Skoda Lucas, Acher Charles, Kay Jonathan, Williamson Ashley, Bontekoe Jack, Gober Leah, Wynn Martha
Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI.
Department of Vascular Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
J Vasc Surg. 2025 Jun 5. doi: 10.1016/j.jvs.2025.05.020.
Spinal cord injury (SCI) is a complication of open and endovascular thoracic aortic aneurysm (TAA) and thoracoabdominal aortic aneurysm (TAAA) repair. Spinal fluid drainage (SFD) is used to reduce SCI risk in open surgery; however, many question the safety of SFD in endovascular repair. The objective of this retrospective study was to review the risks of prophylactic SFD in 1445 patients undergoing open and endovascular TAA and TAAA repair from 1987 to 2023.
Spinal drains were placed in open TAAA repairs and endovascular repairs planning >12 cm aortic coverage. Cardiac anesthesiologists placed and managed all drains. From 2000 to 2023, spinal drains for elective surgery were placed using fluoroscopic guidance. SF was drained to <5 to 8 mm Hg depending on SCI risk. If bloody fluid appeared, drainage was stopped and a computed tomography (CT) can of the head was obtained. Drainage was stopped when patient demonstrated normal leg strength; drains were removed at 48 hours if leg strength was normal. A post-SFD headache was treated with a blood patch. We tracked intraoperative fluid drained, neurological complications from SFD (any neurological deficit from intracranial or spinal hematoma), bloody SF, intracranial blood on head CT without neurological deficit, headache requiring blood patch, transient SCI (paraparesis/paraplegia), and permanent SCI (paraparesis/paraplegia).
Of the 1445 patients (1029 open, 416 endovascular) undergoing TAA/TAAA repair, 1007 (777 open, 230 endovascular) had SFD. Before 2000, 263 open repairs done with smaller drains had an average of 125 mL of fluid drained intraoperatively to achieve pressure goals. From 2000 to 2023, intraoperative SFD to achieve pressure goals averaged 132 mL in open and 81 mL in endovascular repairs. Six patients (0.6%) had neurological complications from SFD; five of these (0.77%) occurred in open patients. Only one patient undergoing endovascular repair had a neurological complication from SFD (0.43%). From 2000 to 2023, other events not resulting in neurological deficit included bloody SF (20.7% open; 21.7% endovascular), intracranial blood on CT without neurological deficit (9.9% open; 6.1% endovascular), and headache requiring blood patch (7.6% open; 11.7% endovascular). From 2000 to 2023, 5.6% of open patients had transient SCI, 4.2% had permanent SCI. 3.6% of endovascular patients had transient SCI, and 1.2% had permanent SCI.
Prophylactic SFD can be performed with acceptable risk in both endovascular and open TAAA repairs. We advocate that prophylactic SFD be used to reduce risk of SCI in both endovascular and open TAAA repairs.
脊髓损伤（SCI）是开放性和血管腔内胸主动脉瘤（TAA）及胸腹主动脉瘤（TAAA）修复术的一种并发症。脑脊液引流（SFD）用于降低开放性手术中脊髓损伤的风险；然而，许多人质疑血管腔内修复术中脑脊液引流的安全性。这项回顾性研究的目的是评估1987年至2023年期间1445例接受开放性和血管腔内TAA及TAAA修复术患者进行预防性脑脊液引流的风险。
在开放性TAAA修复术和计划主动脉覆盖范围>12 cm的血管腔内修复术中放置脊髓引流管。所有引流管均由心脏麻醉医生放置和管理。2000年至2023年期间，择期手术的脊髓引流管在透视引导下放置。根据脊髓损伤风险将脑脊液引流至<5至8 mmHg。如果出现血性液体，则停止引流，并进行头部计算机断层扫描（CT）检查。当患者腿部力量恢复正常时停止引流；如果腿部力量正常，则在48小时后拔除引流管。脑脊液引流后头痛采用血液补片治疗。我们追踪了术中引流的液体量、脑脊液引流引起的神经并发症（颅内或脊髓血肿导致的任何神经功能缺损）、血性脑脊液、头部CT显示的无神经功能缺损的颅内出血、需要血液补片治疗的头痛、短暂性脊髓损伤（轻瘫/截瘫）和永久性脊髓损伤（轻瘫/截瘫）。
在1445例接受TAA/TAAA修复术的患者中（1029例开放性手术，416例血管腔内手术），1007例（777例开放性手术，230例血管腔内手术）进行了脑脊液引流。2000年前，263例使用较小引流管的开放性修复术中，术中平均引流125 mL液体以达到压力目标。2000年至2023年期间，开放性手术中为达到压力目标的术中脑脊液引流平均为132 mL，血管腔内修复术中为81 mL。6例患者（0.6%）因脑脊液引流出现神经并发症；其中5例（0.77%）发生在开放性手术患者中。只有1例接受血管腔内修复术的患者因脑脊液引流出现神经并发症（0.43%）。2000年至2023年期间，其他未导致神经功能缺损的事件包括血性脑脊液（开放性手术20.7%；血管腔内手术21.7%）、CT显示的无神经功能缺损的颅内出血（开放性手术9.9%；血管腔内手术6.1%）和需要血液补片治疗的头痛（开放性手术7.6%；血管腔内手术11.7%）。2000年至2023年期间，5.6%的开放性手术患者出现短暂性脊髓损伤，4.2%出现永久性脊髓损伤。3.6%的血管腔内手术患者出现短暂性脊髓损伤，1.2%出现永久性脊髓损伤。
在血管腔内和开放性TAAA修复术中，预防性脑脊液引流均可在可接受的风险下进行。我们主张在血管腔内和开放性TAAA修复术中均使用预防性脑脊液引流以降低脊髓损伤风险。
