Chen Cheng-Hao Jacky, Jiang Henry, Nguyen Vinh Dat David
Collaborative Research Group (CORE), Sydney, New South Wales, Australia.
Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.
Ann Cardiothorac Surg. 2023 Sep 28;12(5):392-408. doi: 10.21037/acs-2023-scp-17. Epub 2023 Jul 12.
Spinal cord ischemia (SCI) is one of the most devastating complications of thoracic endovascular aortic repair (TEVAR). Prophylactic cerebrospinal fluid drainage (CSFD) has been shown to decrease the risk of SCI in open thoracic aortic procedures; however, its utility in TEVAR remains uncertain. This systematic review and meta-analysis aim to determine the role of prophylactic CSFD in preventing SCI in TEVAR.
A literature search of five databases was performed and all studies published before September 2022 that reported SCI rates in TEVAR patients undergoing prophylactic CSFD were included. A random effects meta-analysis of means or proportions was performed for single-arm data. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported for comparisons between groups.
A total of 4,793 patients undergoing TEVAR from 40 studies were included. The mean age was 68.8 years and 70.9% of patients were male. The overall SCI rate was 3.5%, with a 1.3% rate of immediate SCI and a 1.9% rate of delayed SCI. There were no significant differences in SCI rates between prophylactic CSFD patients and non-drained patients. Routine CSFD did not have a significant impact on SCI rates compared to non-drained patients. There was an increased rate of transient SCI with selective CSFD compared to non-drained patients (OR 2.08; 95% CI: 1.06-4.08; P=0.03). The most common drain-related complication was spinal headache (4.3%). The major complication rate was 1.6%, of which epidural or spinal hematoma (0.9%) was the most common, followed by intracranial or subdural hemorrhage (0.8%) and paraparesis or paraplegia (0.8%).
This study found no significant difference in SCI rates between prophylactic CSFD patients and their non-drained counterparts. CSFD is associated with a small but non-negligible risk of serious complications. Multi-center randomized controlled trials (RCTs) are warranted to help stratify the risk of both SCI and CSFD-related complications in patients undergoing endovascular aortic procedures.
脊髓缺血（SCI）是胸段血管腔内主动脉修复术（TEVAR）最严重的并发症之一。预防性脑脊液引流（CSFD）已被证明可降低开放性胸主动脉手术中SCI的风险；然而，其在TEVAR中的效用仍不确定。本系统评价和荟萃分析旨在确定预防性CSFD在预防TEVAR中SCI的作用。
对五个数据库进行文献检索，纳入2022年9月之前发表的所有报告接受预防性CSFD的TEVAR患者中SCI发生率的研究。对单臂数据进行均值或比例的随机效应荟萃分析。报告组间比较的比值比（OR）及其95%置信区间（CI）。
共纳入40项研究中的4793例接受TEVAR的患者。平均年龄为68.8岁，70.9%的患者为男性。总体SCI发生率为3.5%，即刻SCI发生率为1.3%，延迟性SCI发生率为1.9%。预防性CSFD患者和未引流患者的SCI发生率无显著差异。与未引流患者相比，常规CSFD对SCI发生率无显著影响。与未引流患者相比，选择性CSFD导致的短暂性SCI发生率增加（OR 2.08；95%CI：1.06 - 4.08；P = 0.03）。最常见的与引流相关的并发症是脊柱头痛（4.3%）。主要并发症发生率为1.6%，其中硬膜外或脊髓血肿（0.9%）最常见，其次是颅内或硬膜下出血（0.8%）和轻截瘫或截瘫（0.8%）。
本研究发现预防性CSFD患者与其未引流的对应患者之间的SCI发生率无显著差异。CSFD与严重并发症的风险虽小但不可忽视。有必要进行多中心随机对照试验（RCT），以帮助分层接受血管腔内主动脉手术患者的SCI和CSFD相关并发症风险。
