Mechanisms of Symptomatic Spinal Cord Ischemia After TEVAR: Insights From the European Registry of Endovascular Aortic Repair Complications (EuREC)

被引：128

作者：

Czerny, Martin ^{[1
]}

Eggebrecht, Holger ^{[3
]}

Sodeck, Gottfried ^{[2
]}

Verzini, Fabio ^{[4
]}

Cao, Piergiorgio ^{[5
]}

Maritati, Gabriele ^{[5
]}

Riambau, Vicente ^{[6
]}

Beyersdorf, Friedhelm ^{[7
]}

Rylski, Bartosz ^{[7
]}

Funovics, Martin ^{[8
]}

Loewe, Christian ^{[8
]}

Schmidli, Juerg ^{[1
]}

Tozzi, Piergiorgio ^{[9
]}

Weigang, Ernst ^{[10
]}

Kuratani, Toru ^{[11
]}

Livi, Ugolino ^{[12
]}

Esposito, Giampiero ^{[13
,14
]}

Trimarchi, Santi ^{[15
]}

van den Berg, Jos C. ^{[16
]}

Fu, Weiguo ^{[17
]}

Chiesa, Roberto ^{[18
]}

Melissano, Germano ^{[18
]}

Bertoglio, Luca ^{[18
]}

Lonn, Lars ^{[19
]}

Schuster, Ingrid ^{[20
]}

Grimm, Michael ^{[21
]}

机构：

[1] Univ Hosp Bern, Inselspital, Dept Cardiovasc Surg, CH-3010 Bern, Switzerland

[2] Univ Hosp Bern, Inselspital, Dept Cardiol, CH-3010 Bern, Switzerland

[3] W German Heart Ctr, Dept Cardiol, Essen, Germany

[4] Hosp S Maria Misericordia, Vasc & Endovasc Surg Unit, Perugia, Italy

[5] San Camillo Hosp, Dept Vasc Surg, Rome, Italy

[6] Hosp Clin Barcelona, Thorax Inst, Dept Vasc Surg, Barcelona, Spain

[7] Univ Freiburg, Dept Cardiovasc Surg, Freiburg, Germany

[8] Med Univ Vienna, Dept Intervent Radiol, Vienna, Austria

[9] CHU Vaudois, Dept Cardiovasc Surg, Lausanne, Switzerland

[10] Univ Med Ctr Mainz, Dept Cardiothorac & Vasc Surg, Mainz, Germany

[11] Grad Sch Med, Dept Cardiovasc Surg, Suita, Osaka, Japan

[12] S Maria della Misericordia Hosp, Dept Cardiopulm Sci, Udine, Italy

[13] GVM Hosp Care, Citta Lecce Hosp, Lecce, Italy

[14] GVM Hosp Res, Citta Lecce Hosp, Lecce, Italy

[15] Cardiovasc Ctr E Malan, IRCCS Policlin San Donato, Milan, Italy

[16] Osped Reg Lugano, Serv Intervent Radiol, Lugano, Switzerland

[17] Fudan Univ, Zhongshan Hosp, Dept Vasc Surg, Shanghai 200433, Peoples R China

[18] Ist Sci San Raffaele, Dept Vasc Surg, Milan, Italy

[19] Univ Copenhagen, Dept Vasc Surg & Cardiovasc Radiol, DK-1168 Copenhagen, Denmark

[20] Univ Kosice, Dept Cardiac Surg, Kosice, Slovakia

[21] Med Univ, Dept Cardiac Surg, Innsbruck, Austria

来源：

JOURNAL OF ENDOVASCULAR THERAPY | 2012年 / 19卷 / 01期

关键词：

thoracic aorta; stent-graft; thoracic endovascular aortic repair; complication; spinal cord ischemia; paraplegia; paraparesis; hypotension; hypoperfusion; intercostal arteries; left subclavian artery; risk model; AORTOESOPHAGEAL; PARAPLEGIA; DISSECTION; PERFUSION;

D O I：

10.1583/11-3578.1

中图分类号：

R61 [外科手术学];

学科分类号：

摘要：

Purpose: To test the hypothesis that simultaneous closure of at least 2 independent vascular territories supplying the spinal cord and/or prolonged hypotension may be associated with symptomatic spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR). Methods: A pattern matching algorithm was used to develop a risk model for symptomatic SCI using a prospective 63-patient single-center cohort to test the positive predictive value (PPV) of prolonged intraoperative hypotension and/or simultaneous closure of at least 2 of 4 the vascular territories supplying the spinal cord (left subclavian, intercostal, lumbar, and hypogastric arteries). This risk model was then applied to data extracted from the multicenter European Registry on Endovascular Aortic Repair Complications (EuREC). Between 2002 and 2010, the 19 centers participating in EuREC reported 38 (1.7%) cases of symptomatic spinal cord ischemia among the 2235 patients in the database. Results: In the single-center cohort, direct correlations were seen between the occurrence of symptomatic SCI and both prolonged intraoperative hypotension (PPV 1.00, 95% CI 0.22 to 1.00, p=0.04) and simultaneous closure of at least 2 independent spinal cord vascular territories (PPV 0.67, 95% CI 0.24 to 0.91, p=0.005). Previous closure of a single vascular territory was not associated with an increased risk of symptomatic spinal cord ischemia (PPV 0.07, 95% CI 0.01 to 0.16, p=0.56). The combination of prolonged hypotension and simultaneous closure of at least 2 territories exhibited the strongest association (PPV 0.75, 95% CI 0.38 to 0.75, p<0.0001). Applying the model to the entire EuREC cohort found an almost perfect agreement between the predicted and observed risk factors (kappa 0.77, 95% CI 0.65 to 0.90). Conclusion: Extensive coverage of intercostal arteries alone by a thoracic stent-graft is not associated with symptomatic SCI; however, simultaneous closure of at least 2 vascular territories supplying the spinal cord is highly relevant, especially in combination with prolonged intraoperative hypotension. As such, these results further emphasize the need to preserve the left subclavian artery during TEVAR. J Endovasc Ther. 2012;19:37-43

