Rinaldi Enrico, Melloni Andrea, Gallitto Enrico, Fargion Aaron, Isernia Giacomo, Kahlberg Andrea, Bertoglio Luca, Faggioli Gianluca, Lenti Massimo, Pratesi Carlo, Gargiulo Mauro, Melissano Germano, Chiesa Roberto, Luigi Baccani, Luca Bertoglio, Roberto Chiesa, Gianluca Faggioli, Aaron Fargion, Cecilia Fenelli, Enrico Gallitto, Mauro Gargiulo, Giacomo Isernia, Massimo Lenti, Antonino Logiacco, Andrea Kahlberg, Chiara Mascoli, Germano Melissano, Andrea Melloni, Rodolfo Pini, Carlo Pratesi, Enrico Rinaldi, Gioele Simonte, Sara Speziali
Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.
Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy.
J Endovasc Ther. 2023 Apr;30(2):281-288. doi: 10.1177/15266028221081074. Epub 2022 Mar 3.
The aim of this study is to report an Italian multicenter experience analyzing the incidence and the risk factors associated with spinal cord ischemia (SCI) in a large cohort of thoracoabdominal aortic aneurysms (TAAAs) treated by fenestrated-branched endovascular aneurysm repair (F-/B-EVAR).
All consecutive patients undergoing F-/B-EVAR in 4 Italian university centers between 2008 and 2019 were prospectively recorded and retrospectively analyzed. Spinal cord ischemia, 30 day/in-hospital adverse events, and mortality were assessed as early outcomes. Risk factors for SCI were determined by multivariable analysis.
A total of 351 patients received F-/B-EVAR for a TAAA. Twenty-eight (8.0%) patients died within 30 postoperative days or during the hospitalization. Regarding SCI, 47 patients (13.4%) developed neurological symptoms related to spinal cord impaired perfusion. Among them, 17 (4.8%) had a major permanent impairment. The multivariable analysis identified that SCI was associated with Crawford extent I to III (odds ratio [OR]: 20.90, p=0.004, 95% confidence interval [CI]=2.69-162.57), and with endovascular procedures performed for ruptured TAAA (OR: 5.74, p=0.010, 95% CI=1.53-21.57). Spinal cord ischemia was also significantly associated with a grade 3 bleeding during the visceral stage (OR: 4.34, p=0.005, 95% CI=1.55-12.16) and a grade 2 renal insufficiency at 30 days (OR: 7.45, p=0.002, 95% CI=2.12-26.18).
The present study indicates that SCI is still an open issue after extent I to III TAAA endovascular repair, while its incidence in extent IV TAAA and pararenal/juxtarenal aneurysms is rare. Thoracoabdominal aortic aneurysms extension, urgent TAAA repair for rupture, severe bleeding, and 30 day renal insufficiency have been identified as significant risk factors for SCI. In the presence of such factors, adjunctive strategies may be considered to reduce SCI rates, while in low-risk patients invasive or potentially-risky maneuvers might not be justified.
本研究旨在报告一项意大利多中心研究经验，分析在接受开窗分支型血管腔内动脉瘤修复术（F-/B-EVAR）治疗的大量胸腹主动脉瘤（TAAA）队列中脊髓缺血（SCI）的发生率及相关危险因素。
前瞻性记录并回顾性分析2008年至2019年期间在4个意大利大学中心接受F-/B-EVAR治疗的所有连续患者。评估脊髓缺血、30天/住院期间不良事件及死亡率作为早期结局。通过多变量分析确定SCI的危险因素。
共有351例患者接受了TAAA的F-/B-EVAR治疗。28例（8.0%）患者在术后30天内或住院期间死亡。关于SCI，47例（13.4%）患者出现与脊髓灌注受损相关的神经症状。其中，17例（4.8%）有严重永久性损伤。多变量分析确定，SCI与Crawford范围I至III相关（比值比[OR]：20.90，p = 0.004，95%置信区间[CI] = 2.69 - 162.57），与为破裂TAAA进行的血管腔内手术相关（OR：5.74，p = 0.010，95% CI = 1.53 - 21.57）。脊髓缺血还与内脏阶段3级出血显著相关（OR：4.34，p = 0.005，95% CI = 1.55 - 12.16）以及30天时2级肾功能不全相关（OR：7.45，p = 0.002，95% CI = 2.12 - 26.18）。
本研究表明，在I至III型TAAA血管腔内修复术后，SCI仍然是一个未解决的问题，而其在IV型TAAA及肾旁/近肾动脉瘤中的发生率较低。胸腹主动脉瘤范围、因破裂进行的紧急TAAA修复、严重出血及30天肾功能不全已被确定为SCI的重要危险因素。在存在这些因素的情况下，可考虑采取辅助策略以降低SCI发生率，而在低风险患者中，侵入性或潜在风险操作可能不合理。
