Kieffer Edouard, Chiche Laurent, Cluzel Philippe, Godet Gilles, Koskas Fabien, Bahnini Amine
Department of Vascular Surgery, Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris and University Paris VI, Paris, France.
Ann Vasc Surg. 2009 Jan-Feb;23(1):60-6. doi: 10.1016/j.avsg.2008.07.001. Epub 2008 Sep 21.
The purpose of this study was to present a single center's experience with elective treatment of descending thoracic aortic aneurysms (DTAAs) in the endovascular era. From July 1997 to May 2005, we operated on 173 patients for DTAA. A total of 52 patients (30.1%) underwent endovascular stent-graft repair (group I). Endovascular repair was carried out exclusively in high-surgical risk patients in whom preoperative spinal cord arteriography usually demonstrated that the origin of the Adamkiewicz artery was located outside the zone to be covered by the stent graft. The remaining 121 patients (69.9%) underwent open surgical repair (group II), with partial cardiopulmonary bypass in 78 cases (64.5%) and deep hypothermic circulatory arrest in 43 (35.5%). The two treatment groups differed significantly with regard to age, prevalence of chronic obstructive pulmonary disease, number of aneurysms involving the upper segment or full length of the descending thoracic aorta, and percentage of patients in whom spinal cord arteriography was either deemed unnecessary or demonstrated that the origin of the Adamkiewicz artery was located within the coverage zone. In-hospital mortality was 15.4% (8/52) in group I vs. 5.0% (6/121) in group II (p = 0.02). Five deaths after endovascular repair were due to technical causes. All neurological deficits due to spinal cord ischemia (9/121, 7.4%) including 3.3% of irreversible flaccid paraplegia occurred in group II (p = 0.04). The findings of this study show that open surgical repair achieves excellent results when high-risk surgical candidates are recommended for endovascular repair. However, since preoperative spinal cord arteriography was a selection criterion for endovascular repair, the improvement in mortality was accompanied by a concentration of spinal cord ischemic complications in the patients having open surgical repair. The high mortality associated with endovascular repair in our series should decrease as deployment skill and endovascular technology improve.
本研究的目的是介绍在血管腔内治疗时代，单中心对降主动脉瘤（DTAA）进行择期治疗的经验。1997年7月至2005年5月，我们对173例降主动脉瘤患者进行了手术。共有52例患者（30.1%）接受了血管腔内支架植入修复术（第一组）。血管腔内修复仅用于手术风险高的患者，术前脊髓血管造影通常显示Adamkiewicz动脉的起源位于支架移植物覆盖区域之外。其余121例患者（69.9%）接受了开放手术修复（第二组），其中78例（64.5%）采用部分体外循环，43例（35.5%）采用深低温停循环。两组在年龄、慢性阻塞性肺疾病患病率、累及降主动脉上段或全长的动脉瘤数量以及认为脊髓血管造影不必要或显示Adamkiewicz动脉起源位于覆盖区域内的患者百分比方面存在显著差异。第一组的住院死亡率为15.4%（8/52），而第二组为5.0%（6/121）（p = 0.02）。血管腔内修复术后的5例死亡是由技术原因导致的。所有因脊髓缺血导致的神经功能缺损（9/121，7.4%），包括3.3%的不可逆弛缓性截瘫，均发生在第二组（p = 0.04）。本研究结果表明，当建议将高手术风险患者进行血管腔内修复时，开放手术修复可取得优异的效果。然而，由于术前脊髓血管造影是血管腔内修复的选择标准，死亡率的改善伴随着脊髓缺血并发症集中在接受开放手术修复的患者中。随着植入技术和血管腔内技术的改进，我们系列中与血管腔内修复相关的高死亡率应会降低。
