降主动脉手术中的脊柱保护(Spinalcord-protection-in-surgery-of课件

按一下以編輯母片,第二層,第三層,第四層,第五層,,,*,按一下以編輯母片標題樣式,Spinal cord protection in surgery of descending thoracic aorta,,,Spinal cord protection in surg,1,Case,55,y/o male, HTN for 20+ years with regular medical control for 5 years,Chronic dissecting aortic aneurysm type III noted for 5 years,Left chest pain for 1 week,Denied other systemic diseases,Laboratory data: within normal range,,,Case 55 y/o male, HTN for 20+,2,,,,降主动脉手术中的脊柱保护(Spinalcord-protection-in-surgery-of课件,3,,,,降主动脉手术中的脊柱保护(Spinalcord-protection-in-surgery-of课件,4,,,,降主动脉手术中的脊柱保护(Spinalcord-protection-in-surgery-of课件,5,,,,降主动脉手术中的脊柱保护(Spinalcord-protection-in-surgery-of课件,6,Case,Normal screening spirometry,2-D echocardiography: dilated aortic root(diameter 63mm) & LA, mild MR, good LV contractility,Planning,: 1.Left post-lat thoracotomy 2. Femoral-femoral CPB 3. Hypothermia with circulation arrest and retrograde cerebral perfusion via high CVP 18~20mmHg 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 anastomosis,,,Case Normal screening spiromet,7,,,,降主动脉手术中的脊柱保护(Spinalcord-protection-in-surgery-of课件,8,,,,降主动脉手术中的脊柱保护(Spinalcord-protection-in-surgery-of课件,9,,,降主动脉手术中的脊柱保护(Spinalcord-protection-in-surgery-of课件,10,Case,Cooling to 16℃,Partial bypass: 3hr25min,Total bypass: 2hr30min,Aortic cross clamp: ?min,Circulatory arrest: 20min,Double lumen, single-lumen ET tube ICU weaning and extubation on post-op day 3 without major complications,,,CaseCooling to 16℃,11,Consequences of aortic cross-clamping,Spinal cord ischemia,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 cord,Spinal cord perfusion from: vertebral, deep cervical, intercostal, and lumbar a.radicular a.,The largest radicular a. (artery of Adamkiewicz): origin from T9~12 intercostal a. supply the majority of blood to the lower 2/3 of the spinal cord,,,Consequences of aortic cross-c,12,Spinal cord ischemia,Paraplegia and paraparesis: major cause of morbidity and mortality after extensive TAAA repair,Incidence: 2~40%, 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 hyperglycemia,,,Spinal cord ischemiaParaplegia,13,Spinal cord perfusion pressure,CSF pressure increases during aortic clamping, “spinal cord compartment syndrome”,Reduction of CSF pressure improves SCPP,Lumbar drains,Combined with distal aortic perfusion,,,Spinal cord perfusion pressure,14,Result,CSF pressure was maintained at 10mmHg or less,148 nonemergent patients who received simple cross-clamping,105 with combined adjuncts, 43 with or without the addition of a single adjunct,0.9% vs 7% (,p,<0.04),,,Result CSF pressure was mainta,15,Result,2.6% vs 13.0%,Reduced immediate deficits, particularly paraplegia,Infrequent delayed neurologic deficits in both groups,The longer the ischemic time were, the greater the benefit afforded with CSFD,,,Result 2.6% vs 13.0%,16,Conclusions,Significantly reduced the rate of neurologic deficit during nonemergent repair of descending thoracic aortic aneurysms,The recently reports had convinced most surgeons of the benefit of CSF drainage in descending thoracic aortic aneurysm,,,ConclusionsSignificantly reduc,17,Other adjuncts,Selective cooling spinal cord via lavage of the epidural space: regional hypothemic (26 ℃) protection of at-risk thoracolumbar cord,Corticosteroid, thiopental, NMDA antagonist, papaverine,,,Other adjunctsSelective coolin,18,Complications of lumbar drainage after TAAA repair,Postoperative lower extremity neurologic deficit: result of thromboembolic or delayed ischemic complication or resulting from lumbar drainage,Intradural hematoma: 3.2% in this study,CT, MRI,,,Complications of lumbar draina,19,Hypothermic cardiopulmonary bypass and circulatory arrest,Methylprednisone and thiopental are given during the period of cooling to 15℃,Circulatory arrest intervals: mean, 38min,Postoperative neurologic injury: 2.7%,Conclusion: hypothermic circulatory arrest offers certain advantages over other techniques and using of other adjunctive measures is not necessary,,,Hypothermic cardiopulmonary by,20,References,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,.,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 interval.,Annals of surgery.236(4):471-9,2002 Oct.,Complications of lumbar drainage after thoracoabdominal aortic aneurysm repair.,Journal of vascular surgery.34(4):623-7,2001 Oct.,,,References Hypothermic cardiop,21,Thanks for your attention！,,,Thanks for your attention！,22,。