胸腹主动脉瘤腔内修复术后脊髓缺血的现代防治策略

Treatment strategies of spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysm

胸腹主动脉瘤的腔内修复已经开展20余年,目前已经逐渐成为胸腹主动脉瘤的首选治疗方案。腔内修复术后脊髓缺血是术后的严重并发症之一。主动脉覆盖长度、脊髓侧支循环系统受损、肾功能不全、围手术期低血压等是术后发生脊髓缺血的危险因素。术中进行运动诱发电位监测,围手术期维持适度高血压,对高危患者进行积极的左锁骨下动脉重建,术中及术后针对高危患者进行脑脊液引流,积极的围手术期药物治疗是目前临床上用于监测、预防和治疗术后脊髓缺血的主要措施。

It is more than 20 years since the first endovascular repair of thoracoabdominal aortic aneurysm was performed.Significantly reducing risk of morbidity and mortality compared with open aortic repair,the advent of endovascular repair has revolutionized the treatment of complex aortic disease.It is now the first-line treatment for most thoracoabdominal aortic aneurysm patients.However,spinal cord ischemia(SCI)remains one of the most threatening complications after the procedure,and significantly reduces overall survival.The pathophysiology of spinal cord ischemia remains unclear but may well be multifactorial.Risk factors for SCI include excessive aortic coverage,detriment to the collateral network through occlusion of the left subclavian or internal iliac arteries,perioperative hypotension and chronic renal failure.SCI could be predicted,prevented and ameliorated through the application of motor evoked potential,permissive perioperative hypertension,cerebrospinal fluid drainage(CSFD),preoperative or concomitant left subclavian artery(LSA)revascularization and some drugs.However,there are certain complications and contraindications for CSFD and arterial revascularization.As a result,we must balance the pros and cons of these invasive measures.So we summarize our clinical experience and propose the employment of LSA revascularization and CSFD in certain kinds of high-risk patients respectively.With the development of technology and preventive measures,we believe that SCI could be minimized in the forseeable future.