Safi H J, Subramaniam M H, Miller C C, Coogan S M, Iliopoulos D C, Winnerkvist A, Le Blevec D, Bahnini A
Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA.
Ann Vasc Surg. 1999 Sep;13(5):457-62. doi: 10.1007/s100169900284.
We reviewed our categorization of patients at high risk for neurologic complications in the repair of descending thoracic and thoracoabdominal aortic aneurysm in which we used cerebrospinal fluid drainage and distal aortic perfusion (adjuncts). A total of 409 patients were operated on by one surgeon for descending thoracic or thoracoabdominal aortic aneurysm between 1992 and 1997. Of these patients, 232 had total descending thoracic or type I thoracoabdominal aortic aneurysm, 131 (56%) of whom were operated on with adjuncts. These patients were compared to 101 nonadjunct patients for demographic variables, intraoperative variables, blood product consumption, and neurologic status. In 131 consecutive patients with adjuncts, all but one awoke from anesthesia without neurologic deficit. In nonadjunct patients, however, neurologic deficit occurred in 6 of 101 (6%) (p < 0.003). The adjunct group had more preoperative renal insufficiency (p < 0.05), an established risk factor for neurologic deficit (odds ratio = 2.2 in published studies). All other risk factors for neurologic deficit occurred with comparable frequency in both groups. We conclude that the introduction of adjuncts has dramatically reduced the neurologic risk associated with type I thoracoabdominal or total descending thoracic aortic repair. Previously considered high risk for neurologic complications, these aneurysms can now be reclassified as low risk in surgery accompanied by adjuncts. Future investigations will focus on type II thoracoabdominal aortic aneurysm as the major source of neurologic morbidity.
我们回顾了在降胸段和胸腹主动脉瘤修复中对神经系统并发症高危患者的分类情况，我们在这类手术中采用了脑脊液引流和主动脉远端灌注（辅助措施）。1992年至1997年间，一名外科医生对409例降胸段或胸腹主动脉瘤患者进行了手术。其中，232例为全降胸段或I型胸腹主动脉瘤，其中131例（56%）在手术中采用了辅助措施。将这些患者与101例未采用辅助措施的患者在人口统计学变量、术中变量、血制品消耗量和神经状态方面进行了比较。在连续131例采用辅助措施的患者中，除1例患者外，其余患者均在麻醉苏醒后无神经功能缺损。然而，在未采用辅助措施的患者中，101例中有6例（6%）出现了神经功能缺损（p<0.003）。采用辅助措施的组术前肾功能不全的情况更多（p<0.05），这是神经功能缺损的一个既定风险因素（在已发表的研究中，优势比为2.2）。两组中其他导致神经功能缺损的风险因素出现的频率相当。我们得出结论，辅助措施的引入显著降低了与I型胸腹主动脉或全降胸段主动脉修复相关的神经风险。这些动脉瘤以前被认为是神经系统并发症的高危类型，现在在伴有辅助措施的手术中可重新分类为低风险。未来的研究将聚焦于II型胸腹主动脉瘤，将其作为神经系统发病的主要来源。
