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Abstract
Neuroprotection after acute spinal cord injury is an important strategy to limit secondary injury. Animal studies have shown that systemic hypothermia is an effective neuroprotective strategy that can be combined with other therapies. Systemic hypothermia affects several processes at the cellular level to reduce metabolic activity, oxidative stress, and apoptotic neuronal cell death. Modest systemic hypothermia has been shown to be safe and feasible in the acute phase after cervical spinal cord injury. These data have provided the impetus for an active multicenter randomized controlled trial for modest systemic hypothermia in acute cervical spinal cord injury.
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Haunschild J, VON Aspern K, Misfeld M, Davierwala P, Borger MA, Etz CD. Spinal cord protection in thoracoabdominal aortic aneurysm surgery: a multimodal approach. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:316-325. [PMID: 33496426 DOI: 10.23736/s0021-9509.21.11783-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Spinal cord injury (SCI) is one major complication of open and endovascular thoracic and thoracoabdominal aortic aneurysm repair. Despite numerous neuroprotective adjuncts, the incidence of SCI remains high. This review article discusses established and novel adjuncts for spinal cord protection, including priming and preconditioning of the paraspinal collateral network, intraoperative systemic hypothermia, distal aortic perfusion, motor- and somatosensory evoked potentials and noninvasive cnNIRS monitoring as well as peri- and postoperative drainage of cerebrospinal fluid. Regardless of the positive influence of many of these strategies on neurologic outcome, to date no strategy assures definitive preservation of spinal cord integrity during and after aortic aneurysm repair.
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Affiliation(s)
| | | | - Martin Misfeld
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Medicine and Health, Central Clinical School, University of Sydney, Sydney, Australia.,Institute of Academic Surgery, RPAH, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia
| | - Piroze Davierwala
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Christian D Etz
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany -
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Murana G, Alfonsi J, Di Marco L, Pacini D. Open thoracoabdominal aortic aneurysm repair in expert hands: "all roads lead to Rome". ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:414. [PMID: 29152514 DOI: 10.21037/atm.2017.08.03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Giacomo Murana
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Jacopo Alfonsi
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Luca Di Marco
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Davide Pacini
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
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Wortmann M, Böckler D, Geisbüsch P. Perioperative cerebrospinal fluid drainage for the prevention of spinal ischemia after endovascular aortic repair. GEFASSCHIRURGIE 2017; 22:35-40. [PMID: 28944782 PMCID: PMC5573755 DOI: 10.1007/s00772-017-0261-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Endovascular treatment of thoracic and thoracoabdominal aortic diseases is accompanied by a risk of spinal ischemia in 1-19% of patients, depending on the entity and extent of the disease. The use of perioperative drainage of cerebrospinal fluid is one of the invasive measures to reduce the occurrence of this severe complication. This article reviews the incidence of spinal ischemia, its risk factors, the evidence for carrying out cerebrospinal fluid drainage and its modern use by means of an automated, pressure controlled system (LiquoGuard®7).
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Affiliation(s)
- M Wortmann
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - D Böckler
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - P Geisbüsch
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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5
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Abstract
Spinal cord injury (SCI) is a major health problem and is associated with a diversity of neurological symptoms. Pathophysiologically, dysfunction after SCI results from the culmination of tissue damage produced both by the primary insult and a range of secondary injury mechanisms. The application of hypothermia has been demonstrated to be neuroprotective after SCI in both experimental and human studies. The myriad of protective mechanisms of hypothermia include the slowing down of metabolism, decreasing free radical generation, inhibiting excitotoxicity and apoptosis, ameliorating inflammation, preserving the blood spinal cord barrier, inhibiting astrogliosis, promoting angiogenesis, as well as decreasing axonal damage and encouraging neurogenesis. Hypothermia has also been combined with other interventions, such as antioxidants, anesthetics, alkalinization and cell transplantation for additional benefit. Although a large body of work has reported on the effectiveness of hypothermia as a neuroprotective approach after SCI and its application has been translated to the clinic, a number of questions still remain regarding its use, including the identification of hypothermia's therapeutic window, optimal duration and the most appropriate rewarming rate. In addition, it is necessary to investigate the neuroprotective effect of combining therapeutic hypothermia with other treatment strategies for putative synergies, particularly those involving neurorepair.
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Affiliation(s)
- Jiaqiong Wang
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, the Lois Pope Life Center, Locator code (R-48), PO BOX 016960, Miami, FL 33136, USA.
| | - Damien D Pearse
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, the Lois Pope Life Center, Locator code (R-48), PO BOX 016960, Miami, FL 33136, USA.
