Staged repair significantly reduces paraplegia rate after extensive thoracoabdominal aortic aneurysm repair
Staged repair significantly reduces paraplegia rate after extensive thoracoabdominal aortic aneurysm repair
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DOI：
10.1016/j.jtcvs.2010.02.037
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发表时间：
2010-06-01
影响因子：
6
通讯作者：
Griepp, Randall B.
中科院分区：
文献类型：
--
作者：
Etz, Christian D.;Zoli, Stefano;Griepp, Randall B.
目的：截瘫仍然是广泛胸腹主动脉瘤修复术后的一种破坏性的，并且仍然太频繁的并发症。策略，以防止缺血性脊髓损伤后，广泛的节段性动脉栓塞或闭塞，必要的血管内repairs-are still evolving.Methods：90例接受广泛节段性动脉牺牲（中位数，13;范围，9-15）在开放手术修复从1994年6月至2007年12月进行了回顾性分析。55名患者（平均年龄65 ± 12岁; 49%为男性），大多数患有广泛的Crawford II型胸腹主动脉瘤，接受了单次手术（单期组）。35例患者（平均年龄62 ± 14岁; 57%为男性）接受了2次手术（2期组），通常在Crawford I型降段胸主动脉瘤术后接受Crawford III型或IV型修复术。2期手术之间的中位间隔为5年（3个月至17年）。两组之间在年龄、性别、动脉瘤原因、高血压、慢性阻塞性肺病、急症、既往脑血管意外、手术年份或脑脊液引流方面没有显着差异。在单阶段手术中，29%的患者使用低温停循环，40%的患者使用左侧心脏转流，27%的患者使用部分心肺转流。所有患者均监测了体感诱发电位，39%的患者监测了运动诱发电位。结果：总的住院死亡率为11.1%。两组之间的死亡率、卒中、术后出血、感染、肾衰竭或肺功能不全无显著差异。然而，单期组中15%的患者有永久性脊髓损伤，而二期组中没有（P = 0.02）。2期组截瘫和下肢轻瘫的发生率显著较低，尽管该组中牺牲的节段动脉数量显著较高：中位数为14（11-15）对12（9-15）（P < .0001）。结论：广泛胸腹主动脉瘤修复的分期方法可降低脊髓损伤的发生率。这在设计涉及混合或完全血管内手术的策略时特别重要。（《胸血管外科杂志》2010;139：1464-72）
Objective: Paraplegia remains a devastating, and still too frequent, complication after repair of extensive thoracoabdominal aortic aneurysms. Strategies to prevent ischemic spinal cord damage after extensive segmental artery sacrifice-or occlusion, essential for endovascular repair-are still evolving.Methods: Ninety patients who underwent extensive segmental artery sacrifice (median, 13; range, 9-15) during open surgical repair from June 1994 to December 2007 were reviewed retrospectively. Fifty-five patients (mean age, 65 +/- 12 years; 49% were male), most with extensive Crawford type II thoracoabdominal aortic aneurysms, had a single procedure (single-stage group). Thirty-five patients (mean age, 62 +/- 14 years; 57% were male) had 2 procedures (2-stage group), usually Crawford type III or IV repair after operation for Crawford type I descending thoracic aneurysm. The median interval between the 2-stage procedures was 5 years (3 months to 17 years). There were no significant differences between the groups with regard to age, gender, cause of the aneurysm, hypertension, chronic obstructive pulmonary disease, urgency, previous cerebrovascular accidents, year of procedure, or cerebrospinal fluid drainage. In single-stage procedures, hypothermic circulatory arrest was used in 29% of patients, left-sided heart bypass was used in 40% of patients, and partial cardiopulmonary bypass was used in 27% of patients. Somatosensory-evoked potentials were monitored in all patients, and motor-evoked potentials were monitored in 39% of patients. Cerebrospinal fluid was drained in 84% of patients.Results: Overall hospital mortality was 11.1%. There were no significant differences in mortality, stroke, postoperative bleeding, infection, renal failure, or pulmonary insufficiency between the groups. However, 15% of patients in the single-stage group had permanent spinal cord injury versus none in the 2-stage group (P = .02). The significantly lower rate of paraplegia and paraparesis in the 2-stage group occurred despite a significantly higher number of segmental arteries sacrificed in this group: a median of 14 (11-15) versus 12 (9-15) (P < .0001).Conclusion: A staged approach to extensive thoracoabdominal aortic aneurysm repair may reduce the incidence of spinal cord injury. This is of particular importance in designing strategies involving hybrid or entirely endovascular procedures. (J Thorac Cardiovasc Surg 2010;139:1464-72)