深低温停循环逆行脑灌注行胸主动脉瘤手术体会

20 0 1年 7月至 2 0 0 2年 4月 ,我们采用用深低温停循环(DHCA)辅以上腔静脉持续逆行脑灌注 (CRCP)方法 ,手术治疗 2例急性DeBakeyI型夹层动脉瘤 (DAA)和 1例急性钝性创伤性主动脉峡部破裂伴假性动脉瘤 (FA)病人 ,效果满意。现报道如下。临床资料　 2例DAA均为男性 ;年龄 32、4 4岁。急性胸痛入院 ;经CT、MRI确诊 ;单个内膜裂口 ,分别位于导管韧带旁、左锁骨下动脉旁 ;升主动脉直径 5 4cm、4 6cm ;超声心动图示主动脉瓣微量反流。 1例行升主动脉加半弓置换术 ,1例行升主动脉、全弓置换加“象鼻”术。1例FA为女性 ,38岁。车祸…     

深低温停循环重力脑逆行灌注在主动脉瘤手术中的脑保护作用

目的 探讨深低温停循环重力脑逆行性灌注技术在主动脉夹层动脉瘤手术中对脑和脊髓的保护作用。方法 建立体外循环后，开始降温。肛温17℃时，患者深度头低位（deep trendelenburg position)。控制股静脉回流，股动脉流量降至1．5L／min，升高和维持中心静脉压在20－23cmH2O(1kPa=10.2cmH2O)，即可完成脑逆行性灌注。结果 本组2例患者停循环脑逆行性灌注时间分别为50分钟和116分钟，术后未发生神经系统并发症。结论 深低温停循环重力脑逆行性灌注技术操作简单，能够充分暴露术野，对脑和脊髓有很好的保护作用。     

深低温停循环经上腔静脉逆行灌注眼底微血管血流观测

深低温停循环经上腔静脉逆行灌注 (ＲＣＰ)脑保护在临床的应用已较为普遍 ,但关于ＲＣＰ是否能提供有效的脑灌注尚存在争议。我们的实验采用眼底血管荧光造影 (ＦＦＡ)和彩色多普勒超声检查 ,观察眼底微血管显像和血流状况来评估ＲＣＰ期间的脑灌注效果。材料和方法　健康北京农大小型猪 6只 ,体重 19～ 2 0ｋｇ。 3%戊巴比妥钠腹腔麻醉 ,肌松药采用阿端 0 10～ 0 15ｍｇ ｋｇ ,采用芬太尼 10 μｇ ｋｇ静脉注射维持麻醉。1.术前 2ｄ作ＦＦＡ为对照　经耳缘静脉注射 2 0 %荧光素钠 3ｍｌ,10ｓ后开始拍照 ,直至 3ｍｉｎ后动、静脉均匀显影…     

深低温停循环逆行性灌注脑保护

为评价上腔静脉逆行性灌注对脑保护的效果,对１０余年来的研究成果进行综述。上腔静脉逆行性灌注是深低温停循环环脑保护的辅助手段,已证明在低温状态下,它为脑部提供低流量血流,维持脑部低温状态;提供部分氧和营养物质,运走代谢产物;减少气栓及栓塞的发生,从而延长了深低温度循环脑保护的安全时限,而脑水肿的危险性限制了该方法在临床应用。在脑保护液中加入脑保护药物已取得一定进展,而上腔静脉逆行性灌注中束闭下腔静脉     

深低温停循环在非心脏外科手术中的应用

随着心肺转流(CPB)技术和医疗设备质量的提高,深低温停循环(deep hypothermic circulatory arrest,DHCA)不仅在心脏外科领域得到应用,而且被逐渐推广应用于非心脏外科复杂手术、移植、重症抢救和先天性畸形整形等方面,有效地降低了手术风险,向传统手术方法不可逾越的禁区迈进,拓宽了其应用范围。本文就DHCA在非心脏外科手术中的应用、并发症及其防治措施等方面进行综述。     

深低温停循环在非心脏外科手术中的应用

随着心肺转流（CPB）技术和医疗设备质量的提高，深低温停循环（deep hypothermic circulatory arrest,DHCA)不仅在心脏外科领域得到应用，而且被逐渐推广应用于非心脏外科复杂手术、移植、重症抢救和先天性畸形整形等方面，有效地降低了手术风险，向传统手术方法不可逾越的禁区迈进，拓宽了其应用范围。本文就DHCA在非心脏外科手术中的应用、并发症及其防治措施等方面进行综述。     

