Conrad Mark F, Crawford Robert S, Davison J Kenneth, Cambria Richard P
Division of Vascular and Endovascular Surgery, Harvard Medical School, Boston, Massachusetts, USA.
Ann Thorac Surg. 2007 Feb;83(2):S856-61; discussion S890-2. doi: 10.1016/j.athoracsur.2006.10.096.
A variety of operative approaches and protective adjuncts have been used to minimize organ dysfunction and, in particular, spinal cord injury (SCI) after thoracoabdominal aneurysm (TAA) repair. There is no consensus with respect to the optimal approach.
Reviewed were 445 consecutive TAA repairs done between January 1987 and December 2005. Clinical features included urgent operation in 103 patients (22.6%), of which 52 (11.4%) were ruptures. Operative management consisted of a clamp-and-sew technique with adjuncts in 417 patients (92%). Epidural cooling to prevent SCI was used in 240 (68%) extent I to III repairs. Predictors of mortality and SCI were assessed with multivariate analysis, and long-term survival was determined with Kaplan-Meier life-table analysis.
Operative mortality was 8.2% and was associated with preoperative serum creatinine level of 1.8 mg/dL or more (p = 0.005), intraoperative hypotension (p = 0.01), intraoperative transfusion requirement (p = 0.0008), postoperative SCI (p = 0.02), and postoperative renal failure (p < 0.0001). SCI of any severity occurred in 60 patients (13.2%), and 43 (9.5% of the total cohort) sustained major paraplegia. Epidural cooling significantly reduced the risk of SCI in patients with types I to III TAA (13.7% versus 29%, p = 0.01). Independent predictors of SCI included extent I/II aneurysms (p = 0.02), epidural cooling (p = 0.02), urgent/emergent operation (p = 0.02), intraoperative hypotension (p = 0.005), total aortic cross-clamp time (p = 0.01), and postoperative pulmonary complications (p = 0.003). Late survival rates were at 54.4% at 5 years, 28.7% at 10 years, and 20.5% at 15 years.
Despite the favorable impact of operative adjuncts on perioperative mortality and SCI, major morbidity after TAA remains a challenge; the implications to further develop stent graft strategies are clear.
为尽量减少胸腹主动脉瘤（TAA）修复术后的器官功能障碍，尤其是脊髓损伤（SCI），人们采用了多种手术方法和保护辅助措施。关于最佳手术方法尚无共识。
回顾了1987年1月至2005年12月期间连续进行的445例TAA修复手术。临床特征包括103例患者（22.6%）进行了急诊手术，其中52例（11.4%）为破裂性动脉瘤。417例患者（92%）的手术管理采用了夹闭缝合技术并辅以其他措施。240例I至III级修复手术（68%）采用了硬膜外降温以预防SCI。通过多因素分析评估死亡率和SCI的预测因素，并采用Kaplan-Meier生存表分析确定长期生存率。
手术死亡率为8.2%，与术前血清肌酐水平≥1.8mg/dL（p = 0.005）、术中低血压（p = 0.01）、术中输血需求（p = 0.0008）、术后SCI（p = 0.02）和术后肾衰竭（p < 0.0001）相关。60例患者（13.2%）发生了任何严重程度的SCI，43例（占总队列的9.5%）出现了严重截瘫。硬膜外降温显著降低了I至III型TAA患者发生SCI的风险（13.7%对29%，p = 0.01）。SCI的独立预测因素包括I/II型动脉瘤（p = 0.02）、硬膜外降温（p = 0.02）、急诊/紧急手术（p = 0.02）、术中低血压（p = 0.005）、主动脉总阻断时间（p = 0.01）和术后肺部并发症（p = 0.003）。5年、10年和15年的晚期生存率分别为54.4%、28.7%和20.5%。
尽管手术辅助措施对围手术期死亡率和SCI有积极影响，但TAA术后的主要并发症仍然是一个挑战；进一步开发支架移植物策略的意义不言而喻。