- The Department of Neurological Surgery, University of Miami Miller School of Medicine, the Lois Pope Life Center, Locator code (R-48), PO BOX 016960, Miami, FL 33136, USA.
- The Neuroscience Program, University of Miami Miller School of Medicine, the Lois Pope Life Center, Locator code (R-48), PO BOX 016960, Miami, FL 33136, USA.
- The Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, the Lois Pope Life Center, Locator code (R-48), PO BOX 016960, Miami, FL 33136, USA.
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Etz CD, Weigang E, Hartert M, Lonn L, Mestres CA, Di Bartolomeo R, Bachet JE, Carrel TP, Grabenwöger M, Schepens MA, Czerny M. Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery†. Eur J Cardiothorac Surg 2015; 47:943-57. [DOI: 10.1093/ejcts/ezv142] [Citation(s) in RCA: 173] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Liu F, Guan Y, Wan C, Dong P. The monitoring and preventing of spinal cord ischemic injury during thoracic descending aortic operating. SCAND CARDIOVASC J 2012; 46:239-44. [PMID: 22564059 DOI: 10.3109/14017431.2012.691990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND A model of ischemic injury to the spinal cord was established in pigs by clamping the thoracic descending aorta. The feasibility of monitoring spinal-cord ischemia using the cortical somatosensory evoked potential (CSEP) was evaluated. Outcomes between the simple clamp (SC) group and left-heart bypass (LHB) group were compared. METHODS Twelve mini-pigs were randomly divided into two groups SC group and LHB group randomly. The left intercostal incision was adopted. The thoracic descending aorta was clamped under the left innominate artery outlet. CSEP was recorded to monitor the function of the spinal cord. The behavior score was observed every day after surgery. Mini-pigs were killed on the seventh postoperative day. Ultrastructural changes were observed by transmission electron microscopy. RESULTS The surgical procedures were successful. Two animals developed incomplete paralysis and the remainder developed paraplegia in the SC group. The animals in the LHB group recovered completely and paralysis/paraplegia was not observed. CSEP measurements showed that the amplitude decreased to <50% of baseline values and prolongation of latency was >10% of baseline values in the SC group but not in the LHB group. Changes in CSEP values were in accordance with changes in behavior score. The ultramicrostructure of spinal-cord tissue under clamping indicated severe damage to tissue layers as well as swelling and damage to mitochondria in the SC group, whereas the morphology was almost normal in the LHB group. CONCLUSIONS These data suggest that during a 30-minute clamping time, left-heart bypass may provide superior spinal protection than simple clamping, and monitoring of spinal-cord ischemia using CSEP was rapid and feasible.
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Affiliation(s)
- Feng Liu
- Extracorporeal Circulation Department, Beijing Anzhen Hospital, Capital Medical University, China
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A propensity score–matched comparison of deep versus mild hypothermia during thoracoabdominal aortic surgery. J Thorac Cardiovasc Surg 2012; 143:186-93. [DOI: 10.1016/j.jtcvs.2011.07.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2010] [Revised: 06/14/2011] [Accepted: 07/14/2011] [Indexed: 12/31/2022]
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[Spinal cord infarction following radical nephrectomy using extracorporeal circulation for renal cell carcinoma with tumor thrombus in the inferior vena cava and right atrium: a case report]. Nihon Hinyokika Gakkai Zasshi 2010; 101:689-93. [PMID: 20715501 DOI: 10.5980/jpnjurol.101.689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A 51 year-old man admitted to our hospital for macroscopic hematuria and right abdominal mass. CT demonstrated a large hypervascular mass and tumor thrombus in the inferior vena cava and right atrium. We diagnosed right renal cancer (stage III), and he underwent radical nephrectomy and resection of tumor thrombus with extracorporeal circulation. Operative time was 9 hours. Time for extracorporeal circulation was 119 minutes, and it took 60 minutes for intraoperative balloon occlusion of descending aorta in order to arrest hemorrhage. Pathological diagnosis was clear cell carcinoma of the kidney (pT3c, N0, M0). Four days after surgery, paraplegia was evident, and a diagnosis of spinal cord infarction was made based on neurologic examination and MRI findings. In cases with such a surgery requiring extracorporeal circulation, preoperative meeting with cardiologists and anesthetists is indispensable in order to fully understand the possible complications. Especially, to keep a careful watch and prepare for spinal cord ischemia is mandatory.
