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Coronary Artery Bypass Surgery for Patients with Severe Cerebrovascular Atherosclerosis: Importance of Preoperative Assessment and Perioperative Management

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Surgical Science 2013年第12期4卷 535-542页

作者： Hajime Imura dai nishina Yuuji Maruyama Makoto Shirakawa Motoko Tanoue daigo Suzuki Takahide Yoshio Masami Ochi Department of Cardiovascular Surgery Nippon Medical School Musashikosugi Hospital Kawasaki Japan Nippon Medical School Hospital Kawasaki Japan

Objective: Cerebrovascular atherosclerosis is known to play a crucial role in perioperative stroke in coronary arterial bypass grafting (CABG). This study is to identify the degree of severity of cerebrovascular lesions for which patients can still undergo CABG with an acceptably low risk in current techniques. Methods: Cerebrovascular atherosclerosis was evaluated and graded for 200 consecutive patients prior to CABG. Grading was initially based on the level of stenosis in carotid, vertebral, and cerebral arteries: grade-0: normal or mild stenosis in cerebral arteries or stenosis <50% in other arteries;grade-1: moderate in cerebral arteries or 50% - 69% in others;grade-2: severe in cerebral arteries or 70% - 89% in others;grade-3: occlusion in cerebral arteries or 90% - 100% in others. The grading was finally adjusted to a risk of regional ischemia by considering symptoms, number of lesions, and brain perfusion in scintigram. Therefore, some patients were up-graded. Off-pump CABG was scheduled for all patients. The lowest systolic arterial pressure during surgery was differently controlled in each grade: grade-0: ≥70 mmHg;grade-1: ≥80 mmHg;grade-2: ≥80 mmHg with intra-aortic balloon pump (IABP);grade-3: ≥90 mmHg with IABP;grade-4: ≥90 mmHg with IABP and administration of thyamiral. Results: Grade-1 and -2 included 38 and 29 patients respectively. Grade-3 initially included 36 patients and 14 of them were up-graded to grade-4 (extremely high risk patients). Stroke was seen in one patient (0.5%), for whom mild speaking disturbance occurred on the fifth day from CABG. Conclusion: Patients with severe cerebrovascular atherosclerosis can undergo CABG with a low risk of stroke. Intraoperative management of blood pressure may be critical for stroke prevention in CABG.

关键词： Coronary Arterial Bypass Grafting Stroke Cerebrovascular Disease

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Multiband fitting to three long GRBs with Fermi/LAT data:structured ejecta sweeping up a density-jump medium

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Research in Astronomy and Astrophysics 2011年第9期11卷 1046-1066页

作者： Si-Yi Feng Zi-Gao dai Department of Astronomy Nanjing University Nanjing 210093 China Key Laboratory of Modern Astronomy and Astrophysics （Nanjing University） Ministry of Education Nanjing 210093 China

We present broadband （radio, optical, X-ray and GeV） fits to the afterglow light curves and spectra of three long-duration gamma-ray bursts （GRBs 080916C, 090902B, and 090926A） detected by the Gamma-Ray Burst Monitor and Large Area Telescope （LAT） instruments on the Fermi satellite. Using the observed broadband data, we study the origin of the high energy emission, and suggest that the early-time GeV emission and the late-time radio, optical, and X-ray afterglows can be under- stood as being due to synchrotron emission from an external forward shock caused by structured ejecta propagating in a wind bubble jumping to a homogeneous density medium. If the ceasing time for a majority of the energy injection is assumed to be close to the deceleration time of the forward shock, the structured ejecta with con- tinuous energy injection towards the forward shock can well explain the early rising feature of the GeV mission from these bursts, and the density-jump medium can ac- count for some particular plateaus or flares in the late afterglows. From our fits, we find that, on one hand, the external shock origin of the GeV photons will make the optical depth not have a significant contribution to the early LAT rising part, which will loosen the strong constraint of lower limits of the Lorentz factor. On the other hand, these Fermi-LAT events preferentially occur in a low-density circumburst environment, in which case the Klein-nishina cutoff will significantly suppress the Self- Synchrotron Compton radiation. Such an environment might result from superbubbles or low-metallicity progenitor stars （which have a low mass-loss rate at late times of stellar evolution） of type Ib/c supernovae.

关键词： gamma-rays: bursts -- gamma-rays: theory

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