Department of Cardiac Surgery, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan.
Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany.
Thorac Cardiovasc Surg. 2021 Jun;69(4):347-356. doi: 10.1055/s-0040-1708470. Epub 2020 Apr 12.
Surgical thoracoabdominal aortic aneurysm (TAAA) repair remains challenging. Apart from mortality, spinal cord injury (SCI) is a dreaded complication. We analyzed our experience to identify predictors for SCI in a nonhigh-volume institution.
All patients who underwent TAAA repair between February 1996 and November 2016 ( = 182) were enrolled. Most were male ( = 121; 66.4%), median age was 68 years (range: 21-84). Elective operations were performed in 153 instances (84.1%). Our approach to minimize SCI includes distal aortic perfusion, mild hypothermia, identification of the Adamkiewicz artery, and sequential aortic clamping. Cerebrospinal fluid drainage was introduced in 2001 and liberal use of selective visceral perfusion in 2006.
Early mortality was 12.1%; it was 8.5% after elective procedures. Reduced left ventricular function, nonelective setting, older age, and longer bypass time were identified as independent predictors for mortality in multivariable logistic regression model. Permanent SCI was observed in nine patients (4.9%), of whom seven (3.8%) developed paraplegia. In a multivariable logistic regression model for paraplegia, peripheral arterial disease (PAD), Crawford type II repair, smaller body surface area, and era before 2001 were identified as independent predictors, whereas only PAD was significant for SCI. The incidence of paraplegia was 13.8% in extensive repair out of the first 91 cases, whereas it was improved up to 2.7% thereafter.
Using an integrated approach, acceptable outcome of TAAA repair can be achieved, even in a nonhigh-volume center. PAD and extensive involvement of the aorta are strong independent predictors for spinal cord deficit after TAAA repair.
胸主动脉腹主动脉瘤（TAAA）的外科手术仍然具有挑战性。除了死亡率之外，脊髓损伤（SCI）也是一种可怕的并发症。我们分析了我们的经验，以确定非高容量机构中 SCI 的预测因素。
纳入 1996 年 2 月至 2016 年 11 月期间接受 TAAA 修复的所有患者（ = 182）。大多数为男性（ = 121；66.4%），中位年龄为 68 岁（范围：21-84）。153 例为择期手术（84.1%）。我们通过使用远端主动脉灌注、轻度低温、识别 Adamkiewicz 动脉和顺序主动脉夹闭来尽量减少 SCI。脑脊液引流于 2001 年引入，选择性内脏灌注于 2006 年广泛使用。
早期死亡率为 12.1%；择期手术后为 8.5%。多变量逻辑回归模型确定左心室功能降低、非择期手术、年龄较大和体外循环时间较长是死亡率的独立预测因素。9 例患者（4.9%）出现永久性 SCI，其中 7 例（3.8%）出现截瘫。在截瘫的多变量逻辑回归模型中，外周动脉疾病（PAD）、Crawford Ⅱ型修复、较小的体表面积和 2001 年前的时代被确定为独立预测因素，而只有 PAD 对 SCI 有意义。前 91 例中广泛修复的截瘫发生率为 13.8%，此后提高至 2.7%。
即使在非高容量中心，使用综合方法也可以实现 TAAA 修复的可接受结果。PAD 和主动脉广泛受累是 TAAA 修复后脊髓功能缺损的独立强预测因素。
