Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of University of Pennsylvania, Philadelphia, PA 19104, USA.
J Vasc Surg. 2011 Sep;54(3):677-84. doi: 10.1016/j.jvs.2011.03.259. Epub 2011 May 14.
The purpose of this study was to assess the incidence, risk factors, and clinical manifestations of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR).
A retrospective review of a prospectively collected database was performed for all patients undergoing TEVAR at a single academic institution between July 2002 and June 2010. Preoperative demographics, procedure-related variables, and clinical details related to SCI were examined. Logistic regression analysis was performed to identify risk factors for the development of SCI.
Of the 424 patients who underwent TEVAR during the study period, 12 patients (2.8%) developed SCI. Mean age of this cohort with SCI was 69.6 years (range, 44-84 years), and 7 were women. One-half of these patients had prior open or endovascular aortic repair. Indication for surgery was either degenerative aneurysm (n = 8) or dissection (n = 4). Six TEVARs were performed electively, with the remaining done either urgently or emergently due to contained rupture (n = 2), dissection with malperfusion (n = 2), or severe back pain (n = 2). All 12 patients underwent extent C endovascular coverage. Multivariate regression analysis demonstrated chronic renal insufficiency to be independently associated with SCI (odds ratio [OR], 4.39; 95% confidence interval [CI], 1.2-16.6; P = .029). Onset of SCI occurred at a median of 10.6 hours (range, 0-229 hours) postprocedure and was delayed in 83% (n = 10) of patients. Clinical manifestations of SCI included lower extremity paraparesis in 9 patients and paraplegia in 3 patients. At SCI onset, average mean arterial pressure (MAP) and lumbar cerebrospinal fluid (CSF) pressure was 77 mm Hg and 10 mm Hg, respectively. Therapeutic interventions increased blood pressure to a significantly higher average MAP of 99 mm Hg (P = .001) and decreased lumbar CSF pressure to a mean of 7 mm Hg (P = .30) at the time of neurologic recovery. Thirty-day mortality was 8% (1 of 12 patients). The single patient who expired, never recovered any lower extremity neurologic function. All patients surviving to discharge experienced either complete (n = 9) or incomplete (n = 2) neurologic recovery. At mean follow-up of 49 months, 7 of 9 patients currently alive continued to exhibit complete, sustained neurologic recovery.
Spinal cord ischemia after TEVAR is an uncommon, but important complication. Preoperative renal insufficiency was identified as a risk factor for the development of SCI. Early detection and treatment of SCI with blood pressure augmentation alone or in combination with CSF drainage was effective in most patients, with the majority achieving complete, long-term neurologic recovery.
本研究旨在评估胸主动脉腔内修复术（TEVAR）后脊髓缺血（SCI）的发生率、危险因素和临床表现。
对 2002 年 7 月至 2010 年 6 月在一家学术机构接受 TEVAR 的所有患者进行前瞻性收集数据库的回顾性分析。研究了术前人口统计学、与手术相关的变量以及与 SCI 相关的临床细节。采用 logistic 回归分析确定 SCI 发生的危险因素。
在研究期间接受 TEVAR 的 424 名患者中，有 12 名（2.8%）发生 SCI。该 SCI 队列的平均年龄为 69.6 岁（范围，44-84 岁），其中 7 名为女性。其中一半患者既往有开放或血管内主动脉修复术史。手术指征为退行性动脉瘤（n=8）或夹层（n=4）。6 例 TEVAR 为择期进行，其余 2 例因破裂、2 例夹层伴灌注不良、2 例严重背痛而行紧急或紧急手术。所有 12 例患者均接受了 C 型腔内覆盖。多变量回归分析显示慢性肾功能不全与 SCI 独立相关（比值比[OR]，4.39；95%置信区间[CI]，1.2-16.6；P=0.029）。SCI 的发病时间中位数为术后 10.6 小时（范围，0-229 小时），83%（n=10）的患者发病延迟。SCI 的临床表现包括 9 例下肢不全瘫和 3 例截瘫。在 SCI 发病时，平均平均动脉压（MAP）和腰段脑脊液（CSF）压力分别为 77mmHg 和 10mmHg。血压升高到 99mmHg（P=0.001）和腰段 CSF 压力降低到 7mmHg（P=0.30）的平均水平时，治疗性干预可显著升高 MAP，并在神经恢复时降低平均 MAP。30 天死亡率为 8%（12 例患者中的 1 例）。唯一死亡的患者下肢神经功能从未恢复。所有存活至出院的患者均出现完全（n=9）或不完全（n=2）神经功能恢复。在平均 49 个月的随访中，9 名存活患者中的 7 名继续表现出完全、持续的神经功能恢复。
TEVAR 后脊髓缺血是一种不常见但很重要的并发症。术前肾功能不全被确定为 SCI 发生的危险因素。单独或联合使用血压升高和 CSF 引流来早期发现和治疗 SCI，在大多数患者中是有效的，大多数患者都实现了完全、长期的神经功能恢复。
