Bachet J, Guilmet D, Rosier J, Cron C, Dreyfus G, Goudot B, Piquois A, Brodaty D, Dubois C, de Lentdecker P
Service de Chirurgie Cardio-Vasculaire, Hôpital Foch, Suresnes, France.
Eur J Cardiothorac Surg. 1996;10(10):817-25. doi: 10.1016/s1010-7940(96)80305-8.
To assess the risk of ischemic cord injury, we have retrospectively studied the 115 patients who underwent a replacement of the thoracic descending or thoraco-abdominal aorta between January 1980 and December 1994.
In 72 patients the aortic lesion was located above the diaphragm. The aortic replacement was performed with the aid of extracorporeal circulation in all but 2 patients (97.2%). Only two cases of postoperative paraplegia were observed (2.7%). In 43 patients (10 females and 33 males aged from 26 to 69 years), the occurrence of postoperative paraplegia was considered as a major risk, because of the extension of the aortic lesions (Crawford types I, II and III). Twenty-six patients (60.4%) suffered from chronic dissection and 17 patients had atheromatous aneurysms. Sixteen patients (37.2%) had Marfan syndrome. Twelve patients (27.9%) had already undergone aortic replacement. A preoperative study of the spinal cord vascularization was carried out in 36 patients (83.6%) and the Adamkiewicz artery was visualized in 28 patients (77.8%). In 17 patients (39.5%, group I), the surgical procedure was performed without the aid of extracorporeal circulation. In the remaining 26 patients (60.5%, group II), the surgical procedure was carried out with the aid of cardiopulmonary bypass and profound hypothermic circulatory arrest. Sequential unclamping of the aorta was used in all patients. The cord vascularization was surgically restored in 32 patients (74.4%). When the Adamkiewicz artery was identified, the critical intercostal artery was reimplanted together with the two pairs of adjacent intercostal arteries (25 patients). When the origin of the Adamkiewicz artery remained unknown, the two or three most important patent pairs of intercostal arteries were reimplanted (7 patients). In 8 patients (18.6%) there were no patent intercostal arteries.
Hospital mortality accounted for 37.2% (16 patients, including 5 patients with paraplegia). On univariate analysis, extension of the aortic lesions, emergency and redo surgery were the only significant risk factors of mortality (P = 0.05). Cord ischemia was observed in 9 patients (21%): permanent paraplegia in 7 patients (16.2%) and transient medullar disturbance in 2 patients (4.6%). The occurrence of paraplegia was reduced, though not significantly, in group II (16%) vs group I (29%) and in patients with preoperative assessment of the cord vascularization (18% vs 38%).
In our experience: 1) The risk of paraplegia is related to the extension and the type of the aortic lesions. 2) The preoperative study of the medullar vascularization and the use of extracorporeal circulation with deep hypothermia and sequential aortic unclamping, reduce the risk of severe cord ischemia, and 3) Occurrence of postoperative paraplegia depends on several factors and cannot be totally prevented by the surgical technique.
为评估脊髓缺血性损伤的风险，我们回顾性研究了1980年1月至1994年12月期间接受胸降主动脉或胸腹主动脉置换术的115例患者。
72例患者的主动脉病变位于膈肌上方。除2例患者（97.2%）外，所有患者均在体外循环辅助下进行主动脉置换。仅观察到2例术后截瘫病例（2.7%）。在43例患者（10例女性和33例男性，年龄26至69岁）中，由于主动脉病变的范围（Crawford I型、II型和III型），术后截瘫的发生被视为主要风险。26例患者（60.4%）患有慢性夹层动脉瘤，17例患者患有动脉粥样硬化性动脉瘤。16例患者（37.2%）患有马凡综合征。12例患者（27.9%）曾接受过主动脉置换术。36例患者（83.6%）进行了术前脊髓血管造影，28例患者（77.8%）可见Adamkiewicz动脉。17例患者（39.5%，I组）在无体外循环辅助下进行手术。其余26例患者（60.5%，II组）在体外循环和深低温停循环辅助下进行手术。所有患者均采用主动脉序贯阻断法。32例患者（74.4%）的脊髓血运通过手术得以恢复。当识别出Adamkiewicz动脉时，将关键肋间动脉与相邻的两对肋间动脉一起重新植入（25例患者）。当Adamkiewicz动脉的起源不明时，将两对或三对最重要的通畅肋间动脉重新植入（7例患者）。8例患者（18.6%）没有通畅的肋间动脉。
医院死亡率为37.2%（16例患者，包括5例截瘫患者）。单因素分析显示，主动脉病变范围、急诊手术和再次手术是唯一显著的死亡风险因素（P = 0.05）。9例患者（21%）出现脊髓缺血：7例患者（16.2%）永久性截瘫，2例患者（4.6%）短暂性脊髓功能障碍。II组（16%）与I组（29%）相比，以及术前评估脊髓血运的患者（18% vs 38%）中，截瘫的发生率有所降低，但差异不显著。
根据我们的经验：1）截瘫风险与主动脉病变的范围和类型有关。2）术前脊髓血管造影以及使用深低温体外循环和主动脉序贯阻断法可降低严重脊髓缺血的风险，3）术后截瘫的发生取决于多种因素，手术技术无法完全预防。
