不同体、脑灌注方式对StanfordA型主动脉夹层患者的脑保护研究

摘要：目的探讨不同的体、脑灌注方式对StanfordA型主动脉夹层患者脑保护的影响。方法回顾性分析哈尔滨医科大学附属第一医院2007年4月至2012年3月117例StanfordA型主动脉夹层手术患者的临床资料，依据不同的体、脑灌注方式将患者分为3组，组1：45例，股动脉插管行体循环灌注＋停循环后单侧或双侧顺行性脑灌注组；组2：38例，锁骨下动脉或无名动脉插管行体循环灌注和单侧顺行性脑灌注或双侧顺行性脑灌注组；组3：34例，锁骨下动脉或无名动脉插管＋股动脉插管行顺逆结合体循环灌注和单侧顺行性脑灌注或双侧顺行性脑灌注组。对比分析术后短暂性神经系统功能障碍（transientneurologicaldysfunction，TND）、永久性神经系统功能障碍（permanentneurologicaldysfunction，PND）的发生情况以及影响因素。结果组1脑部并发症发生率高于组2、组3（37．77％vs．13．16％vs．14．71％），差异有统计学意义（P〈0．05）；组3体外循环的降温速度比组1、组2快（35．56±4．35VS．40．00±5．63、39．58_＋6．03），差异有统计学意义（P〈0．05）；其他指标各组间差异无统计学意义（P〉0．05o结论顺行性、逆行结合的体外循环灌注方法联合顺行性脑灌注降温速度均匀快速，可能具有良好的脊髓、肾脏、腹腔器官的保护作用，特别是降低脑部并发症方面证明其是目前最佳的器官保护方法。

Different Modes of Cardiopulmonary Bypass and Cerebral Perfusion for Cerebral Protection in Patients with Stanford Type A Aortic Dissection

Objective To investigate the impact of different modes of cardiopulmonary bypass （CPB） and cerebral perfusion on cerebral protection in patients with Stanford type A aortic dissection （AD）. Methods Clinical data of 117 patients with Stanford type A AD who underwent surgical therapy from April 2007 to March 2012 in the First Affiliated Hospital of Harbin Medical University were retrospectively analyzed. All the patients were divided into 3 groups according to different modes of CPB and cerebral perfusion they received. In group 1,45 patients received CPB perfusion through the femoral artery and unilateral or bilateral antegrade selective cerebral perfusion （ASCP） after circulatory arrest. In group 2, 38 patients received CPB perfusion through the subclavian artery or innominate artery and unilateral or bilateral ASCP after circulatory arrest. In group 3,34 patients received antegrade and retrograde CPB perfusion through both subclavian artery or innominate artery and femoral artery, and unilateral or bilateral ASCP after circulatory arrest. Postoperative occurrence of transient neurological dysfunction （TND）, permanent neurological dysfunction （PND） and influential factors were compared between the 3 groups. Results Incidence of postoperative cerebral complications of group 1 was significantly higher than those of group 2 and 3 （37.77% vs. 13.16% vs. 14.71%, P 〈 0.05 ）. During CPB, cooling time of group 3 was significantly shorter than those of group 1 and 2 （ 35.56＋ 4.35 vs. 40.00＋ 5.63 and 39.58 ＋6.03, P 〈 0.05 ）. There was no statistical difference in other influential factors among the 3 groups （P 〉 0.05）. Conclusion Antegrade and retrograde CPB perfusion in combination with ASCP has a smooth and quicker cooling rate, may provide better protection for the spinal cord, kidney and intraperitoneal organs and especially decrease the incidence of postoperative cerebral complications, therefore is proved current best method for organ protection.