Fate of patients with spinal cord ischemia complicating thoracic endovascular aortic repair.
Fate of patients with spinal cord ischemia complicating thoracic endovascular aortic repair.
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DOI：
10.1016/j.jvs.2013.02.036
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发表时间：
2013-09
影响因子：
4.3
通讯作者：
Beck, Adam W.
中科院分区：
文献类型：
--
作者：
DeSart, Kenneth;Scali, Salvatore T.;Feezor, Robert J.;Hong, Michael;Hess, Philip J., Jr.;Beaver, Thomas M.;Huber, Thomas S.;Beck, Adam W.
脊髓缺血(SCI)是胸主动脉腔内修复术(TEVAR)的一种潜在的破坏性并发症，可导致不同程度的短期和永久性残疾。本研究旨在描述TEVAR后脊髓损伤的临床结果、长期功能影响以及对生存的影响。对佛罗里达大学2000-2011年的所有TEVAR患者进行了回顾性研究，以确定经历SCI的患者，其定义为任何新的、不能归因于其他原因的下肢神经功能缺陷。脊髓损伤分为即刻和延迟性起病，其中即刻起病定义为从麻醉中苏醒时注意到的脊髓损伤，延迟性脊髓损伤定义为功能正常并随后发生神经损伤的时期。通过数据库查询、图表查看和与患者和/或家属的电话访谈来确定患者的活动状态。死亡率是用生命表估计的。607例患者接受了不同适应症的TEVAR术，其中57例(9.4%)术后有脊髓损伤(4.3%为永久性)。SCI患者年龄较大(63.9±15.6比70.5±11.2；P=0.002)，并伴有COPD、高血压、血脂异常和脑血管疾病(P<；0.0001)。54名患者(95%)在护理过程中的某个时间点放置了脑脊液引流管，其中大多数患者(54%)在术后放置了脑脊液引流管。在整个队列中，住院死亡率为8.8%(SCI与非SCI；P=.45)。12名患者立即发生脊髓损伤，40名患者延迟发病，5名患者由于术后镇静时间不分青红皂白而不确定。3名(25%)即刻脊髓损伤患者有可测量的功能改善(FI)，而28名(70%)延迟发病患者经历了某种程度的神经恢复(P=0.04)。在有完整数据的34名患者中，26名(76%)报告了可量化的FI，而只有13名(38%)经历了恢复到术前基线。有脊髓损伤和无脊髓损伤患者的估计平均生存期(±标准差)分别为37.2±4.5和71.6±3.9个月(P<；.0006)。FI患者的平均生存时间为53.9±5.9个月，而未改善的患者为9.6±3.6个月(P<；0.0001)。比较患者手术前后脑脊液引流情况，患者的存活和神经功能恢复情况无显著差异。少数患者在接受TEVAR治疗后经历脊髓损伤后完全恢复到基线功能，而没有早期功能恢复的患者的结果尤其令人沮丧。与无脊髓损伤的患者相比，经历迟发性脊髓损伤的患者更有可能发生脊髓损伤，并且预期的预期寿命与神经功能恢复相似。引流管放置的时机似乎对出院后FI或长期死亡率没有影响。
Spinal cord ischemia(SCI) is a potentially devastating complication of thoracic endovascular aortic repair(TEVAR) that can result in varying degrees of short-term and permanent disability. This study was undertaken to describe the clinical outcomes, long-term functional impact, and influence on survival of SCI after TEVAR. A retrospective review of all TEVAR patients at the University of Florida from 2000–2011 was performed to identify individuals experiencing SCI as defined by any new lower extremity neurologic deficit not attributable to another cause. SCI was dichotomized into immediate or delayed onset, with immediate onset defined as SCI noted upon awakening from anesthesia, and delayed characterized as a period of normal function followed by development of neurologic injury. Ambulatory status was determined using database query, chart review and phone interviews with patients and/or family. Mortality was estimated using life-tables. 607 TEVARs were performed for various indications, with 57 patients(9.4%) noted to have postoperative SCI(4.3% permanent). SCI patients were more likely to be older (63.9±15.6 vs. 70.5±11.2;p=.002) and have a number of comorbidities including: COPD, hypertension, dyslipidemia and cerebrovascular disease(P<.0001). Fifty-four patients(95%) had a CSF drain placed at some point in their care, with the majority placed postoperatively(54%). In-hospital mortality was 8.8% for the entire cohort(SCI vs. No SCI;P=.45). Twelve patients developed immediate SCI, 40 had delayed onset, and 5 were indeterminate due to indiscriminate timing from postoperative sedation. Three(25%) immediate SCI patients had measurable functional improvement (FI), while 28(70%) of the delayed-onset patients experienced some degree of neurologic recovery(P=.04). Of the 34 patients with complete data available, 26(76%) reported quantifiable FI, while only 13(38%) experienced return to preoperative baseline. Estimated mean survival(±standard error) for patients with and without SCI was 37.2±4.5 and 71.6±3.9 months(P<.0006), respectively. Patients with FI had a mean survival of 53.9±5.9 months compared to 9.6±3.6 months for those without improvement(P<.0001). Survival and return of neurologic function were not significantly different when comparing patients with pre- and postoperative CSF drains. The minority of patients experience complete return to baseline function after suffering SCI with TEVAR, and outcomes in patients without early functional recovery are particularly dismal. Patients experiencing delayed SCI are more likely to have FI and may anticipate similar life-expectancy with neurologic recovery compared to patients without SCI. Timing of drain placement does not appear to have an impact on post-discharge FI or long-term mortality.
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