embolism, hypoperfusion type, and solitary-embolism stroke occurred in 2.7%, 2.1%, and 1.6%, respectively. Multivariate analysis revealed that the risk factor for multiple-embolism stroke was high-grade atheroma in the ascending aorta [P < 0.001, odds ratio (OR) 118.0], and that for hypoperfusion type stroke was prolonged brain ischemia time over 120 min (P = 0.004, OR 31.5). No significant risk factor was found for solitary-embolism stroke.
Intraoperative strokes during elective aortic arch surgery under deep hypothermic circulatory arrest and antegrade selective cerebral perfusion are strongly influenced by the presence of a high-grade atheroma in the ascending aorta and prolonged brain ischemia time. The results suggest that these are key issues to reduce stroke in aortic arch surgery.
尽管主动脉弓手术的预后有所改善，但卒中仍然是最具破坏性的并发症之一。因此，识别真正的危险因素并了解术中卒中的发病机制对于减少其发生是必要的。
2002年1月至2010年12月，我院共有251例连续患者在深低温停循环和顺行性选择性脑灌注下接受主动脉弓手术。半弓置换病例被排除。在其余患者中，对190例可获得完整围手术期临床资料的择期病例进行了分析。根据影像学研究中卒中的分布情况，将其分为三种亚型：多发栓塞型、低灌注型和孤立栓塞型。
1.1%（2/190）的患者发生手术死亡，5.3%的患者发生与主动脉弓手术相关的院内死亡。在188名幸存者中，5.9%发生术中卒中。多发栓塞型、低灌注型和孤立栓塞型卒中的发生率分别为2.7%、2.1%和1.6%。多因素分析显示，多发栓塞型卒中的危险因素是升主动脉高级别动脉粥样硬化[P<0.001，比值比（OR）118.0]，低灌注型卒中的危险因素是脑缺血时间延长超过120分钟（P=0.004，OR 31.5）。未发现孤立栓塞型卒中的显著危险因素。
在深低温停循环和顺行性选择性脑灌注下进行的择期主动脉弓手术中，术中卒中受升主动脉高级别动脉粥样硬化和脑缺血时间延长的强烈影响。结果表明，这些是减少主动脉弓手术中卒中的关键问题。