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Coselli JS, Bozinovski J, Cheung C. Hypothermic Circulatory Arrest: Safety and Efficacy in the Operative Treatment of Descending and Thoracoabdominal Aortic Aneurysms. Ann Thorac Surg 2008; 85:956-63; discussion 964. [DOI: 10.1016/j.athoracsur.2007.11.014] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2006] [Revised: 11/02/2007] [Accepted: 11/02/2007] [Indexed: 11/28/2022]
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Use of an epidural cooling catheter with a closed countercurrent lumen to protect against ischemic spinal cord injury in pigs. J Thorac Cardiovasc Surg 2007; 134:1220-6. [DOI: 10.1016/j.jtcvs.2007.06.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2007] [Revised: 05/27/2007] [Accepted: 06/11/2007] [Indexed: 11/22/2022]
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Kahn RA, Stone ME, Moskowitz DM. Anesthetic consideration for descending thoracic aortic aneurysm repair. Semin Cardiothorac Vasc Anesth 2007; 11:205-23. [PMID: 17711972 DOI: 10.1177/1089253207306098] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Anesthesia for surgery of the aorta poses some of the most difficult challenges for anesthesiologists. Major hemodynamic and physiologic stresses and sophisticated techniques of extracorporeal support are superimposed on patients with complex medical disease states. In this review, etiologies, natural history, and surgical techniques of thoracic aortic aneurysm are presented. Anesthetic considerations are discussed in detail, including the management of distal perfusion using partial cardiopulmonary bypass. Considerations of spinal cord protection, including management of proximal hypertension, cerebral spinal fluid drainage, and pharmacological therapies, are presented.
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Affiliation(s)
- Ronald A Kahn
- Department of Anesthesiology, the Mount Sinai School of Medicine, New York, New York 10029-6547, USA.
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Reece TB, Okonkwo DO, Ellman PI, Maxey TS, Tache-Leon C, Warren PS, Laurent JJ, Linden J, Kron IL, Tribble CG, Kern JA. Comparison of systemic and retrograde delivery of adenosine A2A agonist for attenuation of spinal cord injury after thoracic aortic cross-clamping. Ann Thorac Surg 2006; 81:902-9. [PMID: 16488692 DOI: 10.1016/j.athoracsur.2005.09.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2005] [Revised: 09/05/2005] [Accepted: 09/09/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Paraplegia remains a devastating complication of thoracic aortic surgery, which has been attenuated by retrograde adenosine and systemic adenosine A2A receptor activation. We hypothesized that despite retrograde spinal perfusion of an adenosine A2A agonist (ATL-146e), systemic therapy produces superior spinal cord protection with reduced inflammation. METHODS Forty pigs underwent 30-minute thoracic aortic cross-clamping. Pigs received: no therapy (control); retrograde saline (retrograde control); retrograde ATL-146e; systemic ATL-146e; systemic ATL-146e with retrograde saline; or systemic and retrograde ATL-146e. Retrograde therapies were given during ischemia. Systemic ATL-146e (0.06 microg.kg(-1).min(-1)) was given intravenously for 3 hours at reperfusion. At 24 hours, motor function was assessed using the Tarlov scale. Tissue was analyzed for neuronal viability, microtubule-associated protein-2 expression, and neutrophil sequestration (myeloperoxidase activity). RESULTS Four pigs received retrograde barium showing both radiographic and histologic spinal cord perfusion. Tarlov scores at 24 hours were significantly improved versus both control groups in all ATL groups except the combined ATL-146e group (all p < 0.05). Neuronal viability by hematoxylin and eosin stain was significantly preserved in systemic ATL groups compared with both control groups (all p < 0.05). Microtubule-associated protein-2 expression was significantly preserved compared with both control groups in all systemic ATL groups. Systemic ATL significantly lowered myeloperoxidase activity versus both control groups (p < 0.01). CONCLUSIONS Both retrograde and systemic ATL-146e therapies attenuate ischemic spinal cord injury, but combining the two routes was less effective. Given comparable results between the two routes and the simplicity of systemic delivery, peripheral venous ATL-146e at reperfusion should be preferred for spinal cord protection in thoracic aortic surgery.
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Affiliation(s)
- T Brett Reece
- Department of Surgery, University of Virginia, Charlottesville, Virginia, USA.
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Estrera AL, Miller CC, Azizzadeh A, Safi HJ. Adjuncts during surgery of the thoracoabdominal aorta and their impact on neurologic outcome: distal aortic perfusion and cerebrospinal fluid drainage. Multimed Man Cardiothorac Surg 2006; 2006:mmcts.2006.001933. [PMID: 24413335 DOI: 10.1510/mmcts.2006.001933] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The adjunct (distal aortic perfusion, cerebrospinal fluid drainage, and moderate hypothermia) has been our mainstay in the prevention of paraplegia and paraparesis during repair of the descending thoracic and thoracoabdominal aorta.
