继发于慢性血管夹层的II 型胸腹主动脉瘤的修复术

1 引 言 Crawford Ⅱ型胸腹主动脉瘤(TAAA)修复通常包括用合成的血管取代从左锁骨下动脉至肾下腹主动脉分叉的胸腹主动脉全长血管.因为行广泛的动脉替换,Ⅱ型修复出现术后并发症有极高风险[1-6].为了减少这些并发症,我们常规在术中采用联合方法保护相应器官[7-9].为了保护脊髓,我们采用轻度被动降低体温,脑脊液引流术,左心分流术(LHB),序贯交叉夹闭以及选择性肋间动脉或腰动脉再植术[7-8,10-11].我们间断地向肾脏灌注冷晶体溶液用以避免出现缺血性损伤及急性肾衰竭[12-14].我们同时将左心分流回路的等温血液输注至腹腔干和肠系膜上动脉(SMA)以最小化腹腔脏器缺血时间.     

常温非体外循环下全胸腹主动脉替换术

目的 总结常温非体外循环下全胸腹主动脉替换术(total thoracoabdominal aortic aneurysm repair,tTAAAR)的手术方式和早期治疗效果.方法 2009年2月至2010年12月,共完成41例全胸腹主动脉替换术,其中27例CrawfordⅡ型胸腹主动脉瘤(thoracoabdominal aortic aneurysm,TAAA)患者接受常温非体外循环tTAAAR治疗.男18例,女9例;平均年龄(41.85 ±10.11)岁.手术经左侧胸腹联合切口、腹膜外入路,常温非体外循环下建立降主动脉→双侧髂动脉旁路循环,然后采用分段阻断法,重建T6～T12肋间动脉及内脏血管.结果 所有患者均完成手术,降主动脉阻断(13.78 ±3.77) min.脊髓缺血( 19.19±3.93) min,内脏缺血(25.19 ±5.88) min.1例患者术中死亡,其余患者均生存.术后永久性脊髓损伤2例,呼吸系统并发症3例.结论 中国全胸腹主动脉瘤患者应早期积极治疗,常温非体外循环下的全胸腹主动脉替换术是一种安全、有效的治疗策略.     

脑脊液引流在胸降及胸腹主动脉瘤腔内修复术中对截瘫的预防保护

目的:探讨脑脊液引流在胸降、胸腹主动脉瘤腔内修复术中对截瘫的预防保护作用。方法:回顾性分析我科于2007年9月至2009年12月期间的32例胸降、胸腹主动脉瘤行腔内修复术病人,在术中及术后予以脑脊液引流的效果。结果:所有病人痊愈出院,随访1个月~1年。4例病人术后出现轻瘫症状,经脑脊液引流后治愈;其余病人围手术期间及随访期间未出现截瘫表现,治疗期间无严重并发症。结论:脑脊液引流可在胸降、胸腹主动脉瘤腔内修复术中有效地预防及治疗轻瘫及截瘫。     

胸腹主动脉瘤手术治疗中的截瘫并发症

胸腹主动脉瘤（thoracoabdominal aortic aneurysm，TAAA）是指胸主动脉和腹主动脉联合动脉瘤，按照性质可分为真性动脉瘤、假性动脉瘤和夹层动脉瘤。治疗方式主要包括传统外科手术、腔内修复术（endovascular aneurysm repair，EVAR）以及近来新兴的“杂交手术”（hybrid treatment），即联合利用传统外科手术重建脏器血管和腔内技术修复动脉瘤。传统外科手术治疗TAAA已有半个多世纪，术式历经不断改进；EVAR技术应用十余年来发展迅猛，已经历几代产品的变革。但迄今为止无论何种术式，因脊髓缺血而造成截瘫这一灾难性的并发症仍无法完全解决。     

腹主动脉瘤腔内修复与开放手术疗效初探

目的 比较腹主动脉瘤开放手术与腔内治疗的效果.方法 对42例分别行开放手术和腔内修复的腹主动脉瘤患者的手术相关情况、围手术期并发症发生率、病死率、随访情况以及相关的费用进行对比分析.结果 腔内修复组手术时间、术中出血量、输血量均少于开放手术组(P<0.01),两组围手术期并发症差异无统计学意义(P>0.05),两组术后2年生存率差异无统计学意义(P>0.05),但腔内修复组术后远期并发症发生率高于开放手术组(P<0.01).住院费用腔内修复组明显高于开放手术组(P<0.01).结论 腹主动脉瘤腔内修复术具有手术时间短、微创的特点,但具有较高的远期并发症,开放手术组6个月生存质量优于腔内修复组.     