深低温停循环逆行脑灌注脑组织自由基变化的实验研究

研究深低温停循环（ＤＨＣＡ）与逆行脑灌注（ＲＣＰ）时脑组织自由基的变化。健康杂种犬１４只，随机等分为ＤＨＣＡ组和ＲＣＰ组，在停循环前（Ａ点）、ＤＨＣＡ／ＲＣＰ３０分（Ｂ点）、ＤＨＣＡ／ＲＣＰ６０分（Ｃ点）ＤＨＣＡ／ＲＣＰ９０分（Ｄ眯）和复温再灌注３０分（Ｅ点）取脑皮层ｌｇ，检测丙二醛（ＭＤＡ）和超氧化物歧化酶（ＳＯＤ）水平。结果见两组在Ａ点ＭＤＡ和ＳＯＤ无差别。在Ｂ、Ｃ、Ｄ、Ｅ点，ＤＨＣＡ组ＭＤＡ     

深低温停循环与逆行脑灌注的脑保护实验研究

我们用犬体外循环模型比较深低温停循环（ＤＨＣＡ）和经上腔静脉逆行脑灌注（ＲＣＰ）时肌酸激酶脑型同功酶（ＣＫＢＢ）含量的变化及脑组织超微结构的改变,为临床推广应用ＲＣＰ行脑保护提供实验基础和理论依据。材料和方法健康杂种犬１４只,雌雄各半;体重１０～２...     

深低温停循环联合顺行性脑灌注对患者认知功能的影响

目的探讨急性StanfordA型主动脉夹层采用深低温停循环联合顺行性脑灌注对患者认知功能的影响。方法2009年1月至2012年3月南京医科大学附属南京医院48例急性StanfordA型主动脉夹层采用孙氏手术（主动脉弓部置换加支架象鼻手术）,其中男40例,女8例,年龄（51．3±13．6）岁。手术均采用深低温停循环、顺行胜脑灌注技术。记录术中停循环时间、术后苏醒时间,根据简易智力状态检查量表（mini．mentalstatesexamination,MMSE）评价患者术前、术后的认知功能。结果48例患者体外循环时间（237．3±58．5）rain,术中停循环时间（37．3±6．9）min。手术死亡4例,死亡原因：肺部感染、多脏器功能衰竭、心肌梗死和急性呼吸窘迫综合征。4l例患者术后24h内苏醒,苏醒时间（1513±6．5）h。MMSE评分术前为（28．6±1．1）分,术后1周时为（23．6±4．5）分。随访3l例,随访率70．45％,随访时间6个月。术后6个月时31例患者MMSE评分为（27．6±2．1）分,较术后MMSE评分大幅度提高（户〈0．05）,但与术前MMSE比较,差异无统计学意义（P〉0．05）。结论治疗急性StanfordA型主动脉夹层采用深低温停循环联合顺行性脑灌注技术,可以取得满意的脑保护效果,但短期内对认知功能可能存在负面影响;只要头颅CT排除梗塞或出血病灶,这种负面影响在半年内基本可以自行消除。     

Similar Cerebral Protective Effectiveness of Antegrade and Retrograde Cerebral Perfusion During Deep Hypothermic Circulatory Arrest in Aortic Surgery: A Meta‐Analysis of 7023 Patients

In aortic arch surgery, deep hypothermic circulatory arrest (DHCA) combined with cerebral perfusion is employed worldwide as a routine practice. Even though antegrade cerebral perfusion (ACP) is more widely used than retrograde cerebral perfusion (RCP), the difference in benefit and risk between ACP and RCP during DHCA is uncertain. The purpose of this meta‐analysis is to compare neurologic outcomes and early mortality between ACP and RCP in patients who underwent aortic surgery during DHCA. PubMed, EMBASE, and the Cochrane Library were searched using the key words “antegrade,” “retrograde,” “cerebral perfusion,” “cardiopulmonary bypass,” “extracorporeal circulation,” and “cardiac surgery” for studies reporting on clinical endpoints including early mortality, stroke, temporary neurologic dysfunction (TND), and permanent neurologic dysfunction (PND) in aortic surgery requiring DHCA with ACP or RCP. Heterogeneity was analyzed with the Cochrane Q statistic and I² statistic. Publication bias was tested with Begg's funnel plot and Egger's test. Thirty‐four studies were included in this meta‐analysis, with 4262 patients undergoing DHCA + ACP and 2761 undergoing DHCA + RCP. The overall pooled relative risk for TND was 0.722 (95% CI = [0.579, 0.900]), and the z‐score for overall effect was 2.9 (P = 0.004). There was low heterogeneity (I² = 18.7%). The analysis showed that patients undergoing DHCA + ACP had better outcomes than those undergoing DHCA + RCP in terms of TND, while there were no significant differences between groups in terms of PND, stroke, and early mortality. This meta‐analysis indicates that DHCA + ACP has an advantage over DHCA + RCP in terms of TND, while the two methods show similar results in terms of PND, early mortality, and stroke.     

