Outcomes of a Spinal Drain and Intraoperative Neurophysiologic Monitoring Protocol in Thoracic Endovascular Aortic Repair
Outcomes of a Spinal Drain and Intraoperative Neurophysiologic Monitoring Protocol in Thoracic Endovascular Aortic Repair
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DOI：
10.1016/j.avsg.2019.04.022
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发表时间：
2019-11-01
影响因子：
1.5
通讯作者：
Faulds, Jason
中科院分区：
文献类型：
--
作者：
Yang, Gary K.;Misskey, Jonathan;Faulds, Jason
背景：胸主动脉手术中早期发现和治疗脊髓缺血（SCI）的辅助手段得到了开放修复的丰富临床经验的支持。脑脊液（CSF）引流和神经生理监测（NPM）在胸椎血管内主动脉修复（TEVAR）中的应用尚不清楚。本研究的目的是确定使用预防性NPM和CSF的选择性机构脊髓保护方案对标准TEVAR结果的影响。方法：回顾性分析2007年至2016年从单一机构进入前瞻性维护数据库的接受标准TEVAR治疗的患者。回顾术前特征、动脉瘤范围及病因。收集脑脊液引流管的使用情况，包括抽出的液体量、引流时间和导管相关并发症。回顾NPM数据以确定对术中管理的影响。使用精确逻辑回归来确定SCI的独立预测因子。结果：在223例接受TEVAR的患者中，130例符合研究的纳入标准。71例（54.6%）患者使用脑脊液引流，130例中56例（43%）有NPM。7例（5.4%）发生脊髓损伤，其中5例部分或完全恢复。所有病例出现脊髓损伤症状的中位时间均延迟（中位52小时，范围8e312）， 7例伴有NPM的患者中4例均未出现术中改变。术中NPM改变26例（46%），除2例外，其余均表现为单侧腿部缺血。在这两例患者中，与脊髓损伤一致的变化与术中低血压相关，并随着血压升高而消失。两例患者均未发生术后脊髓损伤。脊髓损伤患者的中位住院时间（22天vs. 9天，P = 0.012）、手术室时间（262天vs. 209天，P = 0.040）和围手术期死亡率（28.6% vs. 4.1%, P = 0.046）显著高于无脊髓损伤患者。发现主动脉覆盖长度是脊髓损伤的唯一独立预测因子（优势比8.2,P = 0.026）。4例（5.6%）患者出现脑脊液引流相关并发症，2例（2.8%）患者出现主要并发症，包括1例鞘内血肿和永久性双侧截瘫。结论：在TEVAR中选择性使用预防性脑脊液引流存在中等风险，其获益值得怀疑。使用神经生理监测可以早期发现和治疗脊髓缺血，但其效用受到后勤因素和少数术中脊髓缺血事件患者的限制。
Background: Adjuncts for early detection and treatment of spinal cord ischemia (SCI) in thoracic aortic surgery are supported by robust clinical experience in open repair. The utility of cerebrospinal fluid (CSF) drainage and neurophysiologic monitoring (NPM) in thoracic endovascular aortic repair (TEVAR) is less clear. The purpose of this investigation is to determine the influence of a selective institutional spinal cord protection protocol using prophylactic NPM and CSF on outcomes for standard TEVAR.Methods: Patients undergoing standard TEVAR entered into a prospectively maintained database from a single institution from 2007 to 2016 were retrospectively reviewed. Preoperative characteristics, aneurysm extent, and etiology were reviewed. Utilization of CSF drains including volume of fluid removed, duration of drainage, and catheter-related complications were collected. NPM data were reviewed to determine the influence on intraoperative management. Exact logistic regression was used to identify independent predictors of SCI.Results: Of 223 patients undergoing TEVAR, 130 met inclusion criteria for the study. CSF drains were used in 71 patients (54.6%), and 56 of 130 (43%) had NPM. SCI occurred in 7 patients (5.4%), of whom 5 had partial or complete recovery. Median time to symptoms of SCI was delayed in all cases (median 52 hr, range 8e312), and none of the 4 of 7 patients with adjunct NPM demonstrated intraoperative changes. Intraoperative changes in NPM occurred in 26 (46%), and represented unilateral leg ischemia in all but 2 cases. In both patients, changes consistent with SCI were associated with intraoperative hypotension and resolved with blood pressure augmentation. Neither patient developed postoperative SCI. Median length of stay (22 vs. 9 days, P = 0.012), operative room time (262 vs. 209, P = 0.040), and perioperative mortality (28.6% vs. 4.1%, P = 0.046) were significantly higher for patients with SCI versus those without. Length of aortic coverage was found to be the sole independent predictor of SCI (odds ratio 8.2, P = 0.026). Complications related to CSF drainage occurred in 4 patients (5.6%) with major complications occurring in 2 patients (2.8%), including 1 with an intrathecal hematoma and permanent bilateral paraparesis.Conclusions: Selective use of prophylactic CSF drainage in TEVAR was associated with moderate risk and questionable benefit. The use of neurophysiological monitoring allowed for early detection and treatment of spinal ischemia, but its utility is limited by logistical factors and to the minority of patients with intraoperative spinal ischemic events.