Sugiura Tadahisa, Imoto Kiyotaka, Uchida Keiji, Minami Tomoyuki, Yasuda Shota
Cardiovascular Center, Yokohama City University Medical Center, 4-57 Urafune-Cho, Yokohama, 232-0024, Minami-Ku, Japan.
Gen Thorac Cardiovasc Surg. 2012 Oct;60(10):645-8. doi: 10.1007/s11748-012-0142-z. Epub 2012 Aug 18.
Postoperative disorders of the central nervous system remain a major problem in thoracic aortic surgery. Both retrograde cerebral perfusion and selective antegrade cerebral perfusion have become established techniques for cerebral circulatory management. In this study, we compared neurologic outcomes and mortality between retrograde cerebral perfusion and antegrade selective cerebral perfusion in patients with acute type A aortic dissection who underwent emergency ascending aorta replacement.
Between January 2003 and April 2011, a total of 203 patients with acute type A aortic dissection underwent emergency ascending aorta replacement in our hospital. We performed retrograde cerebral perfusion in 109 patients before 2006, and then mainly performed antegrade selective cerebral perfusion in 94 patients from 2006 onward.
Cardiopulmonary bypass time and systemic circulatory arrest time were significantly longer in the antegrade selective cerebral perfusion group (p = 0.04, p < 0.001, respectively). The incidences of transient brain dysfunction and permanent brain dysfunction after surgery did not differ significantly between the groups. There were also no differences between the groups in other intraoperative variables, such as aortic cross-clamp time and the lowest rectal temperature, or in operative outcomes, including postoperative intensive-care-unit stay, mean peak amylase, and lipase levels until postoperative day 7, and 30-day mortality.
Both retrograde cerebral perfusion and antegrade selective cerebral perfusion were associated with acceptable levels of postoperative neurologic deficits, mortality, and morbidity. Either of these techniques for brain protection can be used selectively, based on a comprehensive assessment of general condition, in patients undergoing surgery for acute type A aortic dissection.
中枢神经系统术后功能障碍仍是胸主动脉手术中的一个主要问题。逆行脑灌注和顺行性选择性脑灌注均已成为脑循环管理的成熟技术。在本研究中，我们比较了接受急诊升主动脉置换术的急性A型主动脉夹层患者中逆行脑灌注和顺行性选择性脑灌注的神经学转归及死亡率。
2003年1月至2011年4月，我院共有203例急性A型主动脉夹层患者接受了急诊升主动脉置换术。2006年前，我们对109例患者进行了逆行脑灌注，从2006年起，主要对94例患者进行了顺行性选择性脑灌注。
顺行性选择性脑灌注组的体外循环时间和全身循环停止时间显著更长（分别为p = 0.04，p < 0.001）。两组术后短暂性脑功能障碍和永久性脑功能障碍的发生率无显著差异。两组在其他术中变量（如主动脉阻断时间和最低直肠温度）或手术结局（包括术后重症监护病房住院时间、术后第7天的平均淀粉酶峰值和脂肪酶水平以及30天死亡率）方面也无差异。
逆行脑灌注和顺行性选择性脑灌注均与术后神经功能缺损、死亡率和发病率的可接受水平相关。对于接受急性A型主动脉夹层手术的患者，可根据对一般情况的全面评估，选择性地使用这两种脑保护技术中的任何一种。
