Risk factors for spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms
Risk factors for spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms
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DOI：
10.1016/j.jvs.2015.01.044
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发表时间：
2015-06-01
影响因子：
4.3
通讯作者：
Austermann, Martin
中科院分区：
文献类型：
--
作者：
Bisdas, Theodosios;Panuccio, Giuseppe;Austermann, Martin
目的：开窗型和多分支覆膜支架的引入改变了胸腹主动脉瘤（TAAA）患者的治疗模式。然而，尽管微创手术的特点，脊髓缺血（SCI）仍然是一个毁灭性的并发症。本研究的目的是解决SCI率腔内TAAA修复术后，并分析潜在的危险因素，导致这种complication.Methods：一个连续的队列的患者与非破裂TAAA治疗的开窗和多分支endografting在2010年1月和2014年9月之间进行了分析。在手术前和出院时由独立的神经科医生进行常规神经系统检查。主要的结局指标是SCI（截瘫或轻瘫）的发作。次要结局是与脑脊液引流（CSFD）相关的神经系统并发症和30天死亡率。最后，多变量回归分析确定了SCI.Results的危险因素：一个连续的142例TAAA患者（克劳福德II型，n = 54 [38%]; III型，n = 76 [54%]; IV型，n = 12 [8%]）被纳入本研究。大多数患者（n = 129 [91%]）接受了动脉粥样硬化性动脉瘤治疗，而13例患者（9%）接受了夹层后动脉瘤治疗。平均最大主动脉直径为65 ± 13 mm。23例患者发生SCI（16%; 12例截瘫[8%]和11例轻瘫[8%]）。在这23名患者中，10名患者（43%）在术后立即出现神经功能缺损，11名患者（48%）在前24小时内出现，2名患者（9%）在24小时后出现。大多数患者的神经功能状态得到改善，只有3例患者（2%）在出院时出现不可逆性截瘫。有和无SCI患者的30天死亡率没有差异（无SCI，n = 3 [3%] vs SCI，n = 1 [4%]; P = 0.511）。64例患者（45%）在术前预防性使用CSFD，其中4例患者（6%）发生了CSFD相关并发症。未发现接受CSFD预防性放置的患者的临床获益（P = .498）。多变量分析显示，胸主动脉覆盖率是SCI的唯一显著风险因素（比值比，1.03; 95%置信区间，1.01-1.05; P = .001）。结论：TAAA腔内修复术后SCI率为16%，其中8%的患者发生截瘫。预防性使用CSFD不能降低SCI发生率，并且与6%的不良事件相关。胸主动脉覆盖率是SCI最有力的决定因素。
Objective: The introduction of fenestrated and multibranched endografting transformed the treatment paradigm of patients with thoracoabdominal aortic aneurysms (TAAAs). However, despite the minimally invasive character of the procedure, spinal cord ischemia (SCI) remains a devastating complication. The aim of this study was to address the SCI rates after endovascular TAAA repair and to analyze potential risk factors leading to this complication.Methods: A consecutive cohort of patients with nonruptured TAAAs treated by means of fenestrated and multibranched endografting between January 2010 and September 2014 was analyzed. Neurologic examination was routinely performed by an independent neurologist before operation and at discharge. The main outcome measure was the onset of SCI (paraplegia or paraparesis). Secondary outcomes were neurologic complications associated with cerebrospinal fluid drainage (CSFD) and 30-day mortality. Finally, a multivariate regression analysis identified risk factors for SCI.Results: A consecutive 142 patients with TAAAs (Crawford type II, n = 54 [38%]; type III, n = 76 [54%]; type IV, n = 12 [8%]) were included in this study. The majority of patients (n = 129 [91%]) were treated for an atherosclerotic aneurysm, whereas 13 patients (9%) were treated for a postdissection aneurysm. The mean maximal aortic diameter was 65 +/- 13 mm. SCI developed in 23 patients (16%; paraplegia in 12 [8%] and paraparesis in 11 [8%]). Of these 23 patients, 10 patients (43%) showed the neurologic deficit directly after the procedure, 11 patients (48%) in the first 24 hours, and 2 patients (9%) after 24 hours. There was an improvement of the neurologic status in the majority of patients, with only three patients (2%) showing irreversible paraplegia at discharge. There was no difference in the 30-day mortality between patients with and without SCI (no SCI, n = 3 [3%] vs SCI, n = 1 [4%]; P = .511). Prophylactic use of CSFD before the procedure was performed in 64 patients (45%), and among them, 4 patients (6%) developed a CSFD-associated complication. No clinical benefit for patients receiving prophylactic placement of CSFD was found (P = .498). The multivariate analysis revealed the percentage of thoracic aortic coverage as the only significant risk factor for SCI (odds ratio, 1.03; 95% confidence interval, 1.01-1.05; P = .001).Conclusions: The SCI rate after endovascular repair of TAAA was 16%, with 8% of those patients suffering from paraplegia. Prophylactic use of CSFD could not reduce the SCI rate and was associated with 6% adverse events. The percentage of thoracic aortic coverage was the most powerful determinant of SCI in these series.