Fujiyoshi Toshiki, Iwahashi Toru, Ogino Hitoshi
Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan.
Ann Cardiothorac Surg. 2023 Sep 28;12(5):468-475. doi: 10.21037/acs-2023-scp-18. Epub 2023 Aug 10.
Some recent reports have demonstrated that preoperative Adamkiewicz artery (AKA) identification and its targeted reconstruction has provided satisfactory outcomes with respect to spinal cord protection. This paper investigates the impact of preoperative identification of the AKA on reducing the incidence of spinal cord injury (SCI) in open repair (OR) and endovascular repair (EVR) of descending thoracic aortic (dTA) and thoracoabdominal aortic aneurysm (TAA) repair.
The clinical data of patients with dTA and TAA treated between 2011 and 2022 were investigated. A total of 256 patients comprising of 201 males and 55 females, with a mean age of 72.1±10.0 years, were included. OR was used in 102 patients and EVR in 154 patients whose distal landing zone was below T8, all of which needed preoperative identification of the AKA.
The AKA was identified in 207 (80.9%) patients, and was located in the level between T8 and T12 in 81.2%. In OR, the responsible arteries, including the identified AKA, were promptly reconstructed in 66 (64.7%) patients. In EVR, 65 (42.2%) patients had the AKA covered by an endovascular prosthesis. Deaths prior to 30 days occurred in seven (2.7%, four in OR and three in EVR) patients. In OR, SCI occurred in six (5.9%) patients including three (2.9%) with paraplegia and three (2.9%) with paraparesis, whereas in EVR ten (6.5%) patients had SCI, including two (1.3%) with paraplegia and eight (5.2%) with paraparesis. The incidence of SCI was significantly higher in patients with the AKA covered than those without it covered [13.8% (9 of 65) 1.1% (1 of 89); P=0.002], whereas no significant differences were found between patients with or without the AKA reconstructed.
Preoperative identification of the AKA was useful enough to determine treatment strategies with less likelihood of SCI in both OR and EVR for dTA and TAA pathologies.
最近的一些报告表明，术前识别Adamkiewicz动脉（AKA）并进行针对性重建在脊髓保护方面取得了令人满意的结果。本文研究术前识别AKA对降低降主动脉（dTA）和胸腹主动脉瘤（TAA）开放修复（OR）和血管内修复（EVR）中脊髓损伤（SCI）发生率的影响。
调查2011年至2022年间接受治疗的dTA和TAA患者的临床资料。共纳入256例患者，其中男性201例，女性55例，平均年龄72.1±10.0岁。102例患者采用OR治疗，154例患者采用EVR治疗，其远端着陆区均在T8以下，所有患者均需要术前识别AKA。
207例（80.9%）患者识别出AKA，其中81.2%位于T8至T12水平。在OR中，66例（64.7%）患者及时重建了包括已识别的AKA在内的责任动脉。在EVR中，65例（42.2%）患者的AKA被血管内假体覆盖。30天内死亡7例（2.7%，OR组4例，EVR组3例）。在OR中，6例（5.9%）患者发生SCI，其中3例（2.9%）截瘫，3例（2.9%）轻瘫；而在EVR中，10例（6.5%）患者发生SCI，其中2例（1.3%）截瘫，8例（5.2%）轻瘫。AKA被覆盖的患者SCI发生率显著高于未被覆盖的患者[13.8%（65例中的9例）对1.1%（89例中的1例）；P = 0.002]，而AKA重建与否的患者之间未发现显著差异。
术前识别AKA对于确定dTA和TAA病变的OR和EVR治疗策略非常有用，可降低SCI发生的可能性。
