Svensson L G, Hess K R, D'Agostino R S, Entrup M H, Hreib K, Kimmel W A, Nadolny E, Shahian D M
Center for Aortic Surgery and Department of Thoracic and Cardiovascular Surgery, Lahey Hitchcock Clinic, Burlington, Massachusetts 01805, USA.
Ann Thorac Surg. 1998 Jul;66(1):132-8. doi: 10.1016/s0003-4975(98)00359-2.
Of all aortic operations, thoracoabdominal aortic repairs have the highest risk of spinal cord neurologic injury, manifest by lower limb paraplegia or paraparesis. Cerebrospinal fluid drainage combined with intrathecal papaverine (CSFDr + IP) may reduce the risk and severity of neurologic injury. The objective of this study was to evaluate the effect of CSFDr + IP to prevent neurologic injury after high-risk thoracoabdominal aneurysm repairs.
We screened 64 patients before operation with descending thoracic or thoracoabdominal aneurysms for possible inclusion in a prospective, randomized study. Thirty-three patients with high-risk type I and II thoracoabdominal aneurysms met inclusion criteria and 17 were randomly assigned to CSFDr + IP and 16 to the control group. The study was terminated early after interim analysis revealed a significant difference.
Of 64 patients screened, 2 patients died after operation (3.1%, 2/64); both were in the randomized study (6%, 2/33), and neither had a neurologic injury. Neurologic injury developed in 2 CSFDr + IP patients and 7 control patients (p = 0.0392). Control patients also had lower postoperative motor strength scores (p = 0.0340). On multivariate analysis, risk factors for neurologic injury included (p < 0.05) longer cross-clamp time, failure to actively cool with bypass, and postoperative hypotension, whereas CSFDr + IP was protective. Logistic regression showed that CSFDr + IP and active cooling significantly reduced the risk of injury and that the two combined modalities were additive. Of 64 patients screened, only 2 (3%) had a permanent neurologic deficit preventing ambulation.
For high-risk thoracoabdominal aneurysms, CSFDr + IP was effective in reducing the incidence and severity of neurologic injury. Active cooling may be further additive to CSFDr + IP protection, although this needs to be confirmed in a larger study.
在所有主动脉手术中，胸腹主动脉修复术导致脊髓神经损伤的风险最高，表现为下肢截瘫或轻瘫。脑脊液引流联合鞘内注射罂粟碱（CSFDr + IP）可能会降低神经损伤的风险和严重程度。本研究的目的是评估CSFDr + IP预防高危胸腹主动脉瘤修复术后神经损伤的效果。
我们在术前对64例降主动脉或胸腹主动脉瘤患者进行筛查，以确定其是否可能纳入一项前瞻性随机研究。33例高危I型和II型胸腹主动脉瘤患者符合纳入标准，其中17例被随机分配至CSFDr + IP组，16例被分配至对照组。中期分析显示存在显著差异后，该研究提前终止。
在筛查的64例患者中，2例术后死亡（3.1%，2/64）；均在随机研究组（6%，2/33），且均未发生神经损伤。2例CSFDr + IP组患者和7例对照组患者发生神经损伤（p = 0.0392）。对照组患者术后运动强度评分也较低（p = 0.0340）。多因素分析显示，神经损伤的危险因素包括（p < 0.05）较长的阻断时间、未通过旁路积极降温以及术后低血压，而CSFDr + IP具有保护作用。逻辑回归显示，CSFDr + IP和积极降温显著降低了损伤风险，且两种联合方式具有相加作用。在筛查的64例患者中，仅2例（3%）出现永久性神经功能缺损，无法行走。
对于高危胸腹主动脉瘤，CSFDr + IP可有效降低神经损伤的发生率和严重程度。积极降温可能会进一步增强CSFDr + IP的保护作用，尽管这需要在更大规模的研究中得到证实。
