一站式复合手术对后循环参与供血的脑动静脉畸形手术风险和预后的影响

Effects of one-stop hybrid operation on the risk and prognosis of brain arteriovenous malformations with posterior feeding artery

目的探索在一站式复合手术应用场景下,栓塞后循环供血动脉辅助显微切除手术对后循环参与供血的脑动静脉畸形手术风险和预后的影响。方法从2016年1月至2019年12月前瞻性、多中心脑动静脉畸形的复合手术外科队列(NCT03209804)的患者中选择存在后循环供血的脑动静脉畸形患者为研究对象。根据是否栓塞后循环供血动脉将患者分为后循环栓塞组和后循环未栓塞组。根据两组患者的一般情况、脑动静脉畸形形态学、血管构筑学特征和病灶Spetzler-Martin分级进行1∶1倾向性评分匹配(PSM)。以神经功能障碍加重为主要终点事件,围手术期相关指标为次要终点事件,比较两组间手术风险和临床预后的差异。结果共计545例患者加入研究,后循环动脉参与供血者占38.3%(n=209例),后循环栓塞组42例,后循环未栓塞组167例,对两组行PSM,栓塞组纳入39例、未栓塞组纳入39例,其中男50例,女28例;年龄5~58(30±13)岁。后循环栓塞组患者术后3个月神经功能障碍加重比例高于未栓塞组,但两组间比较差异无统计学意义[15.4%(6/39)比2.6%(1/39),P=0.107]。组间比较示栓塞组的术中出血量显著少于未栓塞组[M(Q1,Q3),650(500,1500)ml比1200(800,2000)ml,P=0.002]。后循环栓塞组与后循环未栓塞组显微手术时间比较差异无统计学意义[437(374,521)min比424(359,601)min,P=0.865]。术后脑动静脉畸形残留[(5.1%(2/39)比7.7%(3/39),P=1.000],出血性并发症[5.1%(2/39)比0(0),P=0.494],术后缺血性并发症[10.3%(4/39)比5.1%(2/39),P=0.675],出院神经功能障碍[17.9%(7/39)比15.4%(6/39),P=0.755],1年神经功能障碍[5.1%(2/39)比2.6%(1/39),P=1.000]等各类术后并发症发生率及神经功能障碍加重发生率比较差异均无统计学意义(均P>0.05)。结论一站式复合手术术中栓塞脑动静脉畸形的后循环供血动脉能够有效减少术中出血,降低手术风险。栓塞后循环供血动脉未对复合手术的围手术期并发症和神经功能预后产生显著影响。

Objective To explore the effect of the combination of posterior circulation embolization and micro-resection on the risk and prognosis in patients with brain arteriovenous malformations(bAVMs)supplied by posterior circulation in a one-stop hybrid operation setting.Methods Patients with bAVMs supplied by posterior circulation who received surgical treatment in Beijing Tiantan Hospital,Capital Medical University,were enrolled from January 2016 to December 2019 from a prospective,multicentral cohort(NCT03209804).The patients were divided into the posterior circulation embolization group and the non-posterior circulation embolization group.Propensity score matching(PSM)(1∶1)was performed according to the baseline information,the morphology of bAVMs,vascular architecture,and Spetzler-Martin grade of brain lesions.The primary endpoint was the deterioration of neurological function.The secondary endpoints were perioperative complications.The differences in surgical risk and clinical prognosis between the two groups were compared.Results Five hundred and forty-five patients were enrolled in the cohort,and 38.3%met the included criteria(n=209 cases),with 42 cases in the posterior circulation embolization group and 167 cases in the non-posterior circulation embolization group.Depending on whether the patients were posterior circulation embolized,39 patients in the posterior circulation embolization group and 39 patients in the non-posterior circulation embolization group were finally included after performing PSM.There were 50 males and 28 females,aged 5-58(30±13)years.The exacerbation rate of neurological dysfunction in the posterior circulation embolization group was higher than that in the non-posterior circulation embolization group three months after surgery,however there was no statistically significant difference between the two groups[15.4%(6/39)vs 2.6%(1/39),P=0.107].The intraoperative blood loss in the embolization group was significantly less than that in the non-embolization group[650(500,1500)ml vs 1200(800,2000)ml,P=0.002].There was no significant difference in microsurgery time between the two groups[437(374,521)min vs 424(359,601)min,P=0.865].Likewise,there were no statistically significant differences in the incidence of postoperative complications and aggravation of neurological dysfunction,including postoperative bAVMs residual[5.1%(2/39)vs 7.7%(3/39),P=1.000],hemorrhagic complications[5.1%(2/39)vs 0(0),P=0.494],postoperative ischemic complications[10.3%(4/39)vs 5.1%(2/39),P=0.675],neurological dysfunction at discharge(17.9%vs 15.4%,P=0.755),and one-year neurological dysfunction[5.1%(2/39)vs 2.6%(1/39),P=1.000].Conclusions Posterior circulation embolization of bAVMs in a one-stop hybrid operation can effectively reduce intraoperative bleeding and surgical risk.Embolization of the feeding artery has no significant impact on the perioperative complications and neurological outcomes.