胸腹主动脉瘤手术脊髓损伤研究现状

胸腹主动脉瘤手术脊髓损伤研究现状屈正综述孙衍庆审校脊髓缺血性损伤是胸腹主动脉瘤手术中迄今尚未完全解决的严重并发症。其截瘫发生率为０．４％～１８％，甚者达４０％［１～３］。原因和机理目前关于术后截瘫的原因已在器官和细胞水平的很多动物实验中获得解释，而在...     

不同手术方式行全胸腹主动脉替换的临床研究

目的 比较手术治疗的效果,探讨不同手术方式行全胸腹主动脉替换术的适应证和具体手术方法,明确常温非体外循环下全胸腹主动脉替换的可行性和安全性.方法 2009年2月到2011年5月,46例CrawfordⅡ型胸腹主动脉瘤(thoracoabdominal aortic aneurysm,TAAA)患者行全胸腹主动脉替换术(total thoracoabdominal aortic aneurysm repair,tTAAAR).根据术式不同,分为深低温停循环tTAAAR(A)组15例和常温非体外循环tTAAAR(B)组31例.计数资料采用精确概率的x2检验和计数资料经正态性检验后采用t检验等统计学方法,比较了患者的术前、术中和术后ICU治疗情况以及围术期病死率、并发症发生率等.结果 A组和B组术后早期死亡(26.67％对3.20％,P=0.033)和一过性脑功能障碍发生率(33.30％对3.30％,P=0.018)差异有统计学意义.两组手术时间(P＜0.0001)、降主动脉阻断时间(P ＜0.0001),输注红细胞(P=0.013)差异亦有统计学意义.术前情况、内脏缺血时间、脊髓缺血时间、ICU治疗时间、带气管插管时间、脊髓损伤、肾功能不全等差异无统计学意义,P＞0.05.结论 常温非体外循环全胸腹主动脉替换术安全、可靠.适应证为可在常温下建立降主动脉到髂动脉旁路循环的胸腹主动脉动脉瘤.肋间动脉重建是重要的脊髓保护手段.     

胸腹主动脉瘤手术中辅助方法的应用(文献综述)

胸腹主动脉瘤修复手术难度大,术后并发截瘫及内脏功能障碍的发生率高。为提高胸腹主动脉瘤手术的治疗效果,在术中已采用许多辅助方法。本文着重介绍了这些辅助方法的优缺点及其研究进展。     

胸腹主动脉瘤手术中脑脊液引流对脊髓的保护作用

目的探索胸腹主动脉瘤手术患者脑脊液引流(CSFD)对脊髓的保护作用。方法将2008年12月至2009年8月北京安贞医院的30例胸腹主动脉瘤手术患者,按照术中是否行CSFD,采用计算机随机法分为CSFD组(15例,其中男12例,女3例;平均年龄45.0岁)和对照组(15例,其中男11例,女4例;平均年龄45.8岁),进行升主动脉和主动脉弓部置换+降主动脉支架植入或胸腹主动脉联合置换术,部分患者同时行Bentall手术或半弓置换手术,CSFD组行CSFD。术中和术后固定时间点采取血清样本,测定其血清S100B蛋白、神经胶质原纤维酸性蛋白、神经元特异性烯醇化酶,术前、术后72 h和出院时按美国国立卫生研究院卒中量表和脊髓损伤神经学分类国际标准评分。结果对照组4例出现中枢神经系统(CNS)并发症:1例发生脑损伤和脊髓损伤而死亡;1例发生脊髓损伤,早期行CSFD等治疗,截瘫有所恢复后出院;2例患者发生脑损伤,其中1例死亡,另1例同时出现肾功能衰竭和呼吸衰竭等并发症,经治疗后恢复出院。CSFD组仅1例因呼吸衰竭继发多器官功能衰竭而死亡,其余患者恢复良好出院。随访3个月无死亡。CSFD组患者血清S100B(F=7.153,P=0.012)、神经胶质原纤维酸性蛋白(F=3.263,P=0.082)和神经元特异性烯醇化酶(F=4.927,P=0.035)值均低于对照组,且差异有统计学意义。结论脑脊液选择性引流具有明确的脊髓保护作用,在胸腹主动脉瘤手术中安全、有效并可行。     

