Strategies to manage paraplegia risk after endovascular stent repair of descending thoracic aortic aneurysms
Strategies to manage paraplegia risk after endovascular stent repair of descending thoracic aortic aneurysms
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DOI：
10.1016/j.athoracsur.2005.04.027
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发表时间：
2005-10-01
影响因子：
4.6
通讯作者：
Bavaria, JE
中科院分区：
文献类型：
--
作者：
Cheung, AT;Pochettino, A;Bavaria, JE
背景截瘫是胸降主动脉瘤腔内支架修复术后公认的并发症。采用神经功能评估、体感诱发电位监测、动脉压升高和脑脊液引流的管理算法逐渐降低了术后截瘫的风险。对1999年至2004年胸主动脉瘤支架试验中的患者进行截瘫并发症分析。在麻醉后和重症监护室评估下肢力量。对下肢体感诱发电位或下肢力量丧失的患者进行紧急治疗，以维持平均动脉压90 mmHg或更高，脑脊液压10 mmHg或更低。75例患者（男性= 49，女性= 26，年龄= 75 +/- 7.4岁）采用血管内支架植入术修复了胸降主动脉瘤。在动脉瘤范围明显或既往腹主动脉瘤修复术（n = 17）的患者中，选择性地进行了腰椎脑脊液引流（n = 23）和体感诱发电位监测（n = 15）。5名患者（6.6%）发生脊髓缺血; 2名患者在支架置入后出现下肢体感诱发电位丧失，4名患者发生迟发性截瘫。两个完全恢复的反应动脉压升高单独。2例完全恢复，1例在动脉压升高和脑脊液引流后几乎完全恢复。脊髓缺血与腹膜后出血（n = 1）、既往腹主动脉瘤修复术（n = 2）、髂动脉损伤（n = 1）和动脉粥样硬化栓塞（n = 1）相关。早期发现和干预以增加脊髓灌注压可有效降低胸降主动脉瘤腔内支架修复术后脊髓缺血的损伤程度或预防永久性截瘫。常规体感诱发电位监测、系列神经功能评估、动脉压升高和脑脊液引流可能有益于有截瘫风险的患者。
Background. Paraplegia is a recognized complication after endovascular stent repair of descending thoracic aortic aneurysms. A management algorithm employing neurologic assessment, somatosensory evoked potential monitoring, arterial pressure augmentation, and cerebrospinal fluid drainage evolved to decrease the risk of postoperative paraplegia.Methods. Patients in thoracic aortic aneurysm stent trials from 1999 to 2004 were analyzed for paraplegic complications. Lower extremity strength was assessed after anesthesia and in the intensive care unit. A loss of lower extremity somatosensory evoked potential or lower extremity strength was treated emergently to maintain a mean arterial pressure 90 mmHg or greater and a cerebrospinal fluid pressure 10 mm Hg or less.Results. Seventy-five patients (male = 49, female = 26f age = 75 +/- 7.4 years) had descending thoracic aortic aneurysms repaired with endovascular stenting. Lumbar cerebrospinal fluid drainage (n = 23) and somatosensory evoked potential monitoring (n = 15) were performed selectively in patients with significant aneurysm extent or with prior abdominal aortic aneurysm repair (n = 17). Spinal cord ischemia occurred in 5 patients (6.6%); two had lower extremity somatosensory evoked potential loss after stent deployment and 4 developed delayed-onset paraplegia. Two had full recovery in response to arterial pressure augmentation alone. Two had full recovery and one had near-complete recovery in response to arterial pressure augmentation and cerebrospinal fluid drainage. Spinal cord ischemia was associated with retroperitoneal bleed (n = 1), prior abdominal aortic aneurysm repair (n = 2), iliac artery injury (n = 1), and atheroembolism (n = 1).Conclusions. Early detection and intervention to augment spinal cord perfusion pressure was effective for decreasing the magnitude of injury or preventing permanent paraplegia from spinal cord ischemia after endovascular stent repair of descending thoracic aortic aneurysm. Routine somatosensory evoked potential monitoring, serial neurologic assessment, arterial pressure augmentation, and cerebrospinal fluid drainage may benefit patients at risk for paraplegia.