Haunschild Josephina, Köbel Tilo, Misfeld Martin, Etz Christian D
Department of Cardiac Surgery, University Heart Center, Rostock University Medical Center, Rostock, Germany.
German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany.
Ann Cardiothorac Surg. 2023 Sep 28;12(5):492-499. doi: 10.21037/acs-2023-scp-21. Epub 2023 Sep 19.
Minimally invasive staged segmental artery coil embolization (MISACE) is an emerging technology for priming of the paraspinous collateral network prior to open or endovascular thoracoabdominal aortic aneurysm (TAAA) repair. Its safety and efficacy have been previously proven in various experimental settings and confirmed in numerous multicentric pilot studies for open and endovascular repair. MISACE is safe and has the potential to decisively reduce the risk of postoperative paraplegia, the most devastating complication of open and endovascular TAAA repair, still affecting up to 20% of patients. Up to now, MISACE has been clinically implemented with excellent results, and is currently being investigated in the international, multicenter, randomized controlled trial PAPAartis, funded by the German Research foundation, and the European Union. MISACE can be performed under local anesthesia, enabling continuous monitoring of neurological function, and in case of clinical signs of imminent ischemia, preemptive interruption of the procedure. A thorough evaluation of preoperative computed tomography (CT) imaging for identification of open and accessible segmental arteries (SAs) is critical. Segmental artery occlusion can be achieved with either micro coils, or vascular plugs. A maximum number of seven SAs is currently recommended to be occluded in the same session, and a minimum interval of 5 days should be awaited between either two MISACE sessions or between MISACE and the final repair. Adjuvant side-effects of MISACE are the reduction in segmental back-bleeding during open repair leading to harmful steal phenomenon and the reduction of the incidence of type II endoleaks in endovascular repair. Current contraindications for MISACE are emergency cases, hostile anatomy, and a shaggy aorta. Other neuroprotective adjuncts such as cerebrospinal fluid (CSF) drainage, permissive hypertension, motor-evoked potentials (MEP)/somato-sensory evoked potentials (SSEP) and monitoring of paraspinous muscle oxygenation by near-infrared spectroscopy should also be applied independent of prior MISACE procedure.
微创分期节段动脉弹簧圈栓塞术（MISACE）是一种新兴技术，用于在开放或血管内胸腹主动脉瘤（TAAA）修复术前启动椎旁侧支循环网络。其安全性和有效性先前已在各种实验环境中得到证实，并在众多关于开放和血管内修复的多中心试点研究中得到确认。MISACE是安全的，并且有可能决定性地降低术后截瘫的风险，这是开放和血管内TAAA修复最具破坏性的并发症，仍影响高达20%的患者。到目前为止，MISACE已在临床上实施并取得了优异的效果，目前正在由德国研究基金会和欧盟资助的国际多中心随机对照试验PAPAartis中进行研究。MISACE可以在局部麻醉下进行，能够持续监测神经功能，并且在出现即将发生缺血的临床体征时，可以提前中断手术。对术前计算机断层扫描（CT）成像进行全面评估以识别开放且可及的节段动脉（SAs）至关重要。节段动脉闭塞可以通过微弹簧圈或血管塞来实现。目前建议在同一次手术中最多闭塞7条SAs，并且在两次MISACE手术之间或MISACE与最终修复之间应等待至少5天的间隔。MISACE的辅助副作用包括开放修复期间节段性逆向出血减少导致有害的盗血现象，以及血管内修复中II型内漏发生率降低。目前MISACE的禁忌证包括急诊病例、解剖结构复杂和主动脉表面粗糙。其他神经保护辅助措施，如脑脊液（CSF）引流、允许性高血压、运动诱发电位（MEP）/体感诱发电位（SSEP）以及通过近红外光谱监测椎旁肌肉氧合，也应独立于先前的MISACE手术应用。
