Aortic Centre, Hôpital Cardiologique, CHRU de Lille, INSERM U1008, Université Lille Nord de France, 59037 Lille Cedex, France.
King's Health Partners, London, UK.
Eur J Vasc Endovasc Surg. 2015 Mar;49(3):248-54. doi: 10.1016/j.ejvs.2014.11.017. Epub 2015 Jan 6.
OBJECTIVE/BACKGROUND: Spinal cord ischemia (SCI) is a devastating complication following endovascular thoracoabdominal aortic aneurysm (TAAA) repair. In an attempt to reduce its incidence two peri-procedural changes were implemented by the authors in January 2010: (i) all large sheaths are withdrawn from the iliac arteries immediately after deploying the central device and before cannulation and branch extension to the visceral vessels; (ii) the peri-operative protocol has been modified in an attempt to optimize oxygen delivery to the sensitive cells of the cord (aggressive blood and platelet transfusion, median arterial pressure monitoring >85 mmHg, and systematic cerebrospinal fluid drainage).
Between October 2004 and December 2013, 204 endovascular TAAA repairs were performed using custom made devices manufactured with branches and fenestrations to maintain visceral vessel perfusion. Data from all of these procedures were prospectively collected in an electronic database. Early post-operative results in patients treated before (group 1, n = 43) and after (group 2, n = 161 patients) implementation of the modified implantation and peri-operative protocols were compared.
Patients in groups 1 and 2 had similar comorbidities (median age at repair 70.9 years [range 65.2-77.0 years]), aneurysm characteristics (median diameter 58.5 mm [range 53-65 mm]), and length of procedure (median 190 minutes [range 150-240 minutes]). The 30 day mortality rate was 11.6% in group 1 versus 5.6% in group 2 (p = .09). The SCI rate was 14.0% versus 1.2% (p < .01). If type IV TAAAs were excluded from this analysis, the SCI rate was 25.0% (6/24 patients) in group 1 versus 2.1% (2/95 patients) in group 2 (p < .01).
The early restoration of arterial flow to the pelvis and lower limbs, and aggressive peri-operative management significantly reduces SCI following type I-III TAAA endovascular repair. With the use of these modified protocols, extensive TAAA endovascular repairs are associated with low rates of SCI.
目的/背景：脊髓缺血（SCI）是血管内胸腹主动脉瘤（TAAA）修复后一种破坏性的并发症。为了降低其发生率，作者于 2010 年 1 月实施了两项围手术期改变：（i）在部署中央器械后，所有大鞘管立即从髂动脉中撤出，然后再进行内脏血管的插管和分支扩张；（ii）修改围手术期方案，试图优化脊髓敏感细胞的氧输送（积极输血和血小板、监测平均动脉压＞85mmHg 以及系统性脑脊液引流）。
2004 年 10 月至 2013 年 12 月，使用定制的设备进行了 204 例血管内 TAAA 修复，这些设备制造时带有分支和开窗以维持内脏血管灌注。所有这些手术的数据都被前瞻性地收集在一个电子数据库中。比较了接受改良植入和围手术期方案治疗前（组 1，n=43 例）和治疗后（组 2，n=161 例）患者的早期术后结果。
组 1 和组 2 的患者合并症（修复时的中位年龄为 70.9 岁[范围 65.2-77.0 岁]）、动脉瘤特征（中位直径为 58.5mm[范围 53-65mm]）和手术时间（中位 190 分钟[范围 150-240 分钟]）相似。组 1 的 30 天死亡率为 11.6%，组 2 为 5.6%（p=0.09）。SCI 发生率分别为 14.0%和 1.2%（p＜0.01）。如果将 IV 型 TAAA 排除在本分析之外，组 1 的 SCI 发生率为 25.0%（24 例患者中有 6 例），组 2 为 2.1%（95 例患者中有 2 例）（p＜0.01）。
早期恢复骨盆和下肢的动脉血流以及积极的围手术期管理显著降低了 I-III 型 TAAA 血管内修复后的 SCI 发生率。使用这些改良方案，广泛的 TAAA 血管内修复与 SCI 发生率低有关。
