Clinical experience with epidural cooling for spinal cord protection during thoracic and thoracoabdominal aneurysm repair
Clinical experience with epidural cooling for spinal cord protection during thoracic and thoracoabdominal aneurysm repair
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DOI：
10.1016/s0741-5214(97)70365-3
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发表时间：
1997-02-01
影响因子：
4.3
通讯作者：
Abbott, WM
中科院分区：
文献类型：
--
作者：
Cambria, RP;Davison, JK;Abbott, WM
用途：本报告总结了我们的经验，硬膜外冷却（EC），以实现区域脊髓低温，从而降低脊髓缺血性损伤的风险，在下降的胸部动脉瘤（TA）和胸腹部动脉瘤（TAA）修复过程中。1993年7月至1995年12月，70例患者接受了TA（n = 9，13%）或TAA（n = 61）（I型，24 [34%]，II型，11 [15%]，III型，26 [37%]）使用EC技术修复。后者通过将生理盐水（4 ℃）持续输注到T-11-12硬膜外导管中完成;鞘内导管放置在L（3-4）水平，用于监测脑脊液温度（CSFT）和压力（CSFT）。所有手术（一个例外，房股分流术）均采用夹闭缝合技术进行，50%的患者在近端或远端吻合处（30%）或通过单独的包容按钮（20%）保留肋间血管。将神经功能结局与已发表的TAA修复后神经功能缺损发生率预测模型进行比较，并与匹配的（不包括IV型）连续对照组（n = 55），在使用EC之前的1990年至1993年期间接受了TAA修复术。所有患者的EC均成功，平均1442 +/- 718 ml（范围：200 - 3500 ml）输注液体积;主动脉阻断期间，CSFT平均降至24 ± 3 ℃，核心温度维持在34 ± 0.8 ±- C。在交叉钳夹期间，平均CSFP从基线值13 +/- 8 mm Hg增加至31 +/- 6 mm Hg。7名患者（10%）在手术后60天内死亡，但所有患者均存活足够长的时间以评估神经功能缺损。EC组和对照组在平均年龄、急性表现/主动脉夹层/动脉瘤破裂的发生率、TAA类型分布和主动脉阻断时间方面匹配良好。EC患者中观察到2例下肢神经功能缺损（2.9%），对照组中观察到13例（23%）（p < 0.0001）。EC患者中观察到的和预测的缺陷分别为2.9%和20.0%（p = 0.001），对照组为23%和17.8%（p = 0.48）。在考虑EC和对照组患者（n = 115）中，与术后神经功能缺损相关的变量是延长（>60分钟）内脏主动脉阻断时间（相对风险，4.4; 95% CI，1.2至16.5; p = 0.02）和缺乏硬膜外冷却（相对危险度，9.8; 95% CI，2 ~ 48; p = 0.005）。结论：在TA或TAA修复过程中，EC是一种安全有效的增加脊髓缺血耐受性的技术。当与夹缝技术和选择性肋间再吻合策略结合使用时，EC显著降低了TAA修复后神经功能缺损的发生率。
Purpose: This report summarizes our experience with epidural cooling (EC) to achieve regional spinal cord hypothermia and thereby decrease the risk of spinal cord ischemic injury during the course of descending thoracic aneurysm (TA) and thoracoabdominal aneurysm (TAA) repair.Methods: During the interval July 1993 to Dec. 1995, 70 patients underwent TA (n = 9, 13%) or TAA (n = 61) (type I, 24 [34%], type II, 11 [15%], type III, 26 [37%]) repair using the EC technique. The latter was accomplished by continuous infusion of normal saline (4 degrees C) into a T-11-12 epidural catheter; an intrathecal catheter was placed at the L(3-4) level for monitoring of cerebrospinal fluid temperature (CSFT) and pressure (CSFT). All operations (one exception, atriofemoral bypass) were performed with the clamp-and-sew technique, and 50% of patients had preservation of intercostal vessels at proximal or distal anastomoses (30%) or by separate inclusion button (20%). Neurologic outcome was compared with a published predictive model for the incidence of neurologic deficits after TAA repair and with a matched (Type IV excluded) consecutive, control group (n = 55) who underwent TAA repair in the period 1990 to 1993 before use of EC.Results: EC was successful in all patients, with a 1442 +/- 718 ml mean (range, 200 to 3500 ml) volume of infusate; CSFT was reduced to a mean of 24 degrees +/- 3 degrees C during aortic cross-clamping with maintenance of core temperature of 34 degrees +/- 0.8+/- C. Mean CSFP increased from baseline values of 13 +/- 8 mm Hg to 31 +/- 6 mm Hg during cross-clamp. Seven patients (10%) died within 60 days of surgery, but all survived long enough for evaluation of neurologic deficits. The EC group and control group were well-matched with respect to mean age, incidence of acute presentations/aortic dissection/aneurysm rupture, TAA type distribution, and aortic cross-clamp times. Two lower extremity neurologic deficits (2.9%) were observed in the EC patients and 13 (23%) in the control group (p < 0.0001). Observed and predicted deficits in the EC patients were 2.9% and 20.0% (p = 0.001), and for the control group 23% and 17.8% (p = 0.48). In considering EC and control patients (n = 115), variables associated with postoperative neurologic deficit were prolonged (>60 min) visceral aortic cross-clamp time (relative risk, 4.4; 95% CI, 1.2 to 16.5; p = 0.02) and lack of epidural cooling (relative risk, 9.8; 95% CI, 2 to 48; p = 0.005).Conclusions: EC is a safe and effective technique to increase the ischemic tolerance of tile spinal cord during TA or TAA repair. When used in conjunction with a clamp-and-sew technique and a strategy of selective intercostal reanastomosis, EC has significantly reduced the incidence of neurologic deficits after TAA repair.