Yang Gary K, Misskey Jonathan, Arsenault Kyle, Gagnon Joel, Janusz Michael, Faulds Jason
Division of Vascular Surgery, University of British Columbia, Vancouver, BC, Canada.
Division of Vascular Surgery, University of British Columbia, Vancouver, BC, Canada.
Ann Vasc Surg. 2019 Nov;61:124-133. doi: 10.1016/j.avsg.2019.04.022. Epub 2019 Jul 22.
Adjuncts for early detection and treatment of spinal cord ischemia (SCI) in thoracic aortic surgery are supported by robust clinical experience in open repair. The utility of cerebrospinal fluid (CSF) drainage and neurophysiologic monitoring (NPM) in thoracic endovascular aortic repair (TEVAR) is less clear. The purpose of this investigation is to determine the influence of a selective institutional spinal cord protection protocol using prophylactic NPM and CSF on outcomes for standard TEVAR.
Patients undergoing standard TEVAR entered into a prospectively maintained database from a single institution from 2007 to 2016 were retrospectively reviewed. Preoperative characteristics, aneurysm extent, and etiology were reviewed. Utilization of CSF drains including volume of fluid removed, duration of drainage, and catheter-related complications were collected. NPM data were reviewed to determine the influence on intraoperative management. Exact logistic regression was used to identify independent predictors of SCI.
Of 223 patients undergoing TEVAR, 130 met inclusion criteria for the study. CSF drains were used in 71 patients (54.6%), and 56 of 130 (43%) had NPM. SCI occurred in 7 patients (5.4%), of whom 5 had partial or complete recovery. Median time to symptoms of SCI was delayed in all cases (median 52 hr, range 8-312), and none of the 4 of 7 patients with adjunct NPM demonstrated intraoperative changes. Intraoperative changes in NPM occurred in 26 (46%), and represented unilateral leg ischemia in all but 2 cases. In both patients, changes consistent with SCI were associated with intraoperative hypotension and resolved with blood pressure augmentation. Neither patient developed postoperative SCI. Median length of stay (22 vs. 9 days, P = 0.012), operative room time (262 vs. 209, P = 0.040), and perioperative mortality (28.6% vs. 4.1%, P = 0.046) were significantly higher for patients with SCI versus those without. Length of aortic coverage was found to be the sole independent predictor of SCI (odds ratio 8.2, P = 0.026). Complications related to CSF drainage occurred in 4 patients (5.6%) with major complications occurring in 2 patients (2.8%), including 1 with an intrathecal hematoma and permanent bilateral paraparesis.
Selective use of prophylactic CSF drainage in TEVAR was associated with moderate risk and questionable benefit. The use of neurophysiological monitoring allowed for early detection and treatment of spinal ischemia, but its utility is limited by logistical factors and to the minority of patients with intraoperative spinal ischemic events.
在开放性修复的胸主动脉手术中，脊髓缺血（SCI）早期检测和治疗的辅助手段有丰富的临床经验支持。脑脊液（CSF）引流和神经生理监测（NPM）在胸主动脉腔内修复术（TEVAR）中的作用尚不清楚。本研究的目的是确定使用预防性NPM和CSF的选择性机构脊髓保护方案对标准TEVAR结果的影响。
回顾性分析2007年至2016年在单一机构前瞻性维护数据库中接受标准TEVAR的患者。回顾术前特征、动脉瘤范围和病因。收集CSF引流的使用情况，包括引流液量、引流持续时间和导管相关并发症。回顾NPM数据以确定其对术中管理的影响。采用精确逻辑回归分析确定SCI的独立预测因素。
在223例行TEVAR的患者中，130例符合研究纳入标准。71例患者（54.6%）使用了CSF引流，130例中有56例（43%）进行了NPM。7例患者（5.4%）发生了SCI，其中5例部分或完全恢复。所有病例中，SCI症状出现的中位时间均延迟（中位时间52小时，范围8 - 312小时），7例接受辅助NPM的患者中，4例在术中均未出现变化。26例（46%）患者术中NPM出现变化，除2例患者外，其余均表现为单侧下肢缺血。这2例患者中，与SCI一致的变化均与术中低血压有关，血压升高后症状缓解。这2例患者术后均未发生SCI。SCI患者的中位住院时间（22天对9天，P = 0.012）、手术室时间（262分钟对209分钟，P = 0.040）和围手术期死亡率（28.6%对4.1%，P = 0.046）均显著高于未发生SCI的患者。发现主动脉覆盖长度是SCI的唯一独立预测因素（比值比8.2，P = 0.026）。4例患者（5.6%）发生了与CSF引流相关的并发症，2例患者（2.8%）发生了严重并发症，包括1例鞘内血肿和永久性双侧下肢轻瘫。
在TEVAR中选择性使用预防性CSF引流存在中度风险且益处存疑。神经生理监测的使用有助于早期发现和治疗脊髓缺血，但其效用受到后勤因素的限制，且仅适用于少数术中发生脊髓缺血事件的患者。