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Affiliation(s)
- Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas at Houston Medical School, Memorial Hermann Heart and Vascular Institute, Houston, TX, USA
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Safi HJ, Estrera AL, Miller CC, Huynh TT, Porat EE, Azizzadeh A, Meada R, Goodrick JS. Evolution of Risk for Neurologic Deficit After Descending and Thoracoabdominal Aortic Repair. Ann Thorac Surg 2005; 80:2173-9; discussion 2179. [PMID: 16305866 DOI: 10.1016/j.athoracsur.2005.05.060] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2005] [Revised: 05/16/2005] [Accepted: 05/17/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Cross-clamp time has been reported to correlate with risk of neurologic deficit after thoracoabdominal aortic aneurysm repair. Introduction of cerebrospinal fluid drainage and distal aortic perfusion (adjunct) has greatly reduced the incidence of neurologic deficit. We reevaluated the effect of cross-clamp time before and after introduction of adjunct during a 13-year period. METHODS Between 1991 and 2004, we repaired 1,106 thoracic and thoracoabdominal aortic aneurysms. Four hundred one patients were female and 705 were male (median age, 67 years). Selective use of adjunct was begun in late 1992, with its routine use by 1993. RESULTS Aortic cross-clamp times have increased significantly (34 seconds/year; p < 0.0001) since 1991. Despite this increase in cross-clamp time, neurologic deficit rates have declined from the first to the fourth quartile (p < 0.02). This decrease in neurologic deficit is most pronounced with the extent II thoracoabdominal aortic aneurysms (21.1% to 3.3%). The use of the adjunct increased the cross-clamp time by a mean of 12 minutes (p < 0.0001), but was associated with a significant protective effect against neurologic deficit (odds ratio = 0.4; p < 0.0002). Although other previously established risk factors remained significantly associated with neurologic deficit, cross-clamp time is no longer significant. CONCLUSIONS Adjunct significantly reduced the risk of neurologic deficit, despite increasing cross-clamp time. The use of the adjunct appears to blunt the effect of the cross-clamp time and may provide the surgeon the ability to operate without being hurried. Because cross-clamp time has been effectively eliminated as a risk factor with the use of the adjunct, using this variable to construct risk models becomes irrelevant in our experience.
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Affiliation(s)
- Hazim J Safi
- Department of Cardiothoracic and Vascular Surgery, The University of Texas, Houston Medical School, Memorial Hermann Hospital, Houston, Texas, USA.
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Estrera AL, Miller CC, Chen EP, Meada R, Torres RH, Porat EE, Huynh TT, Azizzadeh A, Safi HJ. Descending Thoracic Aortic Aneurysm Repair: 12-Year Experience Using Distal Aortic Perfusion and Cerebrospinal Fluid Drainage. Ann Thorac Surg 2005; 80:1290-6; discussion 1296. [PMID: 16181856 DOI: 10.1016/j.athoracsur.2005.02.021] [Citation(s) in RCA: 181] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2004] [Revised: 02/01/2005] [Accepted: 02/03/2005] [Indexed: 11/22/2022]
Abstract
BACKGROUND The benefit of distal aortic perfusion and cerebrospinal fluid drainage over the "clamp and sew" technique during repairs of the descending thoracic aorta is still being debated. The purpose of this report is to analyze our experience with regard to neurologic deficit (paraplegia and paraparesis) and mortality using the adjuncts of distal aortic perfusion and cerebrospinal fluid drainage. METHODS Between February 1991 and September 2004, we repaired 355 descending thoracic aortic aneurysms. Excluded from analysis were 29 patients who required profound hypothermic circulatory arrest as a result of transverse arch involvement and 26 patients with aortic rupture, leaving a group of 300 patients for which outcomes were analyzed. Mean patient age was 67 years, and 102 (34%) of the patients were women. The adjunct group of distal aortic perfusion and cerebrospinal fluid drainage used in 238 (79.3%) patients was compared with a group of 62 patients who underwent simple cross-clamp with or without the addition of a single adjunct. Multivariable data were analyzed by Cox regression. RESULTS The incidence of neurologic deficit after all repairs was 2.3% (7 of 300 patients). The incidence of neurologic deficit (immediate and delayed) in the adjunct group was 1.3% (3 of 238 patients), and in the nonadjunct group was 6.5% (4 of 62 patients; p < 0.02). One case of delayed paraplegia occurred in each group. All neurologic deficits occurred in patients with aneurysmal involvement of the entire descending thoracic aorta (extent C; p < 0.02). Statistically significant predictors for neurologic deficit were the use of the adjunct (odds ratio [OR], 0.19; p = 0.02), previous repaired abdominal aortic aneurysm (OR, 7.0; p = 0.005), type C aneurysm (OR, 13.73; p = 0.02), and cerebrovascular disease history (OR, 4.7; p < 0.03). Thirty-day mortality was 8% (24 of 300 patients). Significant multivariate predictors of 30-day mortality were preoperative renal dysfunction (OR, 4.6; p < 0.01) and female sex (OR, 2.9; p < 0.03). CONCLUSIONS Repairs of the descending thoracic aorta using the adjunct of distal aortic perfusion and cerebrospinal fluid drainage can be performed with a low incidence of neurologic deficit and an acceptable mortality. The use of the adjuncts should be considered during elective repairs of the descending thoracic aorta.
