81例胸腹主动脉置换术脊髓保护中肋间动脉重建技术的应用

The protective effect of intercostal artery reconstruction for spinal cord in aorta replacement

目的总结肋间动脉重建在全胸腹主动脉置换术中的脊髓保护作用。方法2003年8月至2010年8月，81例CrawfordII型胸腹主动脉瘤患者，男61例，女20例；平均年龄（39．4±10．32）岁。采用4分支人工血管进行全胸腹主动脉置换。手术经胸腹联合切口，使用深低温、分段停循环技术，对胸（T）6—12肋间动脉和腰（L）1、2动脉进行动脉管法原位重建。腹腔干、肠系膜上动脉、右。肾动脉做成一血管片与人工血管主干吻合，左肾动脉或单独与1根分支血管吻合，或与上述3支血管一起吻合在人工血管主干上，双侧髂动脉与人工血管两分支行端端吻合。结果患者均获随访。术后早期死亡6例；脊髓损伤3例，其中2例截瘫，1例下肢轻瘫，均治愈。出院后20、23、30个月后各有1例患者死亡；术后随访中12例患者重建肋间动脉闭塞，均无截瘫发生，其中2例马方综合征患者重建肋间动脉并发假性动脉瘤。患者平均生存（54．22±3．03）个月（95％CI：44．37～59．90个月），1年生存率为92．37％，2年生存率为89．02％，5年生存率为85．54％。结论肋间动脉重建对降低术后急性脊髓损伤效果确切，远期生存良好。

Objective To retrospectively analysis the role of intercostal artery reconstruction in spinal cord protection for patients with extent thoracoabdominal aotic aneurysm （TAAA） repair. Methods From August 2003 to August 2010, extent Crawford II TAAA repair were performed in 81 consecutive patients with mean age （39.4 ± 10.3 ） years and 61 （75.3%） were males. All the procedures were performed under profound hypothermia with interval cardiac arrest. Patientswere opened with a thoracoabdominal incision. Extracorporeal circulation was instituted with two arterial cannulae and a single venous can- nula in the right atrium. T6 to T12 intercostal arteries and L1,2 lumbar arteries were formed to a neo-intercostal artery in place and were connected to an 8mm branch for keeping spinal cord blood perfusion. Visceral arteries were joined into a patch and anastomosed to the end of the main graft. Left renal artery was anastomosed to an 8ram branch or joined to the patch. The other lOmm branches were anastomosed to iliac arteries. Results With 100% follow-up, early mortality was 7.4% （6/81） ,one pa- tient was dead result from cerebral hemorrhage, three from renal failure, one from heart failure because of myocardial infarction and one from rupture of cliac artery dissection. Postoperative spinal cord deficits was 3.7% （3/81） , temporary paraplegia were observed in 2 patients and paraparesis occurred in 1 patient, but all of them were without bladder or rectum deficits. Neo- inter- costal arteries were clogged in 12 patients within follow-up, and two of those patients with Marfan syndrome underwent pseudoaneurysm after intercostal arteries reconstruction. The mean survival time in this group is （54.22 ± 3.03 ）months （95% CI： 44.37 months,59.90 months） with survival rate 92.37% after 1 year, 89.02% after 2 years, 85.54% after 5 years. Three patient were dead with long term follow-up, one were resulted from cerebral hemorrhage at 20th month, one from rupture of ascending aorta at 23rd month and the last from rupture of aorta ulcer. Conclusion Intercostal artery reconstruction is a reliable method in spinal cord protection for patients with TAAA repair. It is a feasible method with acceptable surgical risks and satisfactory results. It can achieve long term result with less risk of spinal cord deficits and good quality of daily life.