Department of Anesthesiology, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China.
Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu, 610041, Sichuan, China.
BMC Cardiovasc Disord. 2021 Apr 20;21(1):193. doi: 10.1186/s12872-021-02002-9.
Antegrade cerebral perfusion (ACP) under moderate hypothermic circulatory arrest is used during total aortic arch replacement surgery (TARS) in patients with acute type A aortic dissection, but it is associated with high mortality and morbidity. We hypothesized that combining ACP with retrograde inferior vena caval perfusion (RIVP) improves outcomes.
This pilot study was prospective, randomized, controlled and assessor-blinded. Patients scheduled for TARS were randomly treated with either ACP or RIVP + ACP. The primary outcome was a composite of mortality and major complications including paraplegia, postoperative renal failure, severe liver dysfunction, and gastrointestinal complications. Secondary outcomes included neurological complications, length of intubation and requirement of blood products.
A total of 76 patients were recruited (n = 38 per group). Primary outcome occurred in 23 patients (61%) in the ACP group and 16 (42%) in the RIVP + ACP group (OR: 0.60, 95% CI: 0.21-1.62; p = 0.31). There was a lower incidence of transient neurological deficits in the RIVP + ACP group (26% vs. 58%, OR: 0.26; 95% CI: 0.10-0.67,p = 0.006;). The RIVP + ACP group underwent shorter intubation (25 vs 47 h, p = 0.022) and required fewer blood products (red cells, 3.8 units vs 6.5 units, p = 0.047; platelet: 2.0 units vs 2.0 units, p = 0.023) compared with the ACP group.
RIVP + ACP may be associated with lower incidence of transient neurological deficits, shorter intubation and less blood transfusion requirement than ACP alone during TARS. Multi-center, randomized trials with larger samples are required to determine whether RIVP + ACP is associated with lower rates of mortality and major complications.
Pilot study of a RCT registered in clinicaltrials.gov (NCT03607786), Registered 30 July, 2018-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03607786 .
在急性 A 型主动脉夹层患者的全主动脉弓置换术（TARS）中，采用顺行脑灌注（ACP）联合中度低温循环停止，但死亡率和发病率较高。我们假设将 ACP 与逆行下腔静脉灌注（RIVP）相结合可以改善预后。
本研究为前瞻性、随机、对照和盲法评估。接受 TARS 的患者随机接受 ACP 或 RIVP+ACP 治疗。主要结局为死亡率和主要并发症的复合指标，包括截瘫、术后肾功能衰竭、严重肝功能障碍和胃肠道并发症。次要结局包括神经并发症、插管时间和血液制品需求。
共纳入 76 例患者（n=38 例/组）。ACP 组有 23 例（61%）发生主要结局，RIVP+ACP 组有 16 例（42%）发生主要结局（OR：0.60，95%CI：0.21-1.62；p=0.31）。RIVP+ACP 组的短暂性神经功能缺损发生率较低（26%比 58%，OR：0.26；95%CI：0.10-0.67，p=0.006）。与 ACP 组相比，RIVP+ACP 组的插管时间更短（25 比 47 h，p=0.022），血液制品需求更少（红细胞，3.8 单位比 6.5 单位，p=0.047；血小板：2.0 单位比 2.0 单位，p=0.023）。
与单纯 ACP 相比，RIVP+ACP 可能与 TARS 期间短暂性神经功能缺损发生率较低、插管时间较短、血液输血需求较少相关。需要多中心、随机试验，样本量更大，以确定 RIVP+ACP 是否与较低的死亡率和主要并发症发生率相关。
在 clinicaltrials.gov 注册的 RCT 的初步研究（NCT03607786），注册于 2018 年 7 月 30 日-回顾性注册，https://clinicaltrials.gov/ct2/show/NCT03607786。
