Shiiya Norihiko, Washiyama Naoki, Tsuda Kazumasa, Yamanaka Ken, Takahashi Daisuke, Yamashita Katsushi, Natsume Kayoko, Takeuchi Yuki, Kubota Suguru, Matsui Yoshiro
First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan.
Department of Cardiovascular and Thoracic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
Gen Thorac Cardiovasc Surg. 2019 Jan;67(1):187-191. doi: 10.1007/s11748-017-0838-1. Epub 2017 Sep 20.
Operative mortality and morbidity after thoracoabdominal aortic surgery remain high. We report our strategy and outcomes, especially those of spinal cord protection.
Outcomes of 178 patients (age: 26-88 years) who underwent thoracoabdominal aortic replacement were retrospectively analyzed. 65 had aortic dissection, 14 had infected aneurysms, and 22 presented with rupture. Operations were non-elective in 24 and redo through re-thoracotomy in 21. Extent of replacement was Crawford-I in 39, II in 26, III in 78, and IV in 35. Staged repair was recently preferred, which resulted in decrease in extent II repair and increase in redo since 2009. Operations were performed under distal aortic perfusion and multi-segmental sequential repair to maximize collateral blood flow, and deep hypothermic circulatory arrest was preserved for those requiring open aortic anastomosis (n = 20). A total of 166 separate grafts were used for intercostal reconstruction in 88 patients, which was guided by preoperative feeding artery localization. Their patency was studied by postoperative MD-CT in 74 patients for 145 grafts.
There were 3.9% hospital mortality and 5.1% spinal cord injury. Preoperative feeding artery localization resulted in reduced number of reconstruction and improved patency, and grafts connecting to the feeding artery were patent in 92%. Results of redo operations were not different (no mortality and spinal cord injury) from the de novo operations.
Our concept of spinal cord protection, which was based on selective intercostal reconstruction while maximizing spinal cord collateral blood flow, seems justified.
胸腹主动脉手术后的手术死亡率和发病率仍然很高。我们报告我们的策略和结果，尤其是脊髓保护方面的结果。
回顾性分析178例（年龄26 - 88岁）接受胸腹主动脉置换术患者的结果。65例为主动脉夹层，14例为感染性动脉瘤，22例为破裂。24例手术为非择期，21例通过再次开胸进行再次手术。置换范围为Crawford - I型39例，II型26例，III型78例，IV型35例。近年来更倾向于分期修复，自2009年以来导致II型修复范围减少，再次手术增加。手术在远端主动脉灌注和多节段序贯修复下进行，以最大限度地增加侧支血流，对于需要开放主动脉吻合的患者（n = 20）保留深低温循环停搏。88例患者共使用166个单独的移植物进行肋间重建，术前通过定位供血动脉进行指导。术后通过MD - CT对74例患者的145个移植物研究其通畅情况。
医院死亡率为3.9%，脊髓损伤率为5.1%。术前供血动脉定位减少了重建数量并提高了通畅率，连接供血动脉的移植物通畅率为92%。再次手术结果与初次手术无异（无死亡和脊髓损伤）。
我们基于选择性肋间重建同时最大限度增加脊髓侧支血流的脊髓保护理念似乎是合理的。
