Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla.
Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla.
J Thorac Cardiovasc Surg. 2024 Jul;168(1):15-25.e11. doi: 10.1016/j.jtcvs.2022.10.045. Epub 2022 Nov 5.
Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) can cause permanent neurologic deficits and poor long-term survival. Targeted treatment of new SCI symptoms after TEVAR (rescue therapy [RT]) might improve/resolve neurologic symptoms but few data characterize the association of specific interventions with SCI outcomes. We evaluated the effectiveness of post-TEVAR RT at our tertiary aortic center.
Our institutional TEVAR database was reviewed for SCI incidence and details of RT. This included cerebrospinal fluid drainage (CSFD), medical therapy, and optimization of spinal cord oxygen delivery. SCI outcomes were categorized at discharge as paralysis/paraparesis and temporary/permanent.
Nine hundred forty-three TEVAR procedures were performed in 869 patients from 2011 to 2020. Post-TEVAR SCI occurred in 7.8% (n = 74) with permanent paraplegia in 1.5%. Older patient age, chronic obstructive pulmonary disease, and previous abdominal aortic surgery were predictive of SCI. Half (n = 37) of SCI episodes resulted in only temporary paralysis/paraparesis. Rescue postoperative cerebrospinal fluid drains were implanted in 3.7% (n = 35) of procedures and was predicted by higher American Society of Anesthesiologists class, lower serum hemoglobin level, elevated international normalized ratio, bilateral iliac artery occlusion, nonelective procedures, and penetrating atherosclerotic ulcer/intramural hematoma indication. The most commonly used RTs were emergent placement of or increased drainage from an existing cerebrospinal fluid drain (87.8%), induced/permissive hypertension (77.0%), corticosteroid bolus (36.5%), and naloxone infusion (33.8%). Neurologic improvement occurred in 68.9% (n = 51/74). New/increased drainage was associated with improved SCI outcome.
Permanent paraplegia from post-TEVAR SCI is rare (1.5%). Older patients with comorbidities carry greater post-TEVAR SCI risk. SCI symptoms improved/resolved with CSFD and multimodal RT in 68.9% of patients, but no intervention was independently associated with improvement. TEVAR centers should have robust protocols for timely and safe CSFD placement to augment RT strategies for SCI.
胸主动脉腔内修复术（TEVAR）后脊髓缺血（SCI）可导致永久性神经功能缺损和预后不良。针对 TEVAR 后新发 SCI 症状（挽救治疗 [RT]）进行靶向治疗可能改善/解决神经症状，但很少有数据描述特定干预措施与 SCI 结局的关系。我们评估了在我们的三级主动脉中心进行 TEVAR 后 RT 的效果。
我们回顾了机构内 TEVAR 数据库中 SCI 发生率和 RT 细节。这包括脑脊液引流（CSFD）、药物治疗和优化脊髓氧输送。根据出院时的神经功能评估 SCI 结局为瘫痪/截瘫和暂时/永久性。
2011 年至 2020 年，我们共对 869 例患者的 943 例 TEVAR 手术进行了分析。TEVAR 后 SCI 发生率为 7.8%（n=74），其中永久性截瘫 1.5%。年龄较大、慢性阻塞性肺疾病和既往腹主动脉手术是 SCI 的预测因素。一半（n=37）的 SCI 发作仅导致暂时性瘫痪/截瘫。挽救性术后 CSF 引流在 3.7%（n=35）的手术中植入，预测因素为较高的美国麻醉医师协会（ASA）分级、较低的血清血红蛋白水平、升高的国际标准化比值、双侧髂动脉闭塞、非择期手术和穿透性动脉粥样硬化溃疡/壁内血肿指征。最常用的 RT 是紧急放置或增加现有 CSF 引流的引流（87.8%）、诱导/允许性高血压（77.0%）、皮质类固醇冲击（36.5%）和纳洛酮输注（33.8%）。68.9%（n=51/74）的患者神经功能改善。新的/增加的引流与 SCI 结局的改善相关。
TEVAR 后 SCI 导致的永久性截瘫罕见（1.5%）。合并症较多的老年患者 TEVAR 后发生 SCI 的风险更高。CSFD 和多模式 RT 可使 68.9%（n=51/74）的 SCI 患者的症状改善/缓解，但没有干预措施与改善独立相关。TEVAR 中心应制定完善的方案，及时、安全地放置 CSF 引流，以增强 SCI 的 RT 策略。
