DeBakeyⅠ型主动脉夹层“杂交”手术治疗中的神经系统保护  

Nervous system protection in the treatment of DeBakey type I aortic dissection with hybrid procedure

作　　者：吴海卫[1] 景华[1] 李德闽[1] 李忠东[1] 董国华[1] 罗立国[1] 申翼[1] 许飚[1] 钱建军[1] 王常田[1] 张晓华[1] 程晓峰[1] 

机构地区：[1]南京军区总医院心胸外科,210002

出　　处：《中华胸心血管外科杂志》2012年第8期459-463,共5页Chinese Journal of Thoracic and Cardiovascular Surgery

摘　　要：目的总结“杂交”手术治疗DeBakeyI型主动脉夹层时神经系统保护的经验和方法。方法2009年1月至2011年6月，56例DeBakeyI型主动脉夹层患者行“杂交”手术，常规体外循环下行升主动脉段置换、弓部分支血管重建和主动脉弓降部腔内支架置入术，根据术前脑动脉、主动脉CTA检查结果，选择单侧顺行脑灌注（unilateral antegrade cerebral perfusion，UACP）或双侧顺行脑灌注（bilat—eral antegrade cerebral perfusion，BACP）联合股动脉插管灌注的方法对脑和脊髓组织行持续灌注，并选择性重建左锁骨下动脉。结果56例患者手术均成功，术中神经系统灌注采用BACP＋股动脉灌注16例，右侧UACP＋股动脉灌注33例，单纯股动脉灌注7例。19例患者行无名动脉、左颈总动脉重建，37例患者行无名动脉、左颈总动脉、左锁骨下动脉重建。体外循环时间44～95min，平均（65±24）min；主动脉阻断32～71min，平均（48±29）min；脑灌注24—44min，平均（32±13）min。术后1例（1．8％）单纯股动脉灌注患者出现永久性神经功能障碍，5例（8．9％）出现一过性神经功能障碍。1例死于重度感染，1例永久性神经功能障碍患者放弃治疗，54例患者痊愈出院。术后随访1—25个月，所有患者无新发神经系统功能障碍，术后3个月复查主动脉CTA显示人工血管通畅。19例未重建左锁骨下动脉者术后无明显的锁骨下动脉窃血症状，3例患者左上肢肌力轻度减退，6～12个月后恢复正常。结论“杂交”手术治疗DeBakeyI型主动脉夹层时，机体无深低温和停循环状态，UACP或BACP联合股动脉插管灌注的方法，保证了术中脑和脊髓的持续灌注，降低了患者术后神经系统并发症的发生率，具有良好的神经系统保护效果。Objective The present study aims to summarize the clinical experience and methods of nervous system pro- tection in the treatment of DeBakey type I aortic dissection with hybrid procedure. Methods From Jan 2009 to Jun 2011,56 patients suffering from DeBakey I aortic dissection underwent hybrid procedure. The ascending aorta part were replaced under conventional cardiopulmonary bypass, and the aortic arch branch vessels were reconstructed, and then a stent graft was implan- ted to cover the aortic arch and part of the descending aorta. The unilateral antegrade cerebral perfusion（UACP） and/or bilat- eral antegrade cerebral perfusion（BACP） combined with femoral artery peffusion was used, and the left subclavian arteries were selectively reconstructed according to cerebral arteries and aorta computed tomography angiography scan. Results All the patients went through the procedure successfully. BACP combined with femoral artery perfusion was applied in 16 patients, UACP combined with femoral artery perfusion in 33 patients, and 7 were per[used with only femoral artery cannulation. Of all the patients, 19 underwent the innominate artery and left common carotid artery reconstruction and the other 37 patients under- went the innominate artery, the left common carotid artery and the left subclavian artery reconstruction. The cardiopulmonary time was 44-95 min, mean （65±24） min; aortic clamping time was 32-71 min, mean （48 ±29）min; the cerebral perfusion time was 24 -44 min, mean （32 ±13） min. One （1.8%） patient, who was per[used with only femoral artery cannulation, suffered from permanent neurological dysfunction, and 5 （8.9%） had transient neurological dysfunction. One patient died from severe infection, 1 patient was given up because of permanent neurological dysfunction, and the rest 54 patients re- covered and discharged. The patients were followed up 1 to 25 months, and there was no newly occurred neurological dysfunc tion. The CTA examination 3 months post-operative revealed that the

关 键 词：主动脉动脉瘤 夹层 杂交手术 顺行脑灌注 神经功能障碍 

分 类 号：R654.3[医药卫生—外科学]