降主动脉手术中的脊柱保护Spinalcordprotectioninsurgery课件

1、Spinal cord protection in surgery of descending thoracic aortaCase 55 y/o male, HTN for 20+ years with regular medical control for 5 yearsChronic dissecting aortic aneurysm type III noted for 5 yearsLeft chest pain for 1 weekDenied other systemic diseasesLaboratory data: within normal rangeCase Norm

2、al screening spirometry2-D echocardiography: dilated aortic root(diameter 63mm) & LA, mild MR, good LV contractilityPlanning: 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

3、and partial clamp of venous drain tube 4. Restore proximal aorta perfusion after proximal anastomosis through graft cannulation 5. Open distal anastomosisCaseCooling to 16 Partial bypass: 3hr25minTotal bypass: 2hr30minAortic cross clamp: ?minCirculatory arrest: 20minDouble lumen single-lumen ET tube

4、 ICU weaning and extubation on post-op day 3 without major complicationsConsequences of aortic cross-clampingSpinal cord ischemiaVascular 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 cordSpi

5、nal cord perfusion from: vertebral, deep cervical, intercostal, and lumbar a.radicular a. 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 ischemiaParaplegia and paraparesis: major cause of m

6、orbidity and mortality after extensive TAAA repairIncidence: 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 hype

7、rglycemiaSpinal cord perfusion pressureCSF pressure increases during aortic clamping “spinal cord compartment syndrome”Reduction of CSF pressure improves SCPPLumbar drainsCombined with distal aortic perfusionResult CSF pressure was maintained at 10mmHg or less148 nonemergent patients who received si

8、mple cross-clamping105 with combined adjuncts, 43 with or without the addition of a single adjunct0.9% vs 7% (p0.04)Result 2.6% vs 13.0%Reduced immediate deficits, particularly paraplegiaInfrequent delayed neurologic deficits in both groupsThe longer the ischemic time were, the greater the benefit a

9、fforded with CSFDConclusionsSignificantly reduced the rate of neurologic deficit during nonemergent repair of descending thoracic aortic aneurysmsThe recently reports had convinced most surgeons of the benefit of CSF drainage in descending thoracic aortic aneurysmOther adjunctsSelective cooling spin

10、al cord via lavage of the epidural space: regional hypothemic (26 ) protection of at-risk thoracolumbar cordCorticosteroid, thiopental, NMDA antagonist, papaverineComplications of lumbar drainage after TAAA repairPostoperative lower extremity neurologic deficit: result of thromboembolic or delayed i

11、schemic complication or resulting from lumbar drainageIntradural hematoma: 3.2% in this studyCT, MRIHypothermic cardiopulmonary bypass and circulatory arrestMethylprednisone and thiopental are given during the period of cooling to 15Circulatory arrest intervals: mean, 38minPostoperative neurologic i

12、njury: 2.7%Conclusion: hypothermic circulatory arrest offers certain advantages over other techniques and using of other adjunctive measures is not necessary References Hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoraco-abdominal aorta. An

13、nals of thoracic surgery.74(5):S1885-7,2002 Nov.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.Thoracoabdominal aneurysm repair: results with 337 operations performed over a 15-year