Toursavadkohi Shahab, Kakkos Stavros K, Rubinfeld Ilan, Shepard Alexander
Trauma Surgery, Henry Ford Hospital , Detroit, MI , USA.
Vascular Surgery, University Hospital of Patras , Patras , Greece.
Front Surg. 2016 Mar 31;3:18. doi: 10.3389/fsurg.2016.00018. eCollection 2016.
Although previous studies have documented the occurrence of microembolization during abdominal aortic aneurysm (AAA) repair by both open and endovascular approaches, no study has compared the downstream effects of these two repair techniques on lower extremity hemodynamics. In this prospective cohort study, 20 patients were treated with endovascular aneurysm repair (EVAR) (11 Zenith, 8 Excluder, and 1 Medtronic) and 18 patients with open repair (OR) (16 bifurcated grafts, 2 tube grafts). Pre- and postoperative ankle-brachial indices (ABIs) and toe-brachial indices (TBIs) were measured preoperatively and on postoperative day (POD) 1 and 5. Demographics and preoperative ABIs/TBIs were identical in EVAR (0.97/0.63) and OR (0.96/0.63) patients (p = 0.21). There was a significant decrease in ABIs/TBIs following both EVAR (0.83/0.52, p = 0.01) and OR (0.73/0.39, p = 0.003) on POD #1, although this decrease was greater following OR than EVAR (p = 0.002). This difference largely resolved by POD #5 (p = 0.41). In the OR group, TBIs in the limb in which flow was restored first was significantly reduced compared to the contralateral limb (0.50 vs. 0.61, p = 0.03). In the EVAR group, there was also a difference in TBIs between the main body insertion side and the contralateral side (0.50 vs. 0.59, p = 0.02). Deterioration of lower extremity perfusion pressures occurs commonly after AAA repair regardless of repair technique. Toe perfusion is worse in the limb opened first during OR and on the main body insertion side following EVAR, suggesting that microembolization plays a major role in this deterioration. The derangement following OR is more profound than after EVAR on POD #1, but recovers rapidly. This finding suggests that microembolizarion may be worse with OR or alternatively that other factors associated with OR (e.g., the hemodynamic response to surgery with redistribution of flow to vital organs peri-operatively) may play a role.
尽管先前的研究已经记录了在腹主动脉瘤（AAA）修复过程中，无论是开放手术还是血管腔内修复手术都会发生微栓塞现象，但尚无研究比较这两种修复技术对下肢血流动力学的下游影响。在这项前瞻性队列研究中，20例患者接受了血管腔内动脉瘤修复术（EVAR）（11例使用Zenith支架，8例使用Excluder支架，1例使用美敦力支架），18例患者接受了开放修复术（OR）（16例使用分叉移植物，2例使用直管移植物）。术前以及术后第1天和第5天测量踝肱指数（ABI）和趾肱指数（TBI）。EVAR组（0.97/0.63）和OR组（0.96/0.63）患者的人口统计学特征和术前ABI/TBI相同（p = 0.21）。在术后第1天，EVAR组（0.83/0.52，p = 0.01）和OR组（0.73/0.39，p = 0.003）的ABI/TBI均显著下降，尽管OR组的下降幅度大于EVAR组（p = 0.002）。到术后第5天，这种差异基本消失（p = 0.41）。在OR组中，首先恢复血流的肢体的TBI与对侧肢体相比显著降低（0.50对0.61，p = 0.03）。在EVAR组中，主体支架置入侧与对侧的TBI也存在差异（0.50对0.59，p = 0.02）。无论采用何种修复技术，AAA修复术后下肢灌注压通常都会恶化。在OR手术中首先开放的肢体以及EVAR术后主体支架置入侧的趾部灌注更差，这表明微栓塞在这种恶化中起主要作用。术后第1天，OR组的紊乱比EVAR组更严重，但恢复迅速。这一发现表明，OR手术中的微栓塞可能更严重，或者与OR相关的其他因素（例如，手术期间血流重新分布到重要器官的血流动力学反应）可能起作用。
