Selective Unilateral And Bilateral Cerebral Perfusion Applied To Acute Stanford Type A Dissection And Correcting The Clinical Effect Of Contrast Research

Background and ObjectiveAortic dissection is a lethal disease of aorta. According to many studies, the incidence of acute aortic dissection is about 2.95/100000, which is 0.2/100000~0,8/100000 per year in USA, and the average annual incidence of developed countries is 5/1 million, ~10/1 million.Epidemiological studies of aortic dissection could underestimate the true incidence,because data are derived from retrospective registries in specialised centres, and might not include deaths before hospital admission.A group of autopsy report shows, only about 15% of the patients had been diagnosed.Recent years,the incidence of aortic dissection is arising along with the improved diagnosis level, the aging of the population, the morbidity rate of hypertension increased, people lifestyle changed, and expected life extended.An analysis from the International Registry of Acute Aortic Dissections(IRAD) reported a mean age at presentation of 63 years,which is younger in China.The phenomenon is due to hypertension and Marfan syndrome,which are the two main factors of aortic dissection, and the incidence of the two diseases in China ranked first in the world. Anatomically, acute aortic dissection can be classified according to the De Bakey and Stanford systems.The Stanford type A aortic dissection is more common, accounting for about 60%~70% of aortic diseases,Acute aortic dissection is so dangerous,, that comprehensive treatment including emergency operation should be taken once diagnosed. During the first 48 h,the untreated mortality of type A dissection has been reported to be approximately 1% to 2%/h after symptom onset.Even though the diagnosis and treatment is accurate and reasonable in the earlytime, there is still a high mortality rate due to a variety of potential complications.The operation technique of aortic dissection is complicated, and the perioperative mortality is still high, especially for Stanford A type aortic dissection, of which mortality was 20%~30% worldwide.Therefore, every effort should be made to reduce the operation complications and mortality, including artificial blood vessel graft,protection technology of brain and spinal cord, the technique of cardiopulmonary bypass, the technique of retention of aortic valve etc, however,the cannulation strategy plays an important role.The operation of aortic arch disease, especially acute Stanford type A aortic dissection, couldn’t be carried out smoothly without DHCA(deep hypothermic circulatory arrest, DHCA) technology,because it can provide good vision intra-operation, and supply hypothermic protection for viscera including brain.However, circulatory arrest without blood flow will cause damage to the viscera, especially on the hypoxia sensitive organs and tissues such as the brain and heart.DHCA alone can provide a safe window of 25~30 min, which is not enough for Stanford type A aortic dissection.It will cause neurological dysfunction if beyond the period.At present, the main causes of post-operation deaths of Stanford type A aortic dissection are heart failure and neurological dysfunction.Many studies declared that the outcome of Stanford type A aortic dissection with cerebral perfusion is better than that without cerebral perfusion.With antegrade cerebral perfusion(antegrade cerebral perfusion, ACP) and retrograde cerebral perfusion(retrograde cerebral perfusion, RCP) are successfully used, a certain extension of the safe time of circulatory arrest achieved.The antegrade cerebral perfusion is dominant except for a few cases whom suffer severe carotid artery stenosis and so on. Antegrade cerebral perfusion has two ways:Unilateral cerebral perfusion and bilateral cerebral perfusion.But so far, a dispute.about unilateral cerebral perfusion and bilateral cerebral perfusion is still fierce.In this study, we will provide a basis for the selection of the appropriate method of operation of cerebral perfusion,with a comparative analysis of the clinical outcomes of selective unilateral and bilateral cerebral perfusion in acute Stanford type A dissection surgery.MethodSelect 60 patients with Stanford type A aortic dissection,who underwent surgery in the first affiliated hospital of zhengzhou university from January 1, 2012 to August 30, 2014。All of them were diagnosed with 256 row helical CT, underwent emergency operation and anterograde cerebral perfusion, 32 of whom underwent selective unilateral cerebral perfusion and 28 underwent bilateral cerebral perfusion. Observe the postoperative clinical outcome and postoperative recovery, and compare the relevant operation parameters.The relevant operation parameters including: CPB time, DHCA time, awake time, mechanical ventilation time, in hospital time andICU time. The diversity of the two groups of patients with age, sex, history of hypertension and body weight were no statistical significant.ResultsThe DHCA time and CPB time in bilateral cerebral perfusion group are less than that in unilateral cerebral perfusion group, the diversity was statistically significant(P < 0.05), the postoperative recovery time, ICU time and hospitalization time of bilateral cerebral perfusion group were less than their reference, the diversity was statistically significant(P < 0.05).ConclusionsThe technique of DHCA combined with bilateral cerebral perfusion is simple.Compared with unilateral cerebral perfusion,it can provide longer safe time of intraoperative cerebral protection and has a lower incidence of neurological complications. We can choose the bilateral cerebral perfusion when the brain Willis ring dysplasia, axillary artery dissection and so on.