Permissive Hypertension and Collateral Revascularization May Allow Avoidance of Cerebrospinal Fluid Drainage in Thoracic Endovascular Aortic Repair.
Permissive Hypertension and Collateral Revascularization May Allow Avoidance of Cerebrospinal Fluid Drainage in Thoracic Endovascular Aortic Repair.
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DOI：
10.1016/j.athoracsur.2020.04.101
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发表时间：
2020-11
期刊：
影响因子：
--
通讯作者：
Hughes GC
中科院分区：
文献类型：
--
作者：
Weissler EH;Voigt SL;Raman V;Jawitz O;Doberne J;Anand J;Plichta R;Gaca JG;McCann RL;Hughes GC
脑脊液引流（CSFD）在预防胸血管内主动脉修复（TEVAR）后脊髓缺血（SCI）中的应用尚不清楚。我们之前发表了我们的机构算法，将术前CSFD限制在被认为是SCI高风险的患者。自该论文发表以来，我们的算法不断发展，所有接受孤立下行+/−弓TEVAR的患者术前都避免了CSFD。本研究在当代队列中评估了更新后的算法。2012年2月至2018年9月在单一中心因降主动脉+/ -弓病理接受TEVAR的患者从机构主动脉手术数据库中确定。该算法包括在没有保留顺行血流的覆盖情况下进行左锁骨下动脉（LSA）血运重建术，允许高血压，并使用诱发电位监测。主要终点为脊髓损伤或术后CSFD。在研究期间，N=225例患者接受下行+/ - arch TEVAR。2例患者（0.9%）在TEVAR之前违反算法存在CSFD，被排除在研究队列之外。81%的患者T6以下有内移植物覆盖。100例患者（47%）的LSA完全覆盖，所有患者都进行了LSA血运重建术。根据更新后的算法，暂时性或永久性脊髓损伤的发生率为0%。无患者术后需要CSFD。在下行+/ - arch TEVAR下，限制性腰椎CSFD算法包括允许性高血压和LSA血管重建术，在连续治疗的223例患者中，在6.5年的时间间隔内，脊髓损伤的发生率为0%，这是安全的。我们建议考虑进一步的前瞻性研究来评估该算法。
The utility of cerebrospinal fluid drainage (CSFD) for prevention of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) remains unclear. We previously published our institutional algorithm restricting preoperative CSFD to patients deemed high risk for SCI. Since that publication, our algorithm has evolved with preoperative CSFD avoided in all patients undergoing isolated descending +/− arch TEVAR. This study evaluates the updated algorithm in a contemporary cohort. Patients who underwent TEVAR for descending aortic +/− arch pathology between 2/2012 - 9/2018 at a single center were identified from an institutional aortic surgery database. The algorithm includes left subclavian artery (LSA) revascularization in cases of coverage with no preservation of antegrade flow, permissive hypertension, and use of evoked potential monitoring. The primary endpoints were SCI or postoperative CSFD. N=225 patients underwent descending +/− arch TEVAR during the study interval. 2 patients (0.9%) had CSFD prior to TEVAR in violation of the algorithm and were excluded from the study cohort. 81% had endograft coverage below T6. The LSA was fully covered in 100 patients (47%), all of whom underwent LSA revascularization. Following the updated algorithm, the incidence of temporary or permanent SCI was 0%. No patient required postoperative CSFD. A restrictive lumbar CSFD algorithm including permissive hypertension and LSA revascularization in the setting of descending +/− arch TEVAR appears safe with a 0% incidence of SCI in 223 consecutive patients treated over a 6.5-year interval. We recommend consideration of further prospective study to evaluate this algorithm.
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影响因子：
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