资源描述
Spinal cord protection in surgery of descending thoracic aortaCase w 55 y/o male,HTN for 20+years with regular medical control for 5 yearsw Chronic dissecting aortic aneurysm type III noted for 5 yearsw Left chest pain for 1 weekw Denied other systemic diseasesw Laboratory data:within normal rangeCase w Normal screening spirometryw 2-D echocardiography:dilated aortic root(diameter 63mm)&LA,mild MR,good LV contractilityw Planning:1.Left post-lat thoracotomy 2.Femoral-femoral CPB 3.Hypothermia with circulation arrest and retrograde cerebral perfusion via high CVP 1820mmHg by femoral artery perfusion and partial clamp of venous drain tube 4.Restore proximal aorta perfusion after proximal anastomosis through graft cannulation 5.Open distal anastomosisCasew Cooling to 16 w Partial bypass:3hr25minw Total bypass:2hr30minw Aortic cross clamp:?minw Circulatory arrest:20minw Double lumen single-lumen ET tube ICU weaning and extubation on post-op day 3 without major complicationsConsequences of aortic cross-clampingw Spinal cord ischemiaw Vascular anatomy:single ant.spinal a.from vertebral a.supply ant.2/3 of spinal cord;pair of post.spinal a.from post.cerebellar a.supply remainder of spinal cordw Spinal cord perfusion from:vertebral,deep cervical,intercostal,and lumbar a.radicular a.w The largest radicular a.(artery of Adamkiewicz):origin from T912 intercostal a.supply the majority of blood to the lower 2/3 of the spinal cordSpinal cord ischemiaw Paraplegia and paraparesis:major cause of morbidity and mortality after extensive TAAA repairw Incidence:240%,depending on the site and the degree of aortic lesion,with/without dissection(2-fold),cross-clamp duration(less than 30min),ligation of the artery of Adamkiewicz,elevation in CSF pressure,reperfusion injury,perioperative hyperglycemiaSpinal cord perfusion pressurew CSF pressure increases during aortic clamping“spinal cord compartment syndrome”w Reduction of CSF pressure improves SCPPw Lumbar drainsw Combined with distal aortic perfusionResult w CSF pressure was maintained at 10mmHg or lessw 148 nonemergent patients who received simple cross-clampingw 105 with combined adjuncts,43 with or without the addition of a single adjunctw 0.9%vs 7%(p0.04)Result w 2.6%vs 13.0%w Reduced immediate deficits,particularly paraplegiaw Infrequent delayed neurologic deficits in both groupsw The longer the ischemic time were,the greater the benefit afforded with CSFDConclusionsw Significantly reduced the rate of neurologic deficit during nonemergent repair of descending thoracic aortic aneurysmsw The recently reports had convinced most surgeons of the benefit of CSF drainage in descending thoracic aortic aneurysmOther adjunctsw Selective cooling spinal cord via lavage of the epidural space:regional hypothemic(26)protection of at-risk thoracolumbar cordw Corticosteroid,thiopental,NMDA antagonist,papaverineComplications of lumbar drainage after TAAA repairw Postoperative lower extremity neurologic deficit:result of thromboembolic or delayed ischemic complication or resulting from lumbar drainagew Intradural hematoma:3.2%in this studyw CT,MRIHypothermic cardiopulmonary bypass and circulatory arrestw Methylprednisone and thiopental are given during the period of cooling to 15w Circulatory arrest intervals:mean,38minw Postoperative neurologic injury:2.7%w Conclusion:hypothermic circulatory arrest offers certain advantages over other techniques and using of other adjunctive measures is not necessary References w Hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoraco-abdominal aorta.Annals of thoracic surgery.74(5):S1885-7,2002 Nov.w Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair:results of a randomized clinical trial.Journal of vascular surgery.35(4):631-9,2002 Apr.w Thoracoabdominal aneurysm repair:results with 337 operations performed over a 15-year interval.Annals of surgery.236(4):471-9,2002 Oct.w Complications of lumbar drainage after thoracoabdominal aortic aneurysm repair.Journal of vascular surgery.34(4):623-7,2001 Oct.Thanks for your attention！
展开阅读全文