Estrera A L, Miller C C, Huynh T T, Porat E, Safi H J
Department of Cardiothoracic and Vascular Surgery, The University of Texas at Houston Medical School, Memorial Hermann Hospital, 77030, USA.
Ann Thorac Surg. 2001 Oct;72(4):1225-30; discussion 1230-1. doi: 10.1016/s0003-4975(01)02971-x.
Neurologic deficit (paraparesis and paraplegia) after repair of the thoracic and thoracoabdominal aorta remains a devastating complication. The purpose of this study was to determine the effect of cerebrospinal fluid drainage and distal aortic perfusion upon neurologic outcome during repair of thoracic and thoracoabdominal aortic aneurysm (TAAA) repair.
Between February 1991 and March 2000, we performed 654 repairs of the thoracic and thoracoabdominal aorta. The median age was 67 years and 420 (64%) patients were male. Forty-five cases (6.9%) were performed emergently. Distribution of TAAA was the following: extent I, 164 (25%); extent II, 165 (25%); extent III, 61 (9%); extent IV, 95 (15%); extent V, 23 (3.5%); and descending thoracic, 147 (22%). The adjuncts cerebrospinal fluid drainage and distal aortic perfusion were used in 428 cases (65%).
Thirty-day mortality was 14% (94 of 654). The in-hospital mortality was 16% (106 of 654). Early neurologic deficits occurred in 33 patients (5.0%). Overall, 14 of 428 (3.3%) neurologic deficits were observed in the adjunct group, and 19 of 226 (8.4%) in the nonadjunct group (p = 0.004). When the adjuncts were used during extent II repair, the incidence was 10 of 129 (7.8%) compared with 11 of 36 (30.6%) in the nonadjunct group (p < 0.001). Multivariate analysis demonstrated that risk factors for neurologic deficit were cerebrovascular disease and extent of TAAA (II and III) (p < 0.05).
The combined adjuncts of distal aortic perfusion and cerebrospinal fluid drainage demonstrated improved neurologic outcome with repair of thoracic and TAAAs. In extent II aneurysms, adjuncts continue to make a considerable difference in the outcome and to provide significant protection against spinal cord morbidity. Future research should focus on spinal cord protection in patients with high-risk extent II aneurysms.
胸主动脉和胸腹主动脉修复术后的神经功能缺损（双下肢轻瘫和截瘫）仍然是一种极具破坏性的并发症。本研究的目的是确定脑脊液引流和主动脉远端灌注对胸主动脉和胸腹主动脉瘤（TAAA）修复术中神经功能转归的影响。
1991年2月至2000年3月期间，我们对654例胸主动脉和胸腹主动脉进行了修复手术。患者中位年龄为67岁，男性420例（64%）。45例（6.9%）为急诊手术。TAAA的分布情况如下：I型，164例（25%）；II型，165例（25%）；III型，61例（9%）；IV型，95例（15%）；V型，23例（3.5%）；降主动脉型，147例（22%）。428例（65%）手术中使用了脑脊液引流和主动脉远端灌注辅助措施。
30天死亡率为14%（654例中的94例）。住院死亡率为16%（654例中的106例）。33例患者（5.0%）出现早期神经功能缺损。总体而言，辅助措施组428例中有14例（占3.3%）出现神经功能缺损，未使用辅助措施组226例中有19例（占8.4%）（p = 0.004）。在II型修复术中使用辅助措施时，发生率为129例中的10例（7.8%），而未使用辅助措施组36例中有11例（30.6%）（p < 0.001）。多因素分析表明，神经功能缺损的危险因素为脑血管疾病和TAAA的范围（II型和III型）（p < 0.05）。
主动脉远端灌注和脑脊液引流联合辅助措施在胸主动脉和TAAA修复术中显示出改善的神经功能转归。在II型动脉瘤修复中，辅助措施在转归方面仍有显著差异，并能为预防脊髓并发症提供重要保护。未来的研究应聚焦于高危II型动脉瘤患者的脊髓保护。