腔内修复术与开放手术治疗腹主动脉瘤的对比分析

目的 对比分析传统开放手术与血管腔内修复术治疗腹主动脉瘤的疗效.方法 回顾性分析我科2009年至2012年经外科治疗的43例肾动脉下腹主动脉瘤患者的临床资料,行腔内治疗患者25例,行传统手术的18例,对比分析两组患者术前、术中情况,术后并发症及6个月内死亡情况.结果 两组患者在手术时间、术中失血及输血量方面,两组差异均有统计学意义（t值分别为8.377,5.124,5.043,P均＜0.001）;术后30d内并发症比较,差异有统计学意义（X2=0.09,P＜0.05）;术后6个月内死亡率比较,差异无统计学意义（x2=4.21,P＞0.05）.结论 血管腔内修复术比传统手术创伤小,手术时间短,术中失血及输血量少,术后短期并发症发生率低,但中远期死亡率无明显差别.     

Transient paraplegia following elective infrarenal aortic aneurysm repair. Case report

Paraplegia is a well known complication after surgery for thoracic and thoraco-abdominal aneurysm but is very rare when the level involved is lower than the renal arteries. It is seen most often after treatment of ruptured aneurysm and very few cases are found in the literature reporting spinal cord ischemia after elective repair of an infrarenal abdominal aortic aneurysm. A new case of transient paraplegia following elective repair of an infrarenal abdominal aortic aneurysm is reported and different aspects of this complication are discussed. In our case, probably the interruption of blood flow in lumbar arteries and the duration of crossclamping were likely contributive factors and it suggest that a failure to appreciate the significance of collateral sources of spinal cord blood flow may be responsible for at least some cases of postoperative paraplegia.     

Spinal Cord Protection During Thoracoabdominal Aneurysm Repair

Spinal cord injury after thoracoabdominal aortic surgery remains a devastating and unpredictable complication, caused by clamping of the thoracoabdominal aorta, resulting in exclusion of blood flow in critical and essential intercostal arteries. Various protective methods against spinal cord ischemia have been proposed and performed clinically. These include preoperative spinal angiography, distal aortic perfusion, hypothermia, reattachment of the intercostal artery, cerebrospinal fluid drainage, administration of neuroprotective agents, and monitoring of somatosensory and motor-evoked potentials. The information to date suggests that multimodality approaches should be used to prevent spinal cord injury after thoracic and thoracoabdominal aneurysm repair.     

Endovascular Thoracic Aortic Repair and Previous or Concomitant Abdominal Aortic Repair: Is the Increased Risk of Spinal Cord Ischemia Real?

