Acher C W, Wynn M M, Hoch J R, Kranner P W
Department of Surgery, University of Wisconsin-Madison, 53792-7375, USA.
J Vasc Surg. 1998 May;27(5):821-8; discussion 829-30. doi: 10.1016/s0741-5214(98)70261-7.
We studied factors that influence paralysis risk, renal function, and mortality in thoracoabdominal aortic replacement.
We prospectively collected preoperative demographic and intraoperative physiologic data and used univariate and multivariate analyses to correlate this data with risk factors for paralysis. A mathematical model of paraplegia risk was used to study the efficacy of paraplegia reduction strategies. We analyzed preoperative and operative factors for paralysis risk, renal function, and mortality for 217 consecutive patients surgically treated from 1984 through 1996 for 176 thoracoabdominal and 41 thoracic aneurysms at the University of Wisconsin Hospital and Clinics. No patient had intercostal reimplantation or assisted circulation. One hundred fifty patients (group A) received cerebrospinal fluid drainage (CSFD) and low-dose naloxone (1 microg/kg/hour) as adjuncts to reduce the risk of paralysis. Sixty-seven patients (group B) did not receive CSFD and naloxone.
Seventeen deficits occurred in 205 surviving patients: 5 of the 147 in group A (expected deficits = 31) and 12 of the 58 in group B (expected deficits = 13) (p < 0.001). In a multivariate logistic regression model, acute presentation, Crawford type 2 aneurysm, group B membership, and a decrease in cardiac index with aortic occlusion remained significant risk factors for deficit (p < 0.0001). By odds ratio analysis, group A patients had 1/40th the risk of paralysis of group B. The only significant predictor of postoperative renal function was the preoperative creatinine level (p < 0.0001); renal revascularization significantly improved renal function. The mortality rate was 1.6% (2) for patients undergoing elective treatment and 21% (19) for patients who had acute presentations. Acute presentation, age, and the preoperative creatinine level were found to be significant factors for operative mortality in a logistic regression model (p < 0.001) and defined a group at high risk for death.
CSFD and low-dose naloxone significantly reduce the paralysis risk associated with thoracoabdominal aortic replacement. A decrease in the cardiac index with aortic occlusion is a previously unreported variable that defines a subset of patients at higher risk for paralysis.
我们研究了影响胸腹主动脉置换术中瘫痪风险、肾功能和死亡率的因素。
我们前瞻性收集术前人口统计学和术中生理数据，并使用单变量和多变量分析将这些数据与瘫痪风险因素相关联。使用截瘫风险的数学模型来研究降低截瘫策略的疗效。我们分析了1984年至1996年在威斯康星大学医院及诊所接受手术治疗的217例连续患者的术前和手术因素，这些患者分别患有176例胸腹主动脉瘤和41例胸主动脉瘤。所有患者均未进行肋间血管再植或辅助循环。150例患者（A组）接受脑脊液引流（CSFD）和低剂量纳洛酮（1微克/千克/小时）作为降低瘫痪风险的辅助措施。67例患者（B组）未接受CSFD和纳洛酮。
205例存活患者中出现了17例神经功能缺损：A组147例中有5例（预期缺损数=31），B组58例中有12例（预期缺损数=13）（p<0.001）。在多变量逻辑回归模型中，急性发病、Crawford 2型动脉瘤、B组成员身份以及主动脉阻断时心脏指数下降仍然是神经功能缺损的显著危险因素（p<0.0001）。通过比值比分析，A组患者发生瘫痪的风险是B组的1/40。术后肾功能的唯一显著预测因素是术前肌酐水平（p<0.0001）；肾血管重建术显著改善了肾功能。择期治疗患者的死亡率为1.6%（2例），急性发病患者的死亡率为21%（19例）。在逻辑回归模型中，急性发病、年龄和术前肌酐水平被发现是手术死亡率的显著因素（p<0.001），并确定了一组高死亡风险患者。
CSFD和低剂量纳洛酮可显著降低胸腹主动脉置换术相关的瘫痪风险。主动脉阻断时心脏指数下降是一个先前未报道的变量，它定义了一组瘫痪风险较高的患者亚组。
