Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany.
Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany.
J Vasc Surg. 2019 Feb;69(2):357-366. doi: 10.1016/j.jvs.2018.05.216. Epub 2018 Oct 29.
The aim of our study was to analyze the incidence of spinal cord ischemia (SCI) in patients presenting with complex aortic aneurysms treated with endovascular aneurysm repair (EVAR) and to identify risk factors associated with this complication.
A retrospective study was undertaken of prospectively collected data including patients presenting with complex aortic aneurysm (pararenal abdominal aortic aneurysm and thoracoabdominal aortic aneurysm) treated with fenestrated EVAR (F-EVAR) or branched EVAR (B-EVAR). The primary end point was the incidence of SCI and the assessment of any associated factors.
Between January 2011 and August 2017, a total of 243 patients (mean aneurysm diameter, 65.2 ± 15.3 mm; mean age, 72.4 ± 7.5 years; 73% male) were treated with F-EVAR or B-EVAR. Asymptomatic patients were treated in 73% of the cases (177/243, in contrast to 27% urgent), and 52% (126/243) were treated for thoracoabdominal aortic aneurysm (in contrast to 48% for pararenal abdominal aortic aneurysm). F-EVAR (mean number of fenestrations, 3.3/case) and B-EVAR (mean number of branches, 3.7/case) were undertaken in 67% (164/243) and 33% (79/243), respectively. The total incidence of SCI was 17.7% [43/243; paraplegia in 4% (10/243) and paraparesis in 13.7% (33/243)]. Most of the patients with SCI presented with immediate postoperative symptoms (72% [31/43]). A spinal drain was preoperatively placed in 53% (130/243) and was associated with the prevention of SCI (SCI with spinal drainage, 12% [16/130]; SCI without spinal drainage, 24% [27/113]; P = .018). The 30-day mortality rate was 9% (21/243). After multiple logistic regression analysis, SCI was associated with preoperative renal function (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m: odds ratio [OR], 2.43; 95% confidence interval [CI], 1.18-4.99; P = .016) and the number of vertebral segments covered (SCI with higher position of proximal stent in terms of vertebra: OR, 1.2; 95% CI, 1.1-1.3; P = .000). A similar outcome was derived when the height of the proximal end of the stent graft was replaced by the total length of aortic coverage (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m: OR, 2.36 [95% CI, 1.11-5.00; P = .025]; SCI with longer length of aortic coverage: OR, 1.01 [95% CI, 1.003-1.009; P = .000]).
The majority of SCI incidence after F-EVAR or B-EVAR of complex aortic aneurysms is manifested immediately postoperatively. The use of preoperative spinal drainage may prevent SCI. Patients with GRF <60 mL/min/1.73 m and with longer aortic stent graft coverage are at higher risk of SCI.
本研究旨在分析接受血管内动脉瘤修复术（EVAR）治疗的复杂主动脉瘤患者发生脊髓缺血（SCI）的发生率，并确定与该并发症相关的危险因素。
回顾性分析前瞻性收集的数据，包括接受开窗 EVAR（F-EVAR）或分支 EVAR（B-EVAR）治疗的复杂主动脉瘤（肾周腹主动脉瘤和胸腹主动脉瘤）患者。主要终点是 SCI 的发生率和任何相关因素的评估。
2011 年 1 月至 2017 年 8 月，共 243 例患者（平均动脉瘤直径 65.2±15.3mm；平均年龄 72.4±7.5 岁；73%为男性）接受 F-EVAR 或 B-EVAR 治疗。无症状患者占 73%（177/243，而非 27%为紧急情况），52%（126/243）为胸腹主动脉瘤治疗（而非 48%为肾周腹主动脉瘤）。67%（164/243）和 33%（79/243）分别进行了 F-EVAR（平均开窗数为 3.3/例）和 B-EVAR（平均分支数为 3.7/例）。SCI 的总发生率为 17.7%[43/243；4%（10/243）为截瘫，13.7%（33/243）为截瘫]。大多数 SCI 患者表现为术后即刻症状（72%[31/43]）。53%（130/243）术前放置了脊髓引流管，与 SCI 的预防有关（有脊髓引流管的 SCI，12%[16/130]；无脊髓引流管的 SCI，24%[27/113]；P=0.018）。30 天死亡率为 9%（21/243）。多因素逻辑回归分析后，SCI 与术前肾功能（SCI 术前肾小球滤过率＜60ml/min/1.73m2：比值比[OR]，2.43；95%置信区间[CI]，1.18-4.99；P=0.016）和覆盖的椎体节段数（SCI 近端支架较高位置：OR，1.2；95%CI，1.1-1.3；P=0.000）相关。当支架移植物近端的高度被主动脉覆盖的总长度替代时，也得出了类似的结果（SCI 术前肾小球滤过率＜60ml/min/1.73m2：OR，2.36[95%CI，1.11-5.00；P=0.025]；SCI 主动脉覆盖更长长度：OR，1.01[95%CI，1.003-1.009；P=0.000]）。
F-EVAR 或 B-EVAR 治疗复杂主动脉瘤后 SCI 的发生率大多在术后即刻表现出来。术前使用脊髓引流可能预防 SCI。肾小球滤过率＜60ml/min/1.73m2和主动脉支架覆盖较长的患者发生 SCI 的风险更高。
