Coselli Joseph S, Green Susan Y, Price Matt D, Zhang Qianzi, Preventza Ourania, de la Cruz Kim I, Whitlock Richard, Amarasekara Hiruni S, Woodside Sandra J, Perez-Orozco Andre, LeMaire Scott A
Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex.
Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex.
J Thorac Cardiovasc Surg. 2020 Jan;159(1):1-13. doi: 10.1016/j.jtcvs.2019.01.120. Epub 2019 Feb 12.
Crawford extent II repairs are the most extensive thoracoabdominal aortic aneurysm operations and pose the greatest risk of postoperative spinal cord deficit. We sought to examine spinal cord deficit after open extent II thoracoabdominal aortic aneurysm repair to identify predictors of the most serious type: persistent paraplegia or paraparesis.
We included 1114 extent II thoracoabdominal aortic aneurysm repairs performed from 1991 to 2017. Intercostal/lumbar artery reattachment (n = 959, 86.1%) and cerebrospinal fluid drainage (n = 698, 62.7%) were used to mitigate the risk of postoperative spinal cord deficit. We used univariate and multivariable analyses to examine spinal cord deficit and identify predictors of persistent paraplegia or paraparesis, defined as paraplegia or paraparesis present at the time of early death or hospital discharge.
Spinal cord deficit developed after 151 (13.6%) repairs: 86 (7.7%) cases of persistent paraplegia or paraparesis (51 paraplegia; 35 paraparesis) and 65 (6.1%) cases of transient paraplegia or paraparesis. Patients with spinal cord deficit were older (median 68 vs 65 years, P < .001) and had more rupture (6.6% vs 2.2%, P = .002) and urgent/emergency repair (25.2% vs 16.9%, P = .01) than those without. Persistent paraplegia or paraparesis developed immediately in 47 patients (4.2%) and was delayed in 39 patients (3.5%). Urgent/emergency repair (relative risk ratio, 2.31; P = .002), coronary artery disease (relative risk ratio, 1.80, P = .01), and chronic symptoms (relative risk ratio, 1.76, P = .02) independently predicted persistent paraplegia or paraparesis. Reattaching intercostal/lumbar arteries (relative risk ratio, 0.38, P < .001) and heritable disease (relative risk ratio, 0.36, P = .01) were protective. Early and late survival were poorer in those with persistent paraplegia or paraparesis than in those without.
Spinal cord deficit after extent II thoracoabdominal aortic aneurysm repairs remains concerning; survival is worse in patients with persistent paraplegia or paraparesis. The complexity of spinal cord deficit and persistent paraplegia or paraparesis warrant further study.
克劳福德Ⅱ型修复术是最广泛的胸腹主动脉瘤手术，术后脊髓功能缺损风险最大。我们试图研究开放性Ⅱ型胸腹主动脉瘤修复术后的脊髓功能缺损情况，以确定最严重类型（持续性截瘫或轻截瘫）的预测因素。
我们纳入了1991年至2017年期间进行的1114例Ⅱ型胸腹主动脉瘤修复术。采用肋间/腰动脉再植术（n = 959，86.1%）和脑脊液引流术（n = 698，62.7%）来降低术后脊髓功能缺损的风险。我们使用单因素和多因素分析来研究脊髓功能缺损情况，并确定持续性截瘫或轻截瘫的预测因素，持续性截瘫或轻截瘫定义为在早期死亡或出院时存在的截瘫或轻截瘫。
151例（13.6%）修复术后出现脊髓功能缺损：86例（7.7%）持续性截瘫或轻截瘫（51例截瘫；35例轻截瘫）和65例（6.1%）短暂性截瘫或轻截瘫。出现脊髓功能缺损的患者年龄更大（中位年龄68岁对65岁，P <.001），与未出现脊髓功能缺损的患者相比，破裂情况更多（6.6%对2.2%，P =.002），急诊/紧急修复手术更多（25.2%对16.9%，P =.01）。47例患者（4.2%）立即出现持续性截瘫或轻截瘫，39例患者（3.5%）出现延迟性截瘫或轻截瘫。急诊/紧急修复手术（相对风险比，2.31；P =.002）冠状动脉疾病（相对风险比，1.80，P =.01）和慢性症状（相对风险比，1.76，P =.02）独立预测持续性截瘫或轻截瘫。肋间/腰动脉再植术（相对风险比，0.38，P <.001）和遗传性疾病（相对风险比，0.36，P =.01）具有保护作用。持续性截瘫或轻截瘫患者的早期和晚期生存率低于未出现该情况的患者。
Ⅱ型胸腹主动脉瘤修复术后的脊髓功能缺损仍然令人担忧；持续性截瘫或轻截瘫患者的生存率更差。脊髓功能缺损以及持续性截瘫或轻截瘫的复杂性值得进一步研究。