Retrograde Cerebral Perfusion Results in Better Perfusion to the Striatum Than the Cerebral Cortex During Deep Hypothermic Circulatory Arrest: A Microdialysis Study

It remains controversial whether contemporary cerebral perfusion techniques, utilized during deep hypothermic circulatory arrest (DHCA), establish adequate perfusion to deep structures in the brain. This study aimed to investigate whether selective antegrade cerebral perfusion (SACP) or retrograde cerebral perfusion (RCP) can provide perfusion equally to various anatomical positions in the brain using metabolic evidence obtained from microdialysis. Eighteen piglets were randomly assigned to 40 min of circulatory arrest (CA) at 18°C without cerebral perfusion (DHCA group, n = 6) or with SACP (SACP group, n = 6) or RCP (RCP group, n = 6). Microdialysis parameters (glucose, lactate, pyruvate, and glutamate) were measured every 30 min in cortex and striatum. After 3 h of reperfusion, brain tissue was harvested for Western blot measurement of α‐spectrin. After 40 min of CA, the DHCA group showed marked elevations of lactate and glycerol and a reduction in glucose in the microdialysis perfusate (all P < 0.05). The changes in glucose, lactate, and glycerol in the perfusate and α‐spectrin expression in brain tissue were similar between cortex and striatum in the SACP group (all P > 0.05). In the RCP group, the cortex exhibited lower glucose, higher lactate, and higher glycerol in the perfusate and higher α‐spectrin expression in brain tissue compared with the striatum (all P < 0.05). Glutamate showed no difference between cortex and striatum in all groups (all P > 0.05). In summary, SACP provided uniform and continuous cerebral perfusion to most anatomical sites in the brain, whereas RCP resulted in less sufficient perfusion to the cortex but better perfusion to the striatum.     

深低温期间高氧血气管理对停循环兔脑组织的保护作用

目的通过研究深低温期间高氧血气管理对深低温停循环(DHCA)兔血气、生化指标、脑组织中超氧化物歧化酶(SOD)活性、丙二醛(MDA)含量、脑组织含水量的影响,探讨高氧管理的脑保护作用。方法建立兔DHCA+选择性脑灌注(ASCP)动物模型,将24只11～13周龄雄性新西兰兔(体重2.7～3.4 kg)用随机数字表法分为3组:假手术组(Sham组),ASCP组(S组),ASCP+高氧管理组(SH组),每组8只。术中检测动脉血氧分压(PaO2)、动脉血氧饱和度(SaO2)、颈静脉球血氧分压(PjvO2)、颈静脉球血氧饱和度(SjvO2)和血乳酸(Lac)含量,术后检测脑组织SOD活性、MDA含量和脑组织含水量。结果停循环前、复灌前和复灌5 min SH组PaO2、PjvO2和SjvO2均高于S组和Sham组(P0.05)。SH组脑组织SOD活性与S组[(213.53±33.52)U/mg.prot vs.(193.02±27.67)U/mg.prot]和Sham组[(213.53±33.52)U/mg.prot vs.(244.38±35.02)U/mg.prot]比较差异无统计学意义(P0.05),但S组SOD活性低于Sham组(P0.05)。SH组脑组织MDA含量低于S组[(1.42±0.30)nmol/mg.prot vs.(2.37±0.55)nmol/mg.prot,P0.05]。结论深低温期间的高氧血气管理在DHCA+ASCP中能提供更好的氧供,有效地提高兔PjvO2和SjvO2,维持脑组织SOD活性,降低MDA含量,具有脑保护作用。     

Deep Hypothermia and Circulatory Arrest in the Surgical Management of Renal Cell Carcinoma with Vena Caval Involvement

Six patients operated on for renal cell carcinoma with vena caval involvement were prospectively studied. The mean age of the four men and two women was 58 (range 51–77) years. In four of them the tumour was excised during cardiopulmonary bypass and deep hypothermic circulatory arrest. The operation was radical in three of these patients and palliative in one. There were no major complications or deaths during hospitalisation averaging 9 (7-17) days. The mean follow-up was 9 (4-14) months, during which two patients had died of metastatic disease. The surgical approach with cardiopulmonary bypass and deep hypothermic circulatory arrest is well tolerated and can be used to facilitate complete tumour thrombectomy, with low operative risk. Need for caval tumour thrombectomy was found in 5% of all patients with renal cell carcinoma during the study period.     