Spinal cord ischemia after endovascular thoracic aortic repair remains a significant risk. Previous or concomitant abdominal aortic repair may increase this risk. This investigation reviews the occurrence of spinal cord ischemia after endovascular repair of the descending thoracic aorta in patients with previous or concomitant abdominal aortic repair. Over an 8-year period, 125 patients underwent endovascular exclusion of the thoracic aorta at the Mount Sinai Medical Center. Twenty-eight of these patients had previous or concomitant abdominal aortic repair. The 27 patients who underwent staged repairs all had cerebrospinal fluid (CSF) drainage during and following repair. This population was analyzed for the complication of spinal cord ischemia and factors related to its occurrence. Mean follow-up was 19.3 months (range 1-61). Spinal cord ischemia developed in four of the 28 patients (14.3%) who underwent endovascular thoracic aortic repair with previous or concomitant abdominal aortic repair, while one of 97 patients (1.0%) developed ischemia among the remaining thoracic endograft population. One patient with concomitant abdominal aortic repair developed cord ischemia that manifested 12 hr following the procedure. The remaining three patients with previous abdominal aortic repair developed more delayed-onset paralysis ranging from the third postoperative day to 7 weeks following repair. Irreversible cord ischemia occurred in three patients, with full recovery in one patient. Major complications from CSF drainage occurred in one patient (3.7%). Spinal cord ischemia occurred at a markedly higher rate in patients with previous or concomitant abdominal aortic repair. This risk continued beyond the immediate postoperative period. The benefit of perioperative and salvage CSF drainage remains to be determined.     

Delayed neurologic deficit after endovascular abdominal aortic aneurysm repair

Paraplegia or paraparesis secondary to spinal cord ischemia is an extremely rare complication after elective repair of abdominal aortic aneurysm. We report delayed paraparesis after endovascular abdominal aortic aneurysm repair in which one hypogastric artery was unintentionally occluded due to atheroembolism. A spinal catheter was immediately inserted after onset of paraplegia to promote cerebrospinal fluid drainage, which partially reversed the neurologic deficit. Our case underscores both the importance of the critical spinal collateral supply from the hypogastric artery and the role of spinal fluid drainage to maximize spinal cord perfusion in the setting of spinal cord ischemia.     

Risk of spinal cord ischemia after endograft repair of thoracic aortic aneurysms

BACKGROUND: Surgical repair of thoracoabdominal aneurysms may be associated with a significant risk of perioperative morbidity including spinal cord ischemia, which occurs at a rate of between 5% and 21%. Spinal cord ischemia after endovascular repair of thoracic aortic aneurysms (TAAs) has also been reported. This investigation reviews the occurrence of spinal cord ischemia after endovascular repair of descending TAAs at the Mount Sinai Medical Center. PATIENTS AND METHODS: Between May 1997 and April 2001, 53 patients underwent endovascular exclusion of their TAA. Preprocedure computed tomography scanning and angiography were performed on all patients. All were performed in the operating room using C-arm fluoroscopy. Physical examinations and computed tomography scans were performed at discharge and at 1, 3, 6, and 12 months postoperatively and then annually thereafter. Spinal cord ischemia developed in three of the 53 patients (5.7%) postoperatively. In one patient, cord ischemia developed that manifested as early postoperative left leg weakness occurring after concomitant open infrarenal abdominal and endovascular TAA repair. The neurologic deficit resolved 12 hours after spinal drainage, steroid bolus, and the maintenance of hemodynamic stability. The remaining two patients developed delayed onset paralysis, one patient on the second postoperative day and the other patient 1 month postrepair. Both of these patients had previous abdominal aortic aneurysm repair, and both required long grafts to exclude an extensive area of their thoracic aortas. Irreversible cord ischemia and paralysis occurred in both of these patients. CONCLUSIONS: Endovascular repair of TAA has shown a promising reduction in operative morbidity; however, the risk of spinal cord ischemia remains. Concomitant or previous abdominal aortic aneurysm repair and long segment thoracic aortic exclusion appear to be important risk factors. Spinal cord protective measures (ie, cerebrospinal fluid drainage, steroids, prevention of hypotension) should be used for patients with the aforementioned risk factors undergoing endovascular TAA repair.     

