Jacobs M J, Mommertz G, Koeppel T A, Langer S, Nijenhuis R J, Mess W H, Schurink G W H
Department of Vascular Surgery, University Hospital, Maastricht, The Netherlands.
J Cardiovasc Surg (Torino). 2007 Feb;48(1):49-58.
Morbidity and mortality following thoracoabdominal aortic aneurysm (TAAA) repair are tremendous. Preoperative assessment is essential in detecting cardiac and pulmonary risk factors in order to reduce cardiopulmonary complications. Paraplegia and renal failure are main determinants of postoperative mortality and therefore gained substantial attention during the last decades. Left heart bypass, cerebrospinal fluid (CSF) drainage and epidural cooling have significantly reduced paraplegia rate, however, this dreadful event still occurs in up to 25% of patients undergoing type II repair. Renal failure has been partly prevented by means of retrograde aortic perfusion and cooling but renal failure still remains a significant problem. We have evaluated the effects of protective measures aiming for reduction of paraplegia and renal failure. Monitoring motor evoked potentials (MEPs) is an accurate technique to assess spinal cord integrity during TAAA repair, guiding surgical strategies to prevent paraplegia. Selective volume- and pressure controlled perfusion is a technique to continuously perfuse the kidneys during aortic cross clamping and subsequent circulatory exclusion In patients with atherosclerotic thoracoabdominal aortic aneurysms, blood supply to the spinal cord depends on a highly variable collateral system. In our experience, monitoring MEPs allowed detection of cord ischemia, guiding aggressive surgical strategies to restore spinal cord blood supply and reduce neurologic deficit: overall paraplegia rate was less than 3%. We believe that these protective measures should be included in the surgical protocol of TAAA repair, especially in type II cases. Renal and visceral ischemia can be reduced significantly by continuous perfusion during aortic cross clamping in TAAA repair. Not only sufficient volume flow but also adequate arterial pressure appears to be essential in maintaining renal function.Obviously, endovascular modalities have been successfully applied in TAAA patients, the majority of which as part of hybrid procedures. Technological innovation will eventually cause a shift from open to minimal invasive surgical repair. At present, however, open surgery is considered the gold standard for TAAA repair, especially in (relatively) young patients and patients suffering from Marfan's disease.
胸腹主动脉瘤（TAAA）修复术后的发病率和死亡率极高。术前评估对于检测心脏和肺部危险因素至关重要，以便减少心肺并发症。截瘫和肾衰竭是术后死亡率的主要决定因素，因此在过去几十年中受到了广泛关注。左心转流、脑脊液（CSF）引流和硬膜外降温显著降低了截瘫发生率，然而，这种可怕的事件仍发生在高达25%的II型修复患者中。通过逆行主动脉灌注和降温，肾衰竭已得到部分预防，但肾衰竭仍然是一个重大问题。我们评估了旨在减少截瘫和肾衰竭的保护措施的效果。监测运动诱发电位（MEP）是评估TAAA修复术中脊髓完整性的准确技术，可指导手术策略以预防截瘫。选择性容量和压力控制灌注是一种在主动脉交叉钳夹和随后的循环排除期间持续灌注肾脏的技术。在患有动脉粥样硬化性胸腹主动脉瘤的患者中，脊髓的血液供应依赖于高度可变的侧支循环系统。根据我们的经验，监测MEP可检测脊髓缺血，指导积极的手术策略以恢复脊髓血液供应并减少神经功能缺损：总体截瘫发生率低于3%。我们认为这些保护措施应纳入TAAA修复的手术方案中，尤其是在II型病例中。在TAAA修复中，通过主动脉交叉钳夹期间的持续灌注可显著减少肾脏和内脏缺血。不仅足够的血流量，而且足够的动脉压似乎对维持肾功能至关重要。显然，血管内治疗方式已成功应用于TAAA患者，其中大多数作为杂交手术的一部分。技术创新最终将导致从开放手术向微创手术修复的转变。然而，目前开放手术被认为是TAAA修复的金标准
