Schlösser Felix J V, Mojibian Hamid, Verhagen Hence J M, Moll Frans L, Muhs Bart E
Section of Vascular Surgery, Yale University, New Haven, Connecticut 06510, USA.
J Vasc Surg. 2008 Sep;48(3):761-8. doi: 10.1016/j.jvs.2008.02.006. Epub 2008 May 16.
The purpose of this study was to provide insight into the incidence of thoracic and thoracoabdominal aortic aneurysm repair following previous infrarenal abdominal aortic aneurysm (AAA) surgery and to determine whether thoracic or thoracoabdominal aortic aneurysm repair after prior infrarenal AAA surgery is associated with higher mortality and morbidity rates.
MEDLINE, Cochrane Library CENTRAL, and EMBASE databases were searched for relevant articles. Selected articles were critically appraised and meta-analyses were performed.
A total of 12.4% of patients with thoracic aortic aneurysms and 18.7% of patients with thoracoabdominal aortic aneurysms have had prior AAA surgery. The chance of developing a thoracic aortic aneurysm in patients with AAA is 2.2% and 2.5% for developing a thoracoabdominal aortic aneurysm. The mean time interval between prior AAA surgery and subsequent thoracoabdominal aortic aneurysm surgery or detection is 8.0 years with a wide variation between individuals. Surgery in these patients is technically feasible. The 30-day mortality of patients undergoing open thoracoabdominal aortic aneurysm repair does not significantly differ from patients without prior AAA surgery and the 30-day mortality is 11.8%. No data were available about mortality of patients with prior AAA repair undergoing thoracic aortic aneurysm surgery. Morbidity risks are higher in patients with thoracic or thoracoabdominal aortic aneurysms. Prior AAA repair was a significant risk factor for neurological deficit after thoracic or thoracoabdominal aortic aneurysms surgery with relative risks (RRs) of 11.1 (95% confidence interval [CI] 3.8-32.3, P value < .0001) and 2.90 (95% CI 1.26-6.65, P value = .008), respectively. Prior AAA repair was a significant risk factor for developing renal failure in patients undergoing thoracoabdominal aortic aneurysm repair (RR 3.47, 95% CI 1.74-6.91, P value = .0001). Determinants of the prognosis in these patients include distal aortic perfusion, distal extent of the landing zone of the graft, drainage of cerebrospinal fluid for thoracic aortic aneurysm repair and age, history of cardiac diseases, extent of the aneurysm, rupture, amount of estimated blood loss, aortic clamp time, and visceral ischemic times for thoracoabdominal aortic aneurysm repair.
A considerable group of patients with thoracic or thoracoabdominal aortic aneurysms have had prior AAA repair. The risk of postoperative morbidity is increased in these patients. Mortality appears to be similar for patients with thoracoabdominal aortic aneurysms. Patients with prior AAA repair undergoing thoracic or thoracoabdominal aortic aneurysm repair should be provided maximum care to protect their spinal cord and renal function.
本研究旨在深入了解既往肾下腹主动脉瘤（AAA）手术后胸主动脉和胸腹主动脉瘤修复的发生率，并确定既往肾下AAA手术后胸主动脉或胸腹主动脉瘤修复是否与更高的死亡率和发病率相关。
检索MEDLINE、Cochrane图书馆CENTRAL和EMBASE数据库中的相关文章。对所选文章进行严格评估并进行荟萃分析。
共有12.4%的胸主动脉瘤患者和18.7%的胸腹主动脉瘤患者曾接受过AAA手术。AAA患者发生胸主动脉瘤的几率为2.2%，发生胸腹主动脉瘤的几率为2.5%。既往AAA手术与随后的胸腹主动脉瘤手术或检测之间的平均时间间隔为8.0年，个体差异较大。这些患者的手术在技术上是可行的。接受开放性胸腹主动脉瘤修复的患者30天死亡率与未接受过AAA手术的患者无显著差异，30天死亡率为11.8%。没有关于既往接受AAA修复的患者进行胸主动脉瘤手术死亡率的数据。胸主动脉或胸腹主动脉瘤患者的发病风险更高。既往AAA修复是胸主动脉或胸腹主动脉瘤手术后神经功能缺损的重要危险因素，相对危险度（RRs）分别为11.1（95%置信区间[CI]3.8 - 32.3，P值 <.0001）和2.90（95%CI 1.26 - 6.65，P值 =.008）。既往AAA修复是接受胸腹主动脉瘤修复患者发生肾衰竭的重要危险因素（RR 3.47，95%CI 1.74 - 6.91，P值 =.0001）。这些患者预后的决定因素包括主动脉远端灌注、移植物着陆区的远端范围、胸主动脉瘤修复时脑脊液引流以及年龄、心脏病史、动脉瘤范围、破裂、估计失血量、主动脉阻断时间和胸腹主动脉瘤修复时的内脏缺血时间。
相当一部分胸主动脉或胸腹主动脉瘤患者曾接受过AAA修复。这些患者术后发病风险增加。胸腹主动脉瘤患者的死亡率似乎相似。既往接受AAA修复的患者进行胸主动脉或胸腹主动脉瘤修复时，应给予最大程度的护理以保护其脊髓和肾功能。
