[A randomized controlled trial of rapid artificial cardiac pacing in thoracic endovascular aortic repair].

OBJECTIVE: To compare the safety, efficacy and their impact on stent graft positioning between rapid artificial cardiac pacing induced hypotension and sodium nitroprusside induced hypotension during thoracic endovascular aortic repair (TEVAR). METHODS: From September 2007 to February 2009, a randomized controlled trial as approved by the Ethics Committee of our hospital was conducted in 197 patients undergoing elective thoracic endovascular aortic repair of thoracic aortic dissection (n = 175) or aneurysm (n = 22). The patients were randomized into sodium nitroprusside group (n = 98) and rapid artificial cardiac pacing group (n = 99). During the localization and deployment of stent graft, hypotension was induced by intravenous sodium nitroprusside or rapid artificial cardiac pacing. Hemodynamics, landing precision (deviation from planned placement site), duration of procedure, renal function, neurocognitive function, incidence of endoleaks and paraplegia/hemiplegia were compared. RESULTS: Rapid artificial cardiac pacing was conducted without technical difficulty in all 99 patients. The level of hypotension (mm Hg, 1 mm Hg = 0.133 kPa) was most pronounced in the rapid artificial cardiac pacing group (47 ± 5 vs 82 ± 7, P = 0.003. Once rapid pacing ceased, blood pressure recovered more quickly to the preparing levels in the rapid artificial cardiac pacing group [(9 ± 2) s vs (481 ± 107) s, P < 0.01]. And the duration of procedure was also shorter in the rapid artificial cardiac pacing group [(94 ± 16) min vs (103 ± 24) min, P < 0.01]. Moreover, precise positioning and deployment was observed in rapid artificial cardiac pacing group versus to the sodium nitroprusside group (P < 0.01). There was no difference in renal function and neurocognitive function before and after the procedure in both groups. There was no difference in the incidences of endoleaks and paraplegia/hemiplegia between different groups (P > 0.05). CONCLUSION: As compared with sodium nitroprusside, rapid artificial cardiac pacing is safer in thoracic endovascular aortic repair. It shortens the endovascular procedure and enables more precise positioning and deployment of stent graft.

[Prophylactic antibiotics: a necessity in totally percutaneous thoracic endovascular aortic repair?].

OBJECTIVE: To study the benefit of prophylactic antibiotics (PA) in totally percutaneous aortic endovascular repair (PEVAR) in the catheterization laboratory for reducing stent-graft infection and postimplantation syndrome (PIS). METHODS: The clinical data were analyzed of patients undergoing thoracic endovascular aortic repairs. The patients were divided into non-PA group and PA group according to the use of prophylactic antibiotics before PEVAR. The diagnosis of infection was made by two senior physicians with reference to Hospital Acquired Infection Diagnostic Criteria Assessment released by the Ministry of Health of China. RESULTS: The 95 enrolled patients included 35 with PA and 60 without PA group, who were comparable for baseline characteristics. Infection-related deaths occurred in 1 case in non-PA group and retrograde Stanford type A dissection and death occurred in 1 case in PA group (1.67% vs 2.85%, P=1.00). The PA and non-PA groups showed no significant difference in the incidence of postoperative infection (5% vs 2.86%, P=1.000), hospital stay (9.30±7.21 vs 10.06±5.69, P=0.094), infection-related mortality (1.67% vs 0%, P=1.00), or postoperative fever (70.90% vs 91.43%, P=0.20). The body temperature showed significant variations at different time points after procedure (F=19.831, P<0.001) irrelevant to the use of prophylactic antibiotics (F=0.978, P=0.326). CONCLUSION: The current data do not support the benefit of PA in reducing postoperative infection and PIS in patients undergoing PEVAR, but the patients without PA may have worse clinical outcomes in the event of postoperative infections.

Changes of cerebrospinal fluid pressure after thoracic endovascular aortic repair.

BACKGROUND: Decreasing the intracranial pressure has been advocated as one of the major protective strategies to prevent spinal cord ischemia after endovascular aortic repair. However, the actual changes of cerebrospinal fluid (CSF) pressure and its relation with spinal cord ischemia have been poorly understood. We performed CSF pressure measurements and provisional CSF withdrawal after thoracic endovascular aortic repair, and compared the changes of CSF pressure in high risk patients and in patients with new onset paraplegia and paraparesis. METHODS: Four hundred and nineteen patients were evaluated for the risk of spinal cord ischemia after thoracic endovascular aortic repair. Patients with identified risk factors before the procedure constituted group H and received prophylactic sequential CSF pressure measurement and CSF withdrawal. Patients who actually developed spinal cord ischemia constituted group P and received rescue CSF pressure measurements and CSF withdrawal. RESULTS: Among the 419 patients evaluated, 17 were graded as high risk. Four patients actually developed spinal cord ischemia after endovascular repair. The incidence of spinal cord ischemia in this investigation was 0.9%. The patients who actually developed spinal cord ischemia had no identified risk factors and had elevated CSF pressure, ranging from 15.4 to 30.0 mmHg. Six of the 17 patients graded as high risk had elevated CSF pressure: >20 mmHg in two patients and >15 mmHg in four patients. Sequential CSF pressure measurements and provisional withdrawal successfully decrease CSF pressure and prevented symptomatic spinal cord ischemia in high-risk patients. However, these measurements could only successfully reverse the neurologic deficit in two of the patients who actually developed spinal cord ischemia. CONCLUSIONS: Cerebrospinal fluid pressure was elevated in patients with spinal cord ischemia after thoracic endovascular aortic repair. Sequential measurements of CSF pressure and provisional withdrawal of CSF decreased CSF pressure effectively in high risk patients and provided effective prevention of spinal cord ischemia. Risk factor identification and prophylactic measurements play the key role in prevention of spinal cord ischemia after thoracic endovascular aortic repair.