Department of Vascular Medicine, University Heart and Vascular Center Hamburg, Research Group GermanVasc, German Aortic Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
DAK-Gesundheit, Hamburg, Germany.
J Vasc Surg. 2020 Sep;72(3):837-848. doi: 10.1016/j.jvs.2019.10.095. Epub 2020 Jan 28.
This study aimed to determine predictors and outcomes associated with spinal cord ischemia (SCI) after elective fenestrated or branched endovascular aneurysm repair (F/BEVAR) of thoracoabdominal aortic aneurysm (TAAA), abdominal aortic aneurysm (AAA), or aortic dissection.
Health insurance claims data of Germany's third largest insurance provider, DAK-Gesundheit, were used to investigate SCI in elective F/BEVAR performed between 2008 and 2017. The International Classification of Diseases and German Operation and Procedure Classification System were used. We stratified the results into F/BEVAR with one or two (AAA) vs three or more (TAAA) fenestrations or branches.
A total of 877 patients (18.9% female; 5.8% with SCI) matching the inclusion criteria were identified during the study period. SCI occurred more often after F/BEVAR of TAAA vs AAA (10.7% vs 3.0%; P < .001). SCI was associated with female sex in the AAA group (odds ratio, 3.87; 95% confidence interval [CI], 1.25-11.15; P = .014) and with cardiac arrhythmias in the TAAA group (odds ratio, 2.98; 95% CI, 1.24-7.06; P = .013). Compared with patients without SCI, SCI patients were more likely to suffer from drug use disorders (eg, opioids, cannabinoids, sedatives) in the TAAA group (17.6% vs 2.1%; P < .05). After F/BEVAR of TAAA, the occurrence of SCI was associated with higher 90-day mortality (14.7% vs 1.1%; P < .05), longer postoperative hospital stay (22 vs 9 days; P < .05), and severe adverse events, such as acute respiratory insufficiency (44.1% vs 12.7%), acute renal failure (35.3% vs 11.3%), and pneumonia (29.4% vs 4.9%; all P < .05). In adjusted analyses, SCI was associated with worse long-term survival after F/BEVAR for TAAA (hazard ratio, 2.54; 95% CI, 1.37-4.73; P < .003).
Female AAA patients and TAAA patients with cardiac arrhythmias are at highest risk for development of SCI after F/BEVAR. The occurrence of this event was strongly associated with higher major complication rates and worse short-term and long-term survival. This emphasizes a need to further illuminate the value of spinal cord protection protocols in F/BEVAR.
本研究旨在确定择期开窗或分支腔内血管修复术（F/BEVAR）治疗胸腹主动脉瘤（TAAA）、腹主动脉瘤（AAA）或主动脉夹层后与脊髓缺血（SCI）相关的预测因素和结果。
利用德国第三大保险公司 DAK-Gesundheit 的医疗保险索赔数据，调查 2008 年至 2017 年间进行的择期 F/BEVAR 后发生的 SCI。使用国际疾病分类和德国手术操作分类系统。我们将结果分层为一个或两个（AAA）与三个或更多（TAAA）开窗或分支。
在研究期间，共确定了 877 名符合纳入标准的患者（18.9%为女性；5.8%发生 SCI）。TAAA 的 F/BEVAR 后 SCI 发生率高于 AAA（10.7% vs 3.0%；P<0.001）。在 AAA 组中，女性（比值比，3.87；95%置信区间[CI]，1.25-11.15；P=0.014）和 TAAA 组中的心律失常（比值比，2.98；95%CI，1.24-7.06；P=0.013）与 SCI 相关。与无 SCI 患者相比，TAAA 组中 SCI 患者更可能患有药物使用障碍（例如阿片类药物、大麻素、镇静剂）（17.6% vs 2.1%；P<0.05）。TAAA 后 F/BEVAR 后，SCI 的发生与 90 天死亡率较高（14.7% vs 1.1%；P<0.05）、术后住院时间较长（22 天 vs 9 天；P<0.05）和严重不良事件（如急性呼吸功能不全（44.1% vs 12.7%）、急性肾功能衰竭（35.3% vs 11.3%）和肺炎（29.4% vs 4.9%；均 P<0.05）相关。在调整分析中，TAAA 的 F/BEVAR 后 SCI 与长期生存不良相关（风险比，2.54；95%CI，1.37-4.73；P<0.003）。
女性 AAA 患者和 TAAA 合并心律失常的患者在 F/BEVAR 后发生 SCI 的风险最高。该事件的发生与更高的主要并发症发生率以及短期和长期生存不良密切相关。这强调了需要进一步阐明 F/BEVAR 中脊髓保护方案的价值。
