Griepp R B, Ergin M A, Galla J D, Lansman S, Khan N, Quintana C, McCollough J, Bodian C
Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, N.Y 10029, USA.
J Thorac Cardiovasc Surg. 1996 Nov;112(5):1202-13; discussion 1213-5. doi: 10.1016/s0022-5223(96)70133-2.
All patients undergoing resection of thoracic or thoracoabdominal aneurysms at Mount Sinai Hospital since November 1993 had spinal cord function monitored with somatosensory-evoked potentials as part of a multimodality approach to reducing spinal cord injury. In the segment to be resected, each pair of intersegmental vessels was sequentially clamped, and they were subsequently sacrificed only if no change in somatosensory evoked potentials occurred within 8 to 10 minutes after occlusion. Adjunctive protective measures included mild hypothermia (31 degrees to 33 degrees C), distal perfusion, corticosteroids, maintenance of high normal blood pressures, avoidance of nitroprusside, and cerebrospinal fluid drainage. Ninety-five consecutive patients operated on since 1993 (group II) were compared with 138 earlier patients (group I). Preoperative characteristics such as age, sex, etiology of aneurysm, emergency operation, and reoperation did not differ between groups, nor did operative variables such as incidence of rupture and extent of resection. Group I had slightly more smokers and slightly fewer hypertensive individuals. Group II patients had a significantly better outcome with respect to in-hospital mortality (10.5% vs 18%, p = 0.045) and paraplegia (2% vs 8%, p = 0.008). By multivariate analysis, rupture and diabetes were associated with significantly higher in-hospital mortality, and smoking greatly increased the incidence of paraplegia. The extent of the aneurysm was a major determinant of mortality and paraplegia. The low paraplegia rate in group II was achieved without reattachment of a single intercostal or lumbar artery. No patient with fewer than 10 intersegmental arteries severed had paraplegia, and spinal cord ischemia was reversible in three patients after adjunctive maneuvers were performed to improve perfusion, suggesting that spinal cord blood supply is unlikely to depend on a single "artery of Adamkiewicz."
自1993年11月起，在西奈山医院接受胸段或胸腹段动脉瘤切除术的所有患者，其脊髓功能均采用体感诱发电位进行监测，作为减少脊髓损伤的多模式方法的一部分。在拟切除节段，每对节段间血管依次夹闭，只有在闭塞后8至10分钟内体感诱发电位无变化时，才随后将其牺牲。辅助保护措施包括轻度低温（31摄氏度至33摄氏度）、远端灌注、皮质类固醇、维持较高的正常血压、避免使用硝普钠以及脑脊液引流。将自1993年以来连续接受手术的95例患者（第二组）与138例早期患者（第一组）进行比较。两组患者术前特征如年龄、性别、动脉瘤病因、急诊手术和再次手术情况无差异，手术变量如破裂发生率和切除范围也无差异。第一组吸烟者略多，高血压患者略少。第二组患者在院内死亡率（10.5%对18%，p = 0.045）和截瘫发生率（2%对8%，p = 0.008）方面有显著更好的结果。通过多变量分析，破裂和糖尿病与显著更高的院内死亡率相关，吸烟大大增加了截瘫发生率。动脉瘤的范围是死亡率和截瘫的主要决定因素。第二组较低的截瘫发生率是在未重新连接任何一根肋间或腰动脉的情况下实现的。切断少于10对节段间动脉的患者无一例发生截瘫，在采取辅助措施改善灌注后，3例患者的脊髓缺血得以逆转，这表明脊髓血供不太可能依赖于单一的“Adamkiewicz动脉”。
