Peppelenbosch Noud, Cuypers Philippe W M, Vahl Anco C, Vermassen Frank, Buth Jacob
Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.
J Vasc Surg. 2005 Oct;42(4):608-14. doi: 10.1016/j.jvs.2005.06.023.
Spinal cord ischemia is a rare complication after open surgical repair for ruptured abdominal aortic aneurysms (rAAA). The use of emergency endovascular aortic aneurysm repair (eEVAR) is increasing, and paraplegia has been observed in a few patients. The objective of this study was to assess the incidence and pathogenesis of spinal cord ischemia after eEVAR in greater detail.
This was a retrospective analysis of patients who had eEVAR for rAAA in three hospitals in The Netherlands and Belgium during a 3-year study period that ended in February 2004. The use of aortouniiliac devices combined with a femorofemoral crossover bypass was the preferred technique. Patients with postoperative symptoms of spinal cord ischemia were identified and the influence of potential risk factors was assessed. These factors included the presence of common iliac artery aneurysms necessitating device limb extension to the external iliac artery with associated overlapping the hypogastric artery, the prolonged interruption of bilateral hypogastric artery arterial inflow during the procedure (defined "functional aortic occlusion time" >30 minutes), and the occurrence of preoperative hemodynamic shock.
Thirty-five patients were treated by EVAR and they constituted the study group. The first-month mortality in the study group with EVAR was 23%. Four patients (11.5%) with EVAR developed paraplegia postoperatively; the unilateral or bilateral hypogastric artery in all four patients became occluded during the procedure. In the other 31 patients who did not have paraplegia, the unilateral or bilateral hypogastric arteries became occluded in 14 patients (45%). This constituted a significant difference in the prevalence of hypogastric artery occlusion in patients with or without paraplegia (P = .04). The functional aortic occlusion time was prolonged in all four patients with paraplegia and in five without spinal cord ischemia (P = .0003). All four patients with spinal cord ischemia presented with hemodynamic shock. This factor did not reach a significant difference from nonparaplegic patients.
Emergency EVAR continues to be a promising approach to reduce the high mortality of rAAA, but the incidence of spinal cord ischemia after endovascular treatment of rAAA was worrisome. Although the pathogenesis is most likely multifactorial, interruption of the hypogastric artery inflow appeared to have significant influence. In patients with aneurysmatic common iliac arteries, any effort should be made to minimize hypogastric occlusion time during the procedure and to maintain hypogastric artery inflow afterwards, either by the use of a bell-bottom iliac extension or by electing open repair.
脊髓缺血是开放性手术修复破裂腹主动脉瘤（rAAA）后一种罕见的并发症。急诊血管腔内主动脉瘤修复术（eEVAR）的应用正在增加，并且在少数患者中观察到了截瘫情况。本研究的目的是更详细地评估eEVAR后脊髓缺血的发生率及发病机制。
这是一项对荷兰和比利时三家医院在截至2004年2月的3年研究期间接受rAAA的eEVAR治疗的患者进行的回顾性分析。使用单髂动脉装置联合股-股交叉旁路是首选技术。确定术后有脊髓缺血症状的患者，并评估潜在危险因素的影响。这些因素包括存在髂总动脉瘤，需要将装置肢体延伸至髂外动脉并伴有与下腹动脉重叠，手术过程中双侧下腹动脉血流的长时间中断（定义为“功能性主动脉阻断时间”>30分钟），以及术前发生血流动力学休克。
35例患者接受了EVAR治疗，他们构成了研究组。研究组中接受EVAR治疗的患者第一个月死亡率为23%。4例（11.5%）接受EVAR治疗的患者术后发生截瘫；所有4例患者的单侧或双侧下腹动脉在手术过程中闭塞。在其他31例未发生截瘫的患者中，14例（45%）的单侧或双侧下腹动脉闭塞。这在有或无截瘫患者的下腹动脉闭塞发生率上构成了显著差异（P = 0.04）。所有4例发生截瘫的患者以及5例无脊髓缺血的患者功能性主动脉阻断时间均延长（P = 0.0003）。所有4例发生脊髓缺血的患者均出现血流动力学休克。该因素与未发生截瘫的患者相比未达到显著差异。
急诊EVAR仍然是降低rAAA高死亡率的一种有前景的方法，但rAAA血管腔内治疗后脊髓缺血的发生率令人担忧。虽然发病机制很可能是多因素的，但下腹动脉血流中断似乎有重大影响。对于患有动脉瘤性髂总动脉的患者，应尽一切努力在手术过程中尽量缩短下腹动脉闭塞时间，并在术后维持下腹动脉血流，可通过使用喇叭口状髂动脉延伸装置或选择开放修复来实现。
