降主動脈手術中的脊柱保護Spinal-cord-protection-in-surgery課件

SpinalcordprotectioninsurgeryofdescendingthoracicaortaSpinalcordprotectioninsurg1Case55y/omale,HTNfor20+yearswithregularmedicalcontrolfor5yearsChronicdissectingaorticaneurysmtypeIIInotedfor5yearsLeftchestpainfor1weekDeniedothersystemicdiseasesLaboratorydata:withinnormalrangeCase55y/omale,HTNfor20+2降主動脈手術中的脊柱保護(Spinal-cord-protection-in-surgery課件3降主動脈手術中的脊柱保護(Spinal-cord-protection-in-surgery課件4降主動脈手術中的脊柱保護(Spinal-cord-protection-in-surgery課件5降主動脈手術中的脊柱保護(Spinal-cord-protection-in-surgery課件6CaseNormalscreeningspirometry2-Dechocardiography:dilatedaorticroot(diameter63mm)&LA,mildMR,goodLVcontractilityPlanning:1.Leftpost-latthoracotomy2.Femoral-femoralCPB3.HypothermiawithcirculationarrestandretrogradecerebralperfusionviahighCVP18~20mmHgbyfemoralarteryperfusionandpartialclampofvenousdraintube4.Restoreproximalaortaperfusionafterproximalanastomosisthroughgraftcannulation5.OpendistalanastomosisCaseNormalscreeningspiromet7降主動脈手術中的脊柱保護(Spinal-cord-protection-in-surgery課件8降主動脈手術中的脊柱保護(Spinal-cord-protection-in-surgery課件9降主動脈手術中的脊柱保護(Spinal-cord-protection-in-surgery課件10CaseCoolingto16℃Partialbypass:3hr25minTotalbypass:2hr30minAorticcrossclamp:?minCirculatoryarrest:20minDoublelumensingle-lumenETtubeICUweaningandextubationonpost-opday3withoutmajorcomplicationsCaseCoolingto16℃11Consequencesofaorticcross-clampingSpinalcordischemiaVascularanatomy:singleant.spinala.fromvertebrala.supplyant.2/3ofspinalcord;pairofpost.spinala.frompost.cerebellara.supplyremainderofspinalcordSpinalcordperfusionfrom:vertebral,deepcervical,intercostal,andlumbara.radiculara.Thelargestradiculara.(arteryofAdamkiewicz):originfromT9~12intercostala.supplythemajorityofbloodtothelower2/3ofthespinalcordConsequencesofaorticcross-c12SpinalcordischemiaParaplegiaandparaparesis:majorcauseofmorbidityandmortalityafterextensiveTAAArepairIncidence:2~40%,dependingonthesiteandthedegreeofaorticlesion,with/withoutdissection(2-fold),cross-clampduration(lessthan30min),ligationofthearteryofAdamkiewicz,elevationinCSFpressure,reperfusioninjury,perioperativehyperglycemiaSpinalcordischemiaParaplegia13SpinalcordperfusionpressureCSFpressureincreasesduringaorticclamping“spinalcordcompartmentsyndrome”ReductionofCSFpressureimprovesSCPPLumbardrainsCombinedwithdistalaorticperfusionSpinalcordperfusionpressure14ResultCSFpressurewasmaintainedat10mmHgorless148nonemergentpatientswhoreceivedsimplecross-clamping105withcombinedadjuncts,43withorwithouttheadditionofasingleadjunct0.9%vs7%(p<0.04)ResultCSFpressurewasmainta15Result2.6%vs13.0%Reducedimmediatedeficits,particularlyparaplegiaInfrequentdelayedneurologicdeficitsinbothgroupsThelongertheischemictimewere,thegreaterthebenefitaffordedwithCSFDResult2.6%vs13.0%16ConclusionsSignificantlyreducedtherateofneurologicdeficitduringnonemergentrepairofdescendingthoracicaorticaneurysmsTherecentlyreportshadconvincedmostsurgeonsofthebenefitofCSFdrainageindescendingthoracicaorticaneurysmConclusionsSignificantlyreduc17OtheradjunctsSelectivecoolingspinalcordvialavageoftheepiduralspace:regionalhypothemic(26℃)protectionofat-riskthoracolumbarcordCorticosteroid,thiopental,NMDAantagonist,papaverineOtheradjunctsSelectivecoolin18ComplicationsoflumbardrainageafterTAAArepairPostoperativelowerextremityneurologicdeficit:resultofthromboembolicordelayedischemiccomplicationorresultingfromlumbardrainageIntraduralhematoma:3.2%inthisstudyCT,MRIComplicationsoflumbardraina19HypothermiccardiopulmonarybypassandcirculatoryarrestMethylprednisoneandthiopentalaregivenduringtheperiodofcoolingto15℃Circulatoryarrestintervals:mean,38minPostoperativeneurologicinjury:2.7%Conclusion:hypothermiccirculatoryarrestofferscertainadvantagesoverothertechniquesandusingofotheradjunctivemeasuresisnotnecessaryHypothermiccardiopulmonaryby20ReferencesHypothermiccardiopulmonarybypassandcirculatoryarrestforoperationsonthedescendingthoracicandthoraco-abdominalaorta.Annalsofthoracicsurgery.74(5):S1885-7,2002Nov.Cerebrospinalfluiddrainagereducesparaplegiaafterthoracoabdominalaorticaneurysmrepair:resultsofarandomizedclinicaltrial.Journalofvascularsurgery.35(4):631-9,2002Apr.Thoracoabdominalaneurysmrepair:resultswith337operationsperformedovera15-yearinterval.Annalsofsurgery.236(4):471-9,2002Oct.Complicationsoflumbardrainageafterthoracoabdominalaorticaneurysmrepair.Journalofvascularsurgery.34(4):623-7,2001Oct.ReferencesHypothermiccardiop21Thanksforyourattention！