Cambria R P, Davison J K, Zannetti S, L'Italien G, Atamian S
The Division of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA.
Ann Surg. 1997 Sep;226(3):294-303; discussion 303-5. doi: 10.1097/00000658-199709000-00009.
Experience over a decade with thoracoabdominal aortic aneurysm (TAA) repair using a clamp-sew technique was reviewed to compare overall results with alternative operative methods.
Controversy continues as to the optimal technique for TAA repair, with frequent contemporary emphasis on bypass-distal perfusion methods. Proponents of this technique claim improved results compared to those of historic control subjects in the parameters of operative mortality, postoperative renal failure, and lower extremity neurologic deficit.
Over the interval from 1987 to 1996, 160 TAA repairs (type I, 32%; type II, 15%; type III, 34%; and type IV, 19%) were performed in 157 patients with a mean age of 70 years and a male-to-female ratio of 1/1. Clinical features included ruptured TAA (10%), urgent operation (22.5%), and aortic dissection (18%). Operative management used a clamp-sew technique with regional hypothermia for spinal cord (epidural cooling, since 1993) and renal protection. Variables associated with the endpoints of operative mortality or major morbidity, particularly spinal cord injury, were assessed with Fisher exact test and logistic regression; late survival was estimated with the Kaplan-Meier method.
In-hospital mortality was 9% and was associated with operation for rupture (p < 0.005) or other acute presentation (p < 0.001). After multivariate analysis, the postoperative complication renal failure (relative risk, 6.5 [95% confidence interval, 1.8-23.6, p = 0.004]) and significant spinal cord injury (relative risk, 16.5 [95% confidence interval, 3.2-83.2, p = 0.001]) were associated independently with operative mortality. Paraparesis-paraplegia occurred in 7%, an incidence significantly (p < 0.001) less than that (18.7%) predicted for this cohort from published models. Variables associated (univariate analysis) with this complication included TAA rupture (p < 0.0001), other acute presentation or dissection (p < 0.001), prolonged (>6 hours) operation (p < 0.04), and excessive (>3 L) transfusions (p < 0.02). Operation for acute presentation or dissection (relative risk, 7.9 [95% confidence interval, 1.7-37.7, p = 0.009]) and prolonged surgery [relative risk, 7.5 [95% confidence interval, 1.5-35.3, p = 0.01]) retained independent association with paraplegia-paraparesis after multivariate analysis. Dialysis was needed in 2.5%. Late survival at 1 and 5 years was 86 +/- 2.9% and 62 +/- 5.8%, respectively.
These data compare favorably with those from contemporary reports using other operative strategies and do not support routine adoption of bypass-distal perfusion as the preferred technique for TAA repair.
回顾采用钳夹缝合技术修复胸腹主动脉瘤（TAA）超过十年的经验，以将总体结果与其他手术方法进行比较。
关于TAA修复的最佳技术仍存在争议，目前经常强调旁路 - 远端灌注方法。该技术的支持者声称，与历史对照对象相比，在手术死亡率、术后肾衰竭和下肢神经功能缺损等参数方面结果有所改善。
在1987年至1996年期间，对157例患者进行了160例TAA修复手术（I型，32%；II型，15%；III型，34%；IV型，19%），患者平均年龄70岁，男女比例为1/1。临床特征包括破裂性TAA（10%）、急诊手术（22.5%）和主动脉夹层（18%）。手术管理采用钳夹缝合技术，并对脊髓进行局部低温（自1993年起采用硬膜外冷却）和肾脏保护。使用Fisher精确检验和逻辑回归评估与手术死亡率或主要并发症终点相关的变量，特别是脊髓损伤；采用Kaplan - Meier方法估计晚期生存率。
住院死亡率为9%，与破裂手术（p < 0.005）或其他急性表现（p < 0.001）相关。多因素分析后，术后并发症肾衰竭（相对风险，6.5 [95%置信区间，1.8 - 23.6，p = 0.004]）和严重脊髓损伤（相对风险，16.5 [95%置信区间，3.2 - 83.2，p = 0.001]）与手术死亡率独立相关。截瘫 - 四肢瘫发生率为7%，该发生率显著低于（p < 0.001）根据已发表模型预测的该队列发生率（18.7%）。与该并发症相关的变量（单因素分析）包括TAA破裂（p < 0.0001）、其他急性表现或夹层（p < 0.001）、手术时间延长（>6小时）（p < 0.04）和输血过多（>3L）（p < 0.02）。急性表现或夹层手术（相对风险，7.9 [95%置信区间，1.7 - 37.7，p = 0.009]）和手术时间延长[相对风险，7.5 [95%置信区间，1.5 - 35.3，p = 0.01]）在多因素分析后与截瘫 - 四肢瘫仍保持独立相关性。2.5%的患者需要透析。1年和5年的晚期生存率分别为86±2.9%和62±5.8%。
这些数据与使用其他手术策略的当代报告数据相比具有优势，不支持常规采用旁路 - 远端灌注作为TAA修复的首选技术。