引用

页码：37 / 43

页数：7

共 17 条

[1]

Adamkiewicz A., 1882, Sitzb Akad Wiss, P101

[2] Neurologic complications associated with endovascular repair of thoracic aortic pathology: Incidence and risk factors. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) Registry [J].

Buth, Jacob ;

Harris, Peter L. ;

Hobo, Roel ;

van Eps, Randolph ;

Cuypers, Philippe ;

Duijm, Lucien ;

Tielbeek, Xander .

JOURNAL OF VASCULAR SURGERY, 2007, 46 (06) :1103-1111

[3] Endovascular treatment of aortoesophageal and aortobronchial fistulae [J].

Chiesa, Roberto ;

Melissano, Germano ;

Marone, Enrico M. ;

Kahlberg, Andrea ;

Marrocco-Trischitta, Massimiliano M. ;

Tshomba, Yamume .

JOURNAL OF VASCULAR SURGERY, 2010, 51 (05) :1195-1202

[4] Successful treatment of an aortoesophageal fistula after emergency endovascular thoracic aortic stent-graft placement [J].

Czerny, M ;

Zimpfer, D ;

Fleck, T ;

Gottardi, R ;

Cejna, M ;

Schoder, M ;

Lammer, J ;

Wolner, E ;

Grabenwoger, M ;

Mueller, MR .

ANNALS OF THORACIC SURGERY, 2005, 80 (03) :1117-1120

[5] Long-term results of thoracic endovascular aortic repair in atherosclerotic aneurysms involving the descending aorta [J].

Czerny, Martin ;

Funovics, Martin ;

Sodeck, Gottfried ;

Dumfarth, Julia ;

Schoder, Maria ;

Juraszek, Andrzej ;

Dziodzio, Tomasz ;

Zimpfer, Daniel ;

Loewe, Christian ;

Lammer, Johannes ;

Rosenhek, Raphael ;

Ehrlich, Marek ;

Grimm, Michael .

JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY, 2010, 140 (06) :S179-S184

[6] Endovascular stent-graft placement in aortic dissection:: a meta-analysis [J].

Eggebrecht, H ;

Nienaber, CA ;

Neuhäuser, M ;

Baumgart, D ;

Kische, S ;

Schmermund, A ;

Herold, U ;

Rehders, TC ;

Jakob, HG ;

Erbel, R .

EUROPEAN HEART JOURNAL, 2006, 27 (04) :489-498

[7] Retrograde Ascending Aortic Dissection During or After Thoracic Aortic Stent Graft Placement Insight From the European Registry on Endovascular Aortic Repair Complications [J].

Eggebrecht, Holger ;

Thompson, Matt ;

Rousseau, Herve ;

Czerny, Martin ;

Loenn, Lars ;

Mehta, Rajendra H. ;

Erbel, Raimund .

CIRCULATION, 2009, 120 (11) :S276-S281

[8] Spinal cord perfusion after extensive segmental artery sacrifice: can paraplegia be prevented? [J].

Etz, Christian D. ;

Homann, Tobias M. ;

Plestis, Konstadinos A. ;

Zhang, Ning ;

Luehr, Maximilian ;

Weisz, Donald J. ;

Kleinman, George ;

Griepp, Randall B. .

EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY, 2007, 31 (04) :643-648

[9] Cerebrospinal fluid drainage as a useful treatment option to relieve paraplegia after stent-graft implantation for acute aortic dissection type B [J].

Fleck, T ;

Hutschala, D ;

Weissl, M ;

Wolner, E ;

Grabenwöger, M .

JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY, 2002, 123 (05) :1003-1005

[10] Supra-aortic Transposition for Combined Vascular and Endovascular Repair of Aortic Arch Pathology [J].

Gottardi, Roman ;

Funovics, Martin ;

Eggers, Nella ;

Hirner, Alexander ;

Dorfmeister, Marion ;

Holfeld, Johannes ;

Zimpfer, Daniel ;

Schoder, Maria ;

Donas, Konstantin ;

Weigang, Ernst ;

Lammer, Johannes ;

Grimm, Michael ;

Czerny, Martin .

ANNALS OF THORACIC SURGERY, 2008, 86 (05) :1524-1529

← 1 2 →