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

. Spinal cord protection in surgery of descending thoracic aorta * . 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 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 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 * . 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 * . 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 perfusion pressure CSF pressure increases during aortic clamping? “spinal cord compartmen