Mastroroberto P, Ciranni S, Indolfi C
Aortic Center, Department of Experimental and Clinical Medicine, Magna Græcia University, Catanzaro, Italy -
J Cardiovasc Surg (Torino). 2013 Aug;54(4):523-30. Epub 2013 Feb 1.
The study aims to analyze retrospective results of extensive endovascular repair of the descending thoracic aorta with special attention to spinal cord malperfusion.
From April 2002 through November 2011, 21 patients underwent stent-graft coverage of the thoracic aorta from the aortic arch at the origin of the left subclavian artery to the celiac trunk, 6 (mean age =72.3±8.1) for aneurysm disease, 13 (mean age =74.3±8.4) for type B aortic dissection and 2 (mean age =52.1±6.5) for aortic rupture. The mean of aortic diameter in cases with aneurysm disease was 7.1±1.6 cm and the causes of aortic rupture were post-traumatic and aneurysm pathology respectively. In all cases needing coverage of the left subclavian artery duplex ultrasonography and flowmetry were performed to evaluate patency and flow of both the vertebral arteries.
Technical success was 100% with 0% in-hospital mortality. The left subclavian artery was crossed with the uncovered portion of the stent-graft in 11 cases (52.4%) and the covered segment in the other 10 patients (47.6%) without subclavian revascularization because no pre-operative hemodynamic alterations of vertebral arteries were revealed by duplex ultrasonography. The incidence of paraplegia was 9.5% in 2 patients who had prior abdominal aortic aneurysm repair: the first case with preoperative type B aortic dissection presented significant lower extremity paresis within 24 hours after the procedure and in the second patient with a large thoracic aneurysm the signs of paraplegia were evident 3 weeks after discharge from Hospital probably due to delayed occlusion of a major medullary artery. The cumulative survival rate after 1, 3 and 9 years was 91%, 81%, and 71%.
The coverage of the entire thoracic aorta is an effective procedure with high probability of success. Spinal cord malperfusion remains a serious complication especially in patients with prior aortic surgery but if collateral blood supply is maintained the occlusion of intercostal arteries do not determine paraplegia or paraparesis. In order to consider acute or chronic occlusion of subclavian, lumbar or hypogastric arteries so preventing spinal cord ischemia, strong preoperative evaluation including analysis of previous surgery for abdominal aortic aneurysm repair and avoidance of T12 aortic segment coverage if feasible is mandatory.
本研究旨在分析降主动脉广泛血管腔内修复术的回顾性结果，特别关注脊髓灌注不良情况。
2002年4月至2011年11月，21例患者接受了从左锁骨下动脉起始处的主动脉弓至腹腔干的胸主动脉覆膜支架置入术，其中6例（平均年龄=72.3±8.1岁）为动脉瘤疾病，13例（平均年龄=74.3±8.4岁）为B型主动脉夹层，2例（平均年龄=52.1±6.5岁）为主动脉破裂。动脉瘤疾病患者的主动脉平均直径为7.1±1.6 cm，主动脉破裂的原因分别为创伤后和动脉瘤病变。在所有需要覆盖左锁骨下动脉的病例中，均进行了双功超声检查和血流测量，以评估双侧椎动脉的通畅情况和血流。
技术成功率为100%，院内死亡率为0%。11例（52.4%）患者的左锁骨下动脉被支架移植物的未覆盖部分穿过，另外10例（47.6%）患者的左锁骨下动脉被覆盖部分穿过，均未进行锁骨下动脉血运重建，因为双功超声检查未发现术前椎动脉血流动力学改变。2例曾接受腹主动脉瘤修复术的患者发生截瘫，发生率为9.5%：第一例术前为B型主动脉夹层，术后24小时内出现明显下肢轻瘫；第二例为巨大胸主动脉瘤患者，出院3周后截瘫体征明显，可能是由于一支主要脊髓动脉延迟闭塞所致。1年、3年和9年的累积生存率分别为91%、81%和71%。
整个胸主动脉的覆盖是一种成功率较高的有效手术。脊髓灌注不良仍然是一种严重并发症，尤其是在既往接受过主动脉手术的患者中，但如果维持侧支血供，肋间动脉闭塞并不一定会导致截瘫或轻瘫。为了考虑锁骨下动脉、腰动脉或下腹动脉的急性或慢性闭塞从而预防脊髓缺血，必须进行严格的术前评估，包括分析既往腹主动脉瘤修复手术情况，可行时避免覆盖T12主动脉节段。
