Tshomba Y, Baccellieri D, Mascia D, Kahlberg A, Rinaldi E, Melissano G, Chiesa R
Department of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy -
J Cardiovasc Surg (Torino). 2015 Oct;56(5):687-97. Epub 2015 Apr 14.
Extent IV thoracoabdominal aortic aneurysm (TAAA) open repair is considered relatively safer to repair than other extents of TAAA in terms of both perioperative mortality and spinal cord ischemia. Our purpose is to report our experience and to perform a literature review regarding extent IV TAAA open repair in order to provide an updated benchmark for comparison with any other alternative strategy in this aortic segment.
From 1993 to 2015 we performed 736 open repairs for TAAA (177 extent I, 196 extent II, 141 extent III, 222 extent IV). In extent IV group there were 164 men (73.9%) and the mean age was 67.4±9.3 years (range 32-84). The aneurysm etiology was degenerative in 198 patients (95.6%). Twelve patients (5.4%) underwent emergent operation. Totally abdominal approach was used in 22.0% of the cases. Until 2006 left heart bypass (LHBP) and cerebrospinal fluid drainage (CSFD) were almost never performed during extent IV repair. Since 2006 we changed our approach with a more aggressive use of LHBP (22.9%) and CSFD (43.4%) in 83 consecutive extent IV. Renal arteries perfusion was performed with 4 °C Ringer's solution until 2009 and with 4 °C Custodiol solution since September 2009 to date. Literature search was performed on several databases (PubMed, BioMedCentral, Embase, and the Cochrane Central Register of clinical trials). Research was updated on March 1th 2015.
Perioperative mortality in our overall group of TAAA and in the extents IV was 10.7% and 4.9%, respectively (P=0.01); spinal cord ischemia rate 11.4% and 2.7%, respectively (P=0.0001). In the extents IV treated between 2006 and 2015 we observed a further trend of outcomes improvement with a rate of perioperative mortality and spinal cord ischemia of 1.2%, and 2.4%, respectively. Database searches yielded a total of 767 articles. Excluding non-pertinent titles or abstracts, we retrieved in complete form and assessed 27 studies according to the selection criteria. Nine studies were further excluded because of our prespecified exclusion criteria. The final 18 manuscripts included a total of 2098 patients. In this group median mortality rate was 4.8% (interquartile range 3-6) and the mean incidence of spinal cord ischemia was 1.56±1.54%.
Perioperative outcomes after extent IV TAAA open repair were significantly better compared to our overall TAAA series. A more aggressive use of CSFD, LHBP and renal perfusion with Custodiol solution allowed a further trend of outcomes improvement in our series of extent IV TAAA open repair. Literature analysis confirmed during extent IV open repair very satisfactory perioperative outcomes with rates of mortality and spinal cord ischemia dropped to under 5% and 2%, respectively.
就围手术期死亡率和脊髓缺血而言，IV型胸腹主动脉瘤（TAAA）开放修复术被认为比其他类型的TAAA修复术相对更安全。我们的目的是报告我们的经验并对IV型TAAA开放修复术进行文献综述，以便提供一个最新的基准，用于与该主动脉段的任何其他替代策略进行比较。
1993年至2015年，我们对TAAA进行了736例开放修复术（I型177例，II型196例，III型141例，IV型222例）。IV型组有164名男性（73.9%），平均年龄为67.4±9.3岁（范围32 - 84岁）。198例患者（95.6%）的动脉瘤病因是退行性的。12例患者（5.4%）接受了急诊手术。22.0%的病例采用全腹部入路。直到2006年，在IV型修复术中几乎从未进行过左心旁路（LHBP）和脑脊液引流（CSFD）。自2006年以来，我们改变了方法，在连续83例IV型手术中更积极地使用LHBP（22.9%）和CSFD（43.4%）。2009年之前用4℃林格氏液进行肾动脉灌注，自2009年9月至今用4℃科多索尔溶液进行肾动脉灌注。在几个数据库（PubMed、BioMedCentral、Embase和Cochrane临床试验中央注册库）上进行了文献检索。研究于2015年3月1日更新。
我们整个TAAA组和IV型的围手术期死亡率分别为10.7%和4.9%（P = 0.01）；脊髓缺血率分别为11.4%和2.7%（P = 0.0001）。在2006年至2015年治疗的IV型病例中，我们观察到结果进一步改善的趋势，围手术期死亡率和脊髓缺血率分别为1.2%和2.4%。数据库搜索共得到767篇文章。排除不相关的标题或摘要后，我们根据选择标准完整检索并评估了27项研究。由于我们预先设定的排除标准，又排除了9项研究。最终的18篇手稿共纳入2098例患者。该组的中位死亡率为4.8%（四分位间距3 - 6），脊髓缺血的平均发生率为1.56±1.54%。
与我们整个TAAA系列相比，IV型TAAA开放修复术后的围手术期结果明显更好。更积极地使用CSFD、LHBP以及用科多索尔溶液进行肾灌注使我们的IV型TAAA开放修复术系列的结果有进一步改善的趋势。文献分析证实，在IV型开放修复术中围手术期结果非常令人满意，死亡率和脊髓缺血率分别降至5%和2%以下。