Successful Resection of Descending Thoracic Aortic Aneurysm Using Hypothermic Total Body Retrograde Perfusion Without Aortic Clamp

A descending thoracic aortic aneurysm was safely resected via a median sternotomy, using total body retrograde perfusion without an aortic clamp. This new technique is an excellent adjunct in surgery for aneurysm of the proximal descending thoracic aorta.     

Cerebral Consequences of Hypothermic Circulatory Arrest in Adults

Despite widespread use of hypothermic circulatory arrest (HCA) in aneurysm surgery and for repair of congenital heart defects, there is continued concern about possible adverse cerebral sequelae. The search for ways to improve implementation of HCA has inspired retrospective clinical studies to try to identify risk factors for cerebral injury, and clinical and laboratory investigations to explore the physiology of HCA. At present, risk factors associated with less favorable cerebral outcome after HCA include: prolonged duration of HCA (usually greater than 60 min); advanced patient age; rapid cooling (less than 20 min); hyperglycemia either before HCA or during reperfusion; preoperative cyanosis or lack of adequate hemodilution; evidence of increased oxygen extraction before HCA or during reperfusion; and delayed reappearance of electroencephalogram (EEG) or marked EEG abnormality. Strategies advocated to increase safety of HCA include: pretreatment with barbiturates and steroids; use of alpha-stat pH regulation during cooling and rewarming; intraoperative monitoring of EEG; slow and adequate cooling, including packing of the head in ice; monitoring of jugular venous oxygen content; hemodilution; and avoidance of hyperglycemia. Current investigation focuses on delineating the relationship of cerebral blood flow (CBF) to cerebral oxygen consumption and glucose metabolism during cooling, HCA, rewarming, and later recovery, and identifying changes in acute intraoperative parameters, including the presence of intracerebral enzymes in cerebral spinal fluid, with cerebral outcome as assessed by neurological evaluation, quantitative EEG, and postmortem histology. Clinically, intraoperative monitoring of EEG and measurement of CBF by tracer washout or Doppler flows are contributing to better understanding of the physiology of HCA, and in the laboratory, nuclear magnetic resonance (NMR) spectroscopy has provided valuable insights into the kinetics of intracerebral energy metabolism. Promising strategies for the future include investigation of other pharmacological agents to increase cerebral protection, and use of "cerebroplegia" or intermittent perfusion between intervals of HCA to improve cerebral tolerance for longer durations of HCA.     

多形核粒细胞渗透和早期NF-kB活性与深低温停循环肺损伤的评估

目的研究深低温停循环（deep hypothermia and circulatory arrest，DHCA）不同时段肺组织内核转录因子kappaB（nuclearfactor—kappaB，NF-kB）、炎症因子和多形核粒细胞（polymorphonuclear cells，PMNs）的变化，推测PMNs渗透和早期NF-kB活性在DHCA肺损伤早期的作用，探讨其可能的机制，为肺保护策略提供实验依据。方法将12只幼猪随机分为两组，每组6只，常温平行循环组（对照组）和DHCA缺血-再灌注组（实验组），分别在不同时间点检测NF-kB和炎症因子的变化。结果两组在平行循环前肺组织标本中NF-kB均为阴性，胞核未见棕染，组间比较差异无统计学意义（P〉O．05）。实验组在缺血-再灌注0．5h时肺组织细胞核内NF-kB的表达达到高峰，且棕染的细胞核以PMNs为主；而对照组平行循环后各时间点比较差异无统计学意义，肺组织标本仍为弱阳性。实验组肿瘤坏死因子-α（TNF-α）在缺血-再灌注1h时较再灌注前含量有显著性变化（P〈0．05），白细胞介素-8（IL-8）、白细胞介素-6（IL-6）含量则在缺血-再灌注1．5h时较再灌注前有显著的变化（P〈0．05）；对照组平行循环后各时点与平行循环前比较差异有统计学意义（P〈0．05），但平行循环后各时间点比较差异无统计学意义（P〉0．05）。结论DHCA的早期激活NF-KB可能在DHCA肺损伤中起着重要的作用。