Schlösser Felix J V, Verhagen Hence J M, Lin Peter H, Verhoeven Eric L G, van Herwaarden Joost A, Moll Frans L, Muhs Bart E
Section of Vascular Surgery, Yale University, New Haven, Connecticut 06510, USA.
J Vasc Surg. 2009 Feb;49(2):308-14; discussion 314. doi: 10.1016/j.jvs.2008.07.093. Epub 2008 Dec 20.
Evidence regarding the impact of prior abdominal aortic aneurysm (AAA) repair on the risk of neurological deficit after thoracic endovascular aortic aneurysm repair (TEVAR) is lacking. The purpose of this study was to characterize the risk of TEVAR-related neurological deficit in patients who previously underwent infrarenal AAA surgery.
Prospective maintained databases of patients undergoing TEVAR in the participating institutions were searched for patients with a history of prior AAA surgery before TEVAR. Patient and procedural characteristics and postoperative mortality and morbidity were subsequently centrally collected and systematically entered in a database. Univariate and multivariate logistic regression were performed associating variables with postoperative spinal cord ischemia (SCI).
Seventy-two patients were identified that underwent TEVAR after prior AAA repair. The risk of SCI was 12.5% (n = 9) and significantly higher than the 1.7% risk of SCI in patients without prior AAA repair (relative risk [RR] 7.2, 95% confidence interval [CI] 2.6 to 19.6, P < .0001). Symptoms of SCI completely resolved in 4 patients with prior AAA repair. Univariate analysis demonstrated that the following variables were significant predictors of SCI in patients with prior AAA repair: preoperative renal insufficiency (odds ratio [OR] 29.5; 95% CI 5.3-164, P < .001), increased length of aorta coverage by TEVAR (OR 1.1; 95% CI 1.0-1.2, P .039) and a lengthened time interval between prior AAA repair and TEVAR (OR 1.2; 95% CI 1.0-1.4, P .026). Preoperative renal insufficiency was also significantly associated with the risk of SCI in multivariate analysis (P .011).
Prior infrarenal AAA repair is associated with dramatic increased risk of SCI after TEVAR compared to patients without prior AAA surgery. Preoperative renal insufficiency appears to be an important predictor of SCI after TEVAR in patients with prior AAA repair. A thorough understanding of the risk profile in patients requiring TEVAR following prior AAA surgery is essential when determining appropriate surgical recommendations. If the diameter and rupture risk are large and TEVAR is indicated, the best available care should be offered for maximal protection of the spinal cord in these patients.
目前缺乏关于既往腹主动脉瘤（AAA）修复对胸主动脉腔内修复术（TEVAR）后神经功能缺损风险影响的证据。本研究的目的是明确既往接受过肾下腹主动脉瘤手术的患者发生TEVAR相关神经功能缺损的风险。
在参与研究的机构中，检索前瞻性维护的接受TEVAR治疗患者的数据库，以查找在TEVAR之前有AAA手术史的患者。随后集中收集患者和手术特征以及术后死亡率和发病率，并系统地录入数据库。进行单因素和多因素逻辑回归分析，将变量与术后脊髓缺血（SCI）相关联。
共识别出72例既往接受AAA修复后接受TEVAR治疗的患者。SCI风险为12.5%（n = 9），显著高于无AAA手术史患者1.7%的SCI风险（相对风险[RR] 7.2，95%置信区间[CI] 2.6至19.6，P <.0001）。4例既往接受AAA修复的患者SCI症状完全缓解。单因素分析表明，以下变量是既往接受AAA修复患者发生SCI的显著预测因素：术前肾功能不全（比值比[OR] 29.5；95% CI 5.3 - 164，P <.001）、TEVAR覆盖主动脉的长度增加（OR 1.1；95% CI 1.0 - 1.2，P.039）以及既往AAA修复与TEVAR之间的时间间隔延长（OR 1.2；95% CI 1.0 - 1.4，P.026）。多因素分析中，术前肾功能不全也与SCI风险显著相关（P.011）。
与无AAA手术史的患者相比，既往肾下腹主动脉瘤修复与TEVAR后SCI风险显著增加相关。术前肾功能不全似乎是既往接受AAA修复患者TEVAR后发生SCI的重要预测因素。在确定合适的手术建议时，全面了解既往接受AAA手术后需要TEVAR的患者的风险特征至关重要。如果动脉瘤直径大且有破裂风险且需要进行TEVAR，应提供最佳可用治疗以最大程度保护这些患者的脊髓。
