A modern theory of paraplegia in the treatment of aneurysms of the thoracoabdominal aorta: An analysis of technique specific observed/expected ratios for paralysis
A modern theory of paraplegia in the treatment of aneurysms of the thoracoabdominal aorta: An analysis of technique specific observed/expected ratios for paralysis
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DOI：
10.1016/j.jvs.2008.10.074
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发表时间：
2009-05-01
影响因子：
4.3
通讯作者：
Wynn, Martha
中科院分区：
文献类型：
--
作者：
Acher, Charles W.;Wynn, Martha
目的：证明胸腹主动脉 (TAAA) 手术中截瘫预防的现代理论主要是非解剖学的，源自经过实验验证的干预措施，这些干预措施可延长缺血耐受性、减少再灌注损伤，并在有或没有辅助循环的情况下增强脊髓的侧支灌注。 方法：使用准确的截瘫风险预测模型 (r(2) > 0.95)，我们研究了 82 个临床系列中保护策略的效果，报告了更多从 1985 年到 2008 年，有超过 15,000 名患者接受治疗。计算每个系列的观察/预期 (O/E) 比率，并按技术对结果进行分组。研究了脊髓液引流 (SFD)、全身低温、硬膜外冷却和纳洛酮等干预措施对 O/E 比的影响。我们分析了从第 1 阶段（1985 年至 1997 年）到第 2 阶段（1997 至 2008 年）的 O/E 比率以及治疗技术随时间的变化。结果。所有截瘫患者的平均 O/E 比从第一代的 1.13 下降到第二代的 0.26。在接受辅助循环 (AC) 治疗的患者中添加 SFD，将 O/E 比从 1.03 降低到 0.24 (P < .0001)。在接受主动脉夹闭而不使用 AC (XCL) 治疗的患者中添加 SFD 可使 O/E 从 0.91 降低至 0.23 (P = .0013)。使用 SFD 时，低温骤停 (HA) 的 O/E 从 0.42 下降至 0.14。 AC、XCL 和 HA 中添加 SFD 是 Eras 之间 O/E 下降的主要原因。其他在 O/E 比值下降中发挥不太明确但重要作用的因素包括对较高平均动脉压 (MAP)、更多低温和神经化学保护的关注。结论：截瘫的原因是解剖学的，但截瘫的预防是生理性的（非解剖学的）。我们证明，通过使用低温、SFD 和增加 MAP，临床医生在截瘫方面有类似的改善，将 O/E 缺陷比从 1.03 降低至低至 0.16，无论是否进行肋间再植，以及是否使用辅助循环。了解截瘫预防的基本原则以及如何应用保护策略可以在使用或不使用辅助循环的临床系列中减少瘫痪。这种现代截瘫理论对于应用相同原理的分支内移植物修复 TAAA 领域的快速发展具有重要意义。 （花瓶外科杂志 2009；49：1117-24。）
Objective: To demonstrate that a modern theory of paraplegia prevention in thoracoabdominal aortic (TAAA) surgery is primarily non-anatomic and derives from experimentally validated interventions that prolong the ischemic tolerance, reduce reperfusion injury, and enhance the collateral perfusion of the spinal cord with or without assisted circulation.Methods: Using an accurate predictive model (r(2) > 0.95) for paraplegia risk we studied the effects of protective strategies in 82 clinical series reporting more than 15,000 patients treated from 1985 to 2008. The observed/expected (O/E) ratios were calculated for each series and the results were grouped by technique. The effect of interventions such as spinal fluid drainage (SFD), systemic hypothermia, epidural cooling, and naloxone on O/E ratios were studied. We analyzed changes in O/E ratios from Era 1 (1985 to 1997) to Era 2 (1997 to 2008) and within treatment techniques over time.Results. The mean O/E ratio for paraplegia for all patients declined from 1.13 in Era I to 0.26 in Era 2. Adding SFD to patients treated with assisted circulation (AC) decreased the O/E ratio from 1.03 to 0.24 (P < .0001). Adding SFD to patients treated with aortic clamping without AC (XCL) decreased O/E from 0.91 to 0.23 (P = .0013). O/E for hypothermic arrest (HA) declined from 0.42 to 0.14 with SFD. The addition of SFD to AC, XCL, and HA accounted for most of the decline in O/E between Eras. Other factors which played a less defined but important role in the decline in O/E ratios were attention to higher mean arterial pressures (MAPs), more hypothermia, and neurochemical protection.Conclusion: Paraplegia causation is anatomic but paraplegia prevention is physiologic (non-anatomic). We demonstrate that by using hypothermia, SFD, and increasing MAP, clinicians had similar improvements in paraplegia, reducing O/E deficit ratios from 1.03 to as low as 0.16, with or without intercostal reimplantation, and whether or not assisted circulation was used. Understanding the fundamental principles of paraplegia prevention and how to apply protective strategies leads to a reduction in paralysis in clinical series with or without the use of assisted circulation. This modern theory of paraplegia has significant implications for the rapidly advancing field of TAAA repair with branched endografts where the same principles apply. (J Vase Surg 2009;49:1117-24.)