Setacci F, Sirignano P, De Donato G, Chisci E, Galzerano G, Massaroni R, Setacci C
Vascular and Endovascular Surgery, Department of Surgery, University of Siena, Siena, Italy.
J Cardiovasc Surg (Torino). 2010 Apr;51(2):169-76.
Spinal cord ischemia (SCI) is one of the most devastating complications undergoing surgical or endovascular repair of the thoracic aorta. The incidence of SCI after thoracic aorta open repair varies from 2% to 21%, depending on the extent of the descending thoracic aorta replacement compared with as high as 12% of cases after endovascular aortic repair. Endoluminal repair allows the avoidance of aortic cross clamping and its sequelae; however, the intercostal arteries covered by the stent graft cannot be reimplanted. Perioperative risk factors contributing to SCI have been reported to include length of aortic coverage, prior abdominal aortic aneurysm (AAA) repair, hypotension, and left subclavian artery coverage. Although the putative mechanism of loss of lumbar collateral perfusion in those who had prior aortic repairs appears reasonable, occurrence of SCI in this subset of patients has not been consistent. Spinal cord perfusion is dependent on the net pressure of the mean arterial pressure minus the mean intrathecal pressure. Systemic pressure can be maximized by volume resuscitation and vasopressors. Intrathecal spinal pressure can be minimized by drainage of the spinal cord, although this is not without its potential risks. More recently, there have been attempts at attenuating the cellular damage caused by SCI, either with systemic or intrathecal administration of pharmacologic agents, which attempt to mitigate the inflammatory response of cellular reperfusion. This is a review of the risk factors for SCI during TEVAR in patients with previous or concomitant treatment for aortic aneurysm.
脊髓缺血（SCI）是胸主动脉手术或血管内修复术中最具破坏性的并发症之一。胸主动脉开放修复术后SCI的发生率在2%至21%之间，具体取决于降主动脉置换的范围，而血管内主动脉修复术后的发生率高达12%。腔内修复可避免主动脉交叉钳夹及其后遗症；然而，被支架移植物覆盖的肋间动脉无法重新植入。据报道，导致SCI的围手术期危险因素包括主动脉覆盖长度、既往腹主动脉瘤（AAA）修复、低血压和左锁骨下动脉覆盖。虽然在那些既往有主动脉修复史的患者中，腰侧支灌注丧失的假定机制似乎合理，但这部分患者中SCI的发生并不一致。脊髓灌注取决于平均动脉压减去平均鞘内压的净压力。可通过液体复苏和血管升压药使全身压力最大化。可通过脊髓引流使鞘内脊髓压力最小化，但这并非没有潜在风险。最近，有人尝试通过全身或鞘内给药药理剂来减轻SCI引起的细胞损伤，这些药理剂试图减轻细胞再灌注的炎症反应。这是一篇关于在接受过主动脉瘤既往治疗或同时接受治疗的患者中，TEVAR期间SCI危险因素的综述。