Thanksforyourattention！22SpinalcordprotectioninsurgeryofdescendingthoracicaortaSpinalcordprotectioninsurg23Case55y/omale,HTNfor20+yearswithregularmedicalcontrolfor5yearsChronicdissectingaorticaneurysmtypeIIInotedfor5yearsLeftchestpainfor1weekDeniedothersystemicdiseasesLaboratorydata:withinnormalrangeCase55y/omale,HTNfor20+24降主動脈手術中的脊柱保護(Spinal-cord-protection-in-surgery課件25降主動脈手術中的脊柱保護(Spinal-cord-protection-in-surgery課件26降主動脈手術中的脊柱保護(Spinal-cord-protection-in-surgery課件27降主動脈手術中的脊柱保護(Spinal-cord-protection-in-surgery課件28CaseNormalscreeningspirometry2-Dechocardiography:dilatedaorticroot(diameter63mm)&LA,mildMR,goodLVcontractilityPlanning:1.Leftpost-latthoracotomy2.Femoral-femoralCPB3.HypothermiawithcirculationarrestandretrogradecerebralperfusionviahighCVP18~20mmHgbyfemoralarteryperfusionandpartialclampofvenousdraintube4.Restoreproximalaortaperfusionafterproximalanastomosisthroughgraftcannulation5.OpendistalanastomosisCaseNormalscreeningspiromet29降主動脈手術中的脊柱保護(Spinal-cord-protection-in-surgery課件30降主動脈手術中的脊柱保護(Spinal-cord-protection-in-surgery課件31降主動脈手術中的脊柱保護(Spinal-cord-protection-in-surgery課件32CaseCoolingto16℃Partialbypass:3hr25minTotalbypass:2hr30minAorticcrossclamp:?minCirculatoryarrest:20minDoublelumensingle-lumenETtubeICUweaningandextubationonpost-opday3withoutmajorcomplicationsCaseCoolingto16℃33Consequencesofaorticcross-clampingSpinalcordischemiaVascularanatomy:singleant.spinala.fromvertebrala.supplyant.2/3ofspinalcord;pairofpost.spinala.frompost.cerebellara.supplyremainderofspinalcordSpinalcordperfusionfrom:vertebral,deepcervical,intercostal,andlumbara.radiculara.Thelargestradiculara.(arteryofAdamkiewicz):originfromT9~12intercostala.supplythemajorityofbloodtothelower2/3ofthespinalcordConsequencesofaorticcross-c34SpinalcordischemiaParaplegiaandparaparesis:majorcauseofmorbidityandmortalityafterextensiveTAAArepairIncidence:2~40%,dependingonthesiteandthedegreeofaorticlesion,with/withoutdissection(2-fold),cross-clampduration(lessthan30min),ligationofthearteryofAdamkiewicz,elevationinCSFpressure,reperfusioninjury,perioperativehyperglycemiaSpinalcordischemiaParaplegia35SpinalcordperfusionpressureCSFpressureincreasesduringaorticclamping“spinalcordcompartmentsyndrome”ReductionofCSFpressureimprovesSCPPLumbardrainsCombinedwithdistalaorticperfusionSpinalcordperfusionpressure36ResultCSFpressurewasmaintainedat10mmHgorless148nonemergentpatientswhoreceivedsimplecross-clamping105withcombinedadjuncts,43withorwithouttheadditionofasingleadjunct0.9%vs7%(p<0.04)ResultCSFpressurewasmainta37Result2.6%vs13.0%Reducedimmediatedeficits,particularlyparaplegiaInfrequentdelayedneurologicdeficitsinbothgroupsThelongertheischemictimewere,thegreaterthebenefitaffordedwithCSFDResult2.6%vs13.0%38ConclusionsSignificantlyreducedtherateofneurologicdeficitduringnonemergentrepairofdescendingthoracicaorticaneurysmsTherecentlyreportshadconvincedmostsurgeonsofthebenefitofCSFdrainageindescendingthoracicaorticaneurysmConclusionsSignificantlyreduc39OtheradjunctsSelectivecoolingspinalcordvialavageoftheepiduralspace:regionalhypothemic(26℃)protectionofat-riskthoracolumbarcordCorticosteroid,thiopental,NMDAantagonist,papaverineOtheradjunctsSelectivecoolin40ComplicationsoflumbardrainageafterTAAArepairPostoperativelowerextremityneurologicdeficit:resultofthromboembolicordelayedischemiccomplicationorresultingfromlumbardrainageIntraduralhematoma:3.2%inthisstudyCT,MRIComplicationsoflumbardraina41HypothermiccardiopulmonarybypassandcirculatoryarrestMethylprednisoneandthiopentalaregivenduringtheperiodofcooling