Department of Surgery and Cancer, Imperial College London, UK.
Division of Vascular and Endovascular Surgery, Department of Clinical Surgical and Health Sciences, University of Trieste, Italy.
Ann Vasc Surg. 2024 Dec;109:206-215. doi: 10.1016/j.avsg.2024.06.012. Epub 2024 Jul 14.
Spinal cord ischemia (SCI) is a potentially devastating complication of thoracic endovascular aortic repair (TEVAR) and fenestrated-branched endovascular aortic repair (F-BEVAR). The aim of this systematic review was to evaluate the efficacy of neuromonitoring modalities to mitigate the risk of SCI during TEVAR and F-BEVAR procedures.
Following the PRISMA guidelines, we conducted a detailed literature search of databases including PubMed, MEDLINE via Ovid, Embase, Scopus, and Cochrane CENTRAL, from 1998 to the present. Inclusion criteria were original research articles examining neuromonitoring during TEVAR and F-BEVAR. The primary outcome was the incidence of SCI, while the secondary outcome included early mortality. The quality of studies was assessed using the Newcastle-Ottawa Scale.
From 1,450 identified articles, 11 met inclusion criteria, encompassing data from 1,069 patients. Neuromonitoring modalities included motor-evoked potentials (MEPs), somatosensory evoked potentials (SSEPs), and near-infrared spectroscopy. The combination of MEPs and SSEPs was most commonly used, with 93% sensitivity and 96% specificity for detecting SCI risks. SCI incidence ranged from 3.8 to 17.3%, with permanent deficits occurring in 2.7-5.8% of cases. In-hospital mortality ranged from 0.4 to 8%. Risk factors for SCI were identified, including operation duration and extent of aortic coverage.
Neuromonitoring with MEPs and SSEPs appears to be effective in detecting perioperative SCI risk during TEVAR and F-BEVAR. However, discrepancies between neuromonitoring changes and actual SCI outcomes suggest the need for cautious interpretation. While the incidence of SCI remains variable, identified risk factors may guide clinical decisions, particularly in high-risk procedures. Future research should focus on prospective studies and randomized controlled trials to validate these findings and improve SCI prevention strategies in TEVAR and F-BEVAR.
脊髓缺血（SCI）是胸主动脉腔内修复术（TEVAR）和分支型腔内主动脉修复术（F-BEVAR）的一种潜在破坏性并发症。本系统评价的目的是评估神经监测方式在 TEVAR 和 F-BEVAR 手术中降低 SCI 风险的效果。
根据 PRISMA 指南，我们对包括 PubMed、Ovid MEDLINE、Embase、Scopus 和 Cochrane CENTRAL 在内的数据库进行了详细的文献检索，检索时间从 1998 年至今。纳入标准为研究 TEVAR 和 F-BEVAR 期间神经监测的原始研究文章。主要结局是 SCI 的发生率，次要结局包括早期死亡率。使用纽卡斯尔-渥太华量表评估研究质量。
从 1450 篇确定的文章中，有 11 篇符合纳入标准，共纳入 1069 例患者的数据。神经监测方式包括运动诱发电位（MEPs）、体感诱发电位（SSEPs）和近红外光谱。最常用的监测方式是 MEP 和 SSEP 的联合应用，其检测 SCI 风险的敏感性为 93%，特异性为 96%。SCI 的发生率为 3.8%至 17.3%，永久性损伤的发生率为 2.7%至 5.8%。住院死亡率为 0.4%至 8%。确定了 SCI 的危险因素，包括手术时间和主动脉覆盖范围。
MEP 和 SSEP 神经监测似乎可以有效检测 TEVAR 和 F-BEVAR 围手术期 SCI 风险。然而，神经监测变化与实际 SCI 结果之间的差异表明需要谨慎解释。尽管 SCI 的发生率仍然存在差异，但确定的危险因素可能指导临床决策，特别是在高风险手术中。未来的研究应侧重于前瞻性研究和随机对照试验，以验证这些发现并改善 TEVAR 和 F-BEVAR 中的 SCI 预防策略。
