Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany.
Ann Thorac Surg. 2013 Jul;96(1):31-8. doi: 10.1016/j.athoracsur.2013.03.010. Epub 2013 May 11.
Examination of a large collective combined with individual case analyses may give new insights into mechanisms and prevention of spinal cord ischemia (SCI) after thoracic endovascular repair.
In an 11-year period, stent-grafts were implanted in 406 patients for various aortic pathologic conditions. The mean age was 63 years (15-91 years) and 300 (74%) patients were men; 58 patients underwent staged thoracic stent-graft procedures. The length of aorta covered was between 75 and 584 mm (mean, 204 mm). Thoracoabdominal branched or fenestrated stent-grafts were implanted in 11 patients. The left subclavian artery was occluded in 161 patients (39%); this occurred in half of them (n = 78) after protective revascularization. Prophylactic cerebrospinal fluid (CSF) drainage was used selectively in 4 cases; no neuromonitoring was used.
The incidence of SCI was 2.7% (n = 11); 6 patients (1.5%) had major permanent deficits. Conditions that had a potential influence on SCI were analyzed. Statistical correlation was found for previous conventional or endovascular abdominal aortic aneurysm repair (odds ratio [OR], 4.8), coverage of the entire descending thoracic aorta (OR, 3.6), and implantation of thoracoabdominal branched and fenestrated stent-grafts (OR, 9.5). Individual analyses revealed other conditions that might have played a role, such as embolization into the segmental arteries, severe visceral ischemia, profound hemorrhagic shock, and heparin-induced thrombocytopenia.
The incidence of SCI is unexpectedly low despite extensive sacrifice of intercostal arteries. Extended coverage of the thoracic and thoracoabdominal aorta seems to have a higher risk, but other factors may contribute to the individual disaster.
对大量病例进行检查并结合个别病例分析，可能会深入了解胸主动脉腔内修复术后脊髓缺血（SCI）的发生机制和预防措施。
在 11 年期间，对 406 例不同主动脉病变患者实施了支架置入术。患者平均年龄为 63 岁（15-91 岁），其中 300 例（74%）为男性；58 例患者接受分期胸主动脉支架置入术。覆盖的主动脉长度为 75-584mm（平均 204mm）。11 例患者植入了胸腹分支或开窗支架。161 例（39%）患者的左锁骨下动脉被闭塞，其中半数（n=78）在进行保护性血管重建后发生。4 例选择性使用预防性脑脊液（CSF）引流；未使用神经监测。
SCI 的发生率为 2.7%（n=11）；6 例（1.5%）患者出现严重永久性神经功能缺损。对可能影响 SCI 的因素进行了分析。发现先前的传统或腔内腹主动脉瘤修复（比值比 [OR]，4.8）、整个降胸主动脉的覆盖（OR，3.6）以及胸腹分支和开窗支架的植入（OR，9.5）与 SCI 具有相关性。个别分析还揭示了其他可能起作用的因素，如节段性动脉栓塞、严重内脏缺血、严重出血性休克和肝素诱导的血小板减少症。
尽管广泛牺牲了肋间动脉，但 SCI 的发生率仍出人意料地低。胸主动脉和胸腹主动脉的广泛覆盖似乎风险更高，但其他因素可能导致个别灾难。
