Okita Yutaka
Division of Cardiovascular Surgery, Department of Surgery, Kobe University, Kobe 650-0017, Japan.
Gen Thorac Cardiovasc Surg. 2011 Feb;59(2):79-90. doi: 10.1007/s11748-010-0668-x. Epub 2011 Feb 10.
Paraplegia or paraparesis after otherwise successful thoracic or thoracoabdominal aortic reconstruction is a devastating complication for both patient and physician. Various strategies have been developed to minimize the incidence of neurological complications after aortic surgery. The incidence of spinal cord ischemia and subsequent neurological complications has been correlated with (1) the duration and severity of ischemia, (2) failure to establish a spinal cord blood supply, and (3) reperfusion injury. Preoperative identification of the arteria radicularis magna, the artery of Adamkiewicz, facilitates identification of critical intercostal vessels for reimplantation, resulting in reestablishing spinal cord blood flow. Techniques for monitoring spinal cord function using evoked potentials have been developed, and surgical techniques have evolved to reduce the duration of ischemia. Furthermore, sequentially sacrificing all the intercostal arteries while maintaining collateral circulation to the cord has produced good outcomes. The severity of ischemia can be minimized by using cerebrospinal fluid drainage, hypothermia, distal bypass, managing the blood pressure, and adjunctive pharmacological therapy. Reperfusion injury can be reduced with the use of antioxidant therapy. Recent advances in endovascular stentgrafting have reduced the incidence of postoperative spinal complications, especially among high-risk patients.
在其他方面成功的胸主动脉或胸腹主动脉重建术后出现截瘫或轻瘫，对患者和医生来说都是一种毁灭性的并发症。已经制定了各种策略来尽量减少主动脉手术后神经并发症的发生率。脊髓缺血及随后的神经并发症发生率与以下因素相关：（1）缺血的持续时间和严重程度；（2）未能建立脊髓血供；（3）再灌注损伤。术前识别大根动脉（Adamkiewicz动脉）有助于识别用于再植入的关键肋间血管，从而重建脊髓血流。已经开发了使用诱发电位监测脊髓功能的技术，并且手术技术也在不断发展以缩短缺血持续时间。此外，在维持脊髓侧支循环的同时依次牺牲所有肋间动脉也取得了良好的效果。通过使用脑脊液引流、低温、远端旁路、控制血压和辅助药物治疗，可以将缺血的严重程度降至最低。使用抗氧化治疗可以减少再灌注损伤。血管内支架植入术的最新进展降低了术后脊髓并发症的发生率，尤其是在高危患者中。
