Kato Masaaki, Motoki Manabu, Isaji Toshihiko, Suzuki Takahiro, Kawai Yusuke, Ohkubo Nobukazu
Department of Cardiovascular Surgery, Morinomiya Hospital, Osaka, Japan
Department of Cardiovascular Surgery, Morinomiya Hospital, Osaka, Japan.
Eur J Cardiothorac Surg. 2015 Oct;48(4):571-7. doi: 10.1093/ejcts/ezu497. Epub 2014 Dec 18.
Postoperative spinal cord injury (SCI) is a devastating complication of surgical repair for thoracoabdominal aortic aneurysm or dissection (TAAD), despite the complex reconstruction of inter-costal or lumbar arteries involved in the surgery. As an alternative technique, endovascular thoracoabdominal aneurysm repair (EVTAR) with visceral artery reconstruction has been accepted as a treatment option for severe comorbid patients of TAAD, because there is a permissible frequency of SCI after EVTAR in spite of no reconstruction of inter-costal or lumbar arteries. We report the results of EVTAR at our hospital with a focus on spinal cord injury.
We analyzed data from 54 consecutive patients with TAAD (mean age, 74 ± 9.6 years; 42 men) who underwent EVTAR at our hospital between February 2007 and February 2014. Three types of EVTAR technique were used: fenestrated and/or branched stent graft implantation in 39 patients, a hybrid technique (bypass grafts to visceral arteries and straight stent graft implantation) in 10 patients, and intentional coverage of the coeliac artery and straight stent graft implantation in 5 patients. In all patients, mean systemic blood pressure was maintained at ≥80 mmHg. Opioid use was avoided in the perioperative period.
According to the Crawford classification, the graft coverage extent was 9% (5/54) in type I, 11% (6/54) in type II, 39% (21/54) in type III, 22%(12/54) in type IV and 19% (10/54) in type V. In most patients (74%, 40/54), cerebrospinal fluid drainage was done intraoperatively and 1 day postoperatively. Hospital mortality was 5.6% (3/54). No patient developed SCI in the perioperative period. However, in the follow-up period 2 patients developed paraplegia as a consequence of shock caused by an aortic event.
With close attention to spinal cord protection, EVTAR may be associated with only a low incidence of SCI in the perioperative period. Therefore, EVTAR is expected to become a promising treatment option for appropriately selected patients with TAAD.
尽管胸腹主动脉瘤或夹层（TAAD）手术修复涉及复杂的肋间或腰动脉重建，但术后脊髓损伤（SCI）仍是该手术极具破坏性的并发症。作为一种替代技术，带内脏动脉重建的血管腔内胸腹主动脉瘤修复术（EVTAR）已被视为TAAD严重合并症患者的一种治疗选择，因为尽管未重建肋间或腰动脉，但EVTAR术后SCI的发生率在可允许范围内。我们报告我院EVTAR的结果，重点关注脊髓损伤情况。
我们分析了2007年2月至2014年2月期间在我院接受EVTAR的54例连续性TAAD患者（平均年龄74±9.6岁；42例男性）的数据。采用了三种类型的EVTAR技术：39例患者行开窗和/或分支支架植入术，10例患者行杂交技术（内脏动脉搭桥移植和直型支架植入），5例患者行腹腔干动脉有意覆盖和直型支架植入。所有患者的平均体循环血压维持在≥80 mmHg。围手术期避免使用阿片类药物。
根据Crawford分类，I型移植物覆盖范围为9%（5/54），II型为11%（6/54），III型为39%（21/54），IV型为22%（12/54），V型为19%（10/54）。大多数患者（74%，40/54）在术中及术后1天进行了脑脊液引流。医院死亡率为5.6%（3/54）。围手术期无患者发生SCI。然而，在随访期间，2例患者因主动脉事件导致的休克而发生截瘫。
密切关注脊髓保护，EVTAR在围手术期SCI的发生率可能较低。因此，对于适当选择的TAAD患者，EVTAR有望成为一种有前景的治疗选择。