Evaluation of spinal cord ischemia in endovascular stent graft repair and surgical operation of descending thoracic or thoracoabdominal aortic aneurysms

Between October 1996 and June 2003, endovascular stent graft repair was performed in 87 patients with descending thoracic aortic aneurysms, graft replacement was performed in 24 patients with thoracoabdominal aortic aneurysms, and endovascular stent graft repair with concomitant surgical bypass of abdominal visceral arteries was performed in 3 patients with thoracoabdominal aortic aneurysms. The retrievable stent graft was inserted and evoked spinal cord potential were monitored in order to predict spinal cord ischemia for stent graft repair. There was no paraplegia or hospital death, although 3 patients had paraparesis in stent graft repair. Two of the 3 patients with paraparesis made a full neurologic recovery. There were no cases of paraplegia or paraparesis in surgical operations with thoracoabdominal aortic aneurysm. The concomitant surgical procedure was a good technique for patients in whom cardiopulmonary bypass could not be used. Our results of stent graft repair and surgical operation for descending thoracic or thoracoabdominal aortic aneurysms were acceptable. The retrievable stent graft was useful for prediction of spinal cord ischemia before endovascular stent graft repair of descending thoracic or thoracoabdominal aortic aneurysm.     

Paraplejía tardía transitoria tras reparación de aneurismas torácico y toracoabdominal

Thoracoabdominal aneurysm requires multidisciplinary management due to its complexity both in surgical technique and anesthetic considerations. One of the most feared postoperative complication is spinal cord ischemia. It can be presented as different clinical patterns, and its recovery may be partial or complete. The postoperative management of spinal cord ischemia is mainly based on techniques to increase spinal cord perfusion, above all, hemodynamic stability and cerebrospinal fluid drainage. We present two cases of delayed paraplegia after an open repair of a thoracoabdominal aneurysm and a descending thoracic aortic aneurysm repair using an endovascular stent graft. They both had a complete neurological recovery after cerebrospinal fluid drainage.     

主动脉手术的脊髓保护

脊髓损伤是胸主动脉手术后的严重并发症,影响手术后脊髓并发症发生的因素包括手术过程中脊髓缺血的时间及程度、主动脉修复后脊髓血运的重建状况、多种生化因素、缺血-再灌注损伤等。目前主动脉手术中脊髓的保护手段有:提高手术技术和改进手术方法;增加脊髓的血液供应,包括提供机械性动力的血液灌注和动脉分流,脑脊液分流;利用低温降低脊髓的代谢率;应用药物防止脊髓缺血-再灌注损伤。现就脊髓的血液循环特点、脊髓损伤的发生机制和脊髓保护的最新进展进行综述。     

Paraplegia after surgery for aneurysm of the descending thoracic aorta

Postoperative paraplegia caused by ischemic injury of the spinal cord is the most disabling complication of thoracoabdominal surgery, particularly when repair of the descending thoracic aorta is involved. We describe the case of a 59-year-old man who underwent emergency surgery for placement of a Dacron prosthesis to repair a ruptured descending thoracic aorta aneurysm, using an aortic cross-clamping technique plus aortic-femoral partial bypass with normothermia and an ischemic time of 165 minutes. The early postoperative course included complete spinal syndrome with motor and sensory loss below T5, with consequent respiratory insufficiency of neuromuscular origin. The result was a difficult postoperative course including prolonged mechanical ventilation and recurrent respiratory infections. Possible causes include prolonged time of ischemia, inadequate monitoring of distal aortic pressure and inappropriate surgical technique related to the absence of angiographic data on spinal vascularization. We conclude that ischemic time should be kept to under 30 minutes whenever possible. In cases of prolonged ischemia, bypass techniques with outflow to the distal aortic segment are more effective whenever mean blood pressure at this point rises to 60 mmHg or more. Vasodilator use should be reserved for cases of severe arterial hypertension and left ventricular failure and/or life-threatening increases in aortic wall stress even if not leading to dangerous decreases in distal aortic pressure. Finally, angiographic study to obtain anatomical details of spinal blood flow is advisable.     

Spinal cord ischemia following surgery for aortoiliac occlusive disease

A 70-year-old man had aortobifemoral bypass for severe aortoiliac occlusive disease. He developed spinal cord ischemia with anterior spinal artery syndrome. He had minimal recovery of muscle function, multiple postoperative complications, and 11 months postoperatively he died. Spinal cord ischemia is a rare and unpredictable complication of abdominal aortic surgery. It most often has occurred following surgery for aneurysm but can also occur after apparently routine surgery for occlusive disease.