Svensson L G, Hess K R, Coselli J S, Safi H J
Center for Aortic Surgery, Lahey Clinic, Burlington, MA 01805.
J Vasc Surg. 1994 Aug;20(2):255-62. doi: 10.1016/0741-5214(94)90013-2.
The purpose of this article was to study the influence of either reattachment or oversewing of patient segmental intercostal or lumbar arteries, extent of aneurysm, and atriofemoral bypass on the incidence of postoperative paraplegia/paraparesis in patients at high risk with type I or II thoracoabdominal aneurysms.
Data were prospectively collected on 99 patients undergoing type I or II thoracoabdominal aneurysm repairs, including exact extent of repair and whether atriofemoral bypass ws used. Patency of intercostal arteries from T3 to T12 and lumbar arteries from L1 to L4 were checked by intraoperative inspection. If the arteries were patent, note was taken of whether they were reattached to the new aortic prosthesis. Postoperative neurologic motor function was graded daily for the first 5 days, and the worst score in the first 30 postoperative days (POD) was used for analysis.
Ninety-five of 99 (96%) patients were 30-day survivors. By POD 30, 31 of 98 (32%) patients had had a neurologic deficit. There was no difference in the incidence of deficits according to whether lumbar or intercostal arteries were reattached, ignoring the effect of patency of the arteries. Of greater importance, however, was whether patent segmental arteries were oversewn at specific levels. Thus, for patients who had one or more arteries at T11, T12, or L1 oversewn (often because they could not be reattached), a deficit developed in 11 of 23 (48%) patients versus 20 of 75 (27%) patients who did not have patent arteries or had all patient arteries reattached (p = 0.05, odds ratio = 2.5). More specifically, if all arteries at this level were oversewn, a neurologic deficit developed in 63% of patients versus 23% if all their arteries were reattached (p = 0.01). Reattachment of patent arteries at individual levels from T7 to L4 showed a trend toward a lower risk of deficits but did not reach statistical significance. On multivariate analysis, atriofemoral bypass was associated with a lower risk of paralysis (p = 0.068), and significantly so when controlled for age (p = 0.0329, odds ratio 0.287). Subgrouping of extent type I thoracoabdominal aneurysms resulted in an incidence of paralysis of 14% (3/22) for subgroup A and 23% (5 of 22) for subgroup B compared with 43% (23 of 55) for type II thoracoabdominal aneurysms (type I [8 of 44 18%], versus type II [p = 0.0097]).
Patients with no or few patent segmental arteries in the aortic segment being replaced have a lower risk of neurologic deficits, compared with those with patent arteries. Every effort should be made to reattach all arteries at T11, T12, and L1 and, when possible within the constraints of technical feasibility and time, also those from T7 to L4. Preoperative angiography or intraoperative hydrogen testing may better identify the arteries that need to be reattached. When feasible, atriofemoral bypass appears to be protective, particularly when sequential clamping and segmental repairs can be performed.
本文旨在研究患者节段性肋间动脉或腰动脉的重新吻合或缝合、动脉瘤范围以及股动脉旁路移植术对 I 型或 II 型胸腹主动脉瘤高危患者术后截瘫/轻瘫发生率的影响。
前瞻性收集了 99 例行 I 型或 II 型胸腹主动脉瘤修复术患者的数据，包括确切的修复范围以及是否使用了股动脉旁路移植术。通过术中检查来确定 T3 至 T12 肋间动脉以及 L1 至 L4 腰动脉的通畅情况。若动脉通畅，则记录其是否重新吻合至新的主动脉人工血管上。术后前 5 天每天对神经运动功能进行评分，并将术后 30 天内的最差评分用于分析。
99 例患者中有 95 例（96%）存活至术后 30 天。至术后 30 天，98 例患者中有 31 例（32%）出现神经功能缺损。忽略动脉通畅情况的影响，根据肋间动脉或腰动脉是否重新吻合，缺损发生率并无差异。然而，更重要的是特定节段的通畅节段性动脉是否被缝合。因此，对于在 T11、T12 或 L1 有一条或多条动脉被缝合的患者（通常是因为无法重新吻合），23 例中有 11 例（48%）出现缺损，而对于没有通畅动脉或所有动脉均重新吻合的 75 例患者，这一比例为 20 例（27%）（p = 0.05，比值比 = 2.5）。更具体地说，如果该节段的所有动脉均被缝合，63%的患者出现神经功能缺损，而如果所有动脉均重新吻合，这一比例为 23%（p = 0.01）。T7 至 L4 各节段通畅动脉的重新吻合显示出神经功能缺损风险较低的趋势，但未达到统计学意义。多因素分析显示，股动脉旁路移植术与较低的瘫痪风险相关（p = 0.068），在控制年龄后具有显著相关性（p = 0.0329，比值比 0.287）。对 I 型胸腹主动脉瘤范围进行亚组分析，A 亚组的瘫痪发生率为 14%（3/22），B 亚组为 23%（5/22），而 II 型胸腹主动脉瘤的这一比例为 43%（23/55）（I 型[8/44，18%]，与 II 型相比[p = 0.0097]）。
与有通畅动脉的患者相比，在被替换的主动脉节段没有或仅有少量通畅节段性动脉的患者发生神经功能缺损的风险较低。应尽一切努力将 T11、T12 和 L1 的所有动脉重新吻合，并在技术可行性和时间限制允许的情况下，尽可能将 T7 至 L4 的动脉也重新吻合。术前血管造影或术中氢气检测可能有助于更好地识别需要重新吻合的动脉。在可行的情况下，股动脉旁路移植术似乎具有保护作用，尤其是在能够进行顺序钳夹和节段性修复时。