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Affiliation(s)
- Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Houston Medical School, Memorial Hermann Hospital, Houston, Texas, USA
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Ackerman LL, Traynelis VC. Treatment of Delayed-onset Neurological Deficit after Aortic Surgery with Lumbar Cerebrospinal Fluid Drainage. Neurosurgery 2002. [DOI: 10.1227/01.neu.0000309117.47581.81] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Laurie L. Ackerman
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Vincent C. Traynelis
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Treatment of Delayed-onset Neurological Deficit after Aortic Surgery with Lumbar Cerebrospinal Fluid Drainage. Neurosurgery 2002. [DOI: 10.1097/00006123-200212000-00011] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Estrera AL, Rubenstein FS, Miller CC, Huynh TT, Letsou GV, Safi HJ. Descending thoracic aortic aneurysm: surgical approach and treatment using the adjuncts cerebrospinal fluid drainage and distal aortic perfusion. Ann Thorac Surg 2001; 72:481-6. [PMID: 11515886 DOI: 10.1016/s0003-4975(01)02679-0] [Citation(s) in RCA: 122] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Neurologic deficit (paraplegia or paraparesis) remains a significant morbidity in the repair of descending thoracic aortic aneurysm. METHODS Between February 1991 and February 2000, we operated on 182 patients for descending thoracic aortic aneurysm. For the purpose of this study-to identify the impact of the combined adjuncts distal aortic perfusion and cerebrospinal fluid (CSF) drainage on neurologic outcome-we selected the 148 of 182 nonemergent patients who had received conventional treatment (simple cross-clamping with or without adjuncts). The mean patient age was 61 years, and 49 of the 148 (33%) patients were women. Nine of the 148 patients (6%) had acute type B dissections. We compared the results of 105 of the 148 patients (71%) who received the combined adjuncts of CSF drainage and distal aortic perfusion with the remaining 43 (29%) patients who underwent repair using the simple cross-clamp with or without the addition of a single adjunct. RESULTS Overall 30-day mortality was 13 of 148 patients (8.8%). Overall early neurologic deficit was 4 of 148 (2.7%): 1 of 105 (0.9%) patients who had received distal aortic perfusion and CSF drainage, versus 3 of 43 (7%) in all other patients (p < 0.04). CONCLUSIONS In our practice the use of the combined adjuncts of CSF drainage and distal aortic perfusion has all but eliminated the incidence of immediate postoperative neurologic deficit in nonemergent patients with aneurysms of the descending thoracic aorta.
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Affiliation(s)
- A L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas at Houston Medical School, Memorial Hermann Hospital, USA
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Affiliation(s)
- N Yamate
- Division of Cardiovascular Surgery, Depertment of Surgery, St. Marianna University School of Medicine, Kawasaki, Japan.
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Gygax E, Schüpbach P, Carrel TP. Thoracoabdominal aortic repair in a 190-kg patient: optimized perfusion with two oxygenators. Ann Thorac Surg 2001; 71:347-9. [PMID: 11216778 DOI: 10.1016/s0003-4975(00)02157-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A 190-kg patient was referred because of an acute type B aortic dissection. Conservative management was initially performed but the 34-year-old patient was shown to have an increasing aortic diameter 2 months later and was scheduled for elective repair of the thoracoabdominal aorta. To anticipate potential difficulties with perfusion and oxygenation the cardiopulmonary bypass circuit was constructed with two parallel oxygenators, which allowed an adequate oxygen supply through all phases of the intervention and accelerated the estimated rewarming time.
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Affiliation(s)
- E Gygax
- Clinic for Cardiovascular Surgery, University Hospital, Berne, Switzerland
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Cooley DA, Golino A, Frazier OH. Single-clamp technique for aneurysms of the descending thoracic aorta: report of 132 consecutive cases. Eur J Cardiothorac Surg 2000; 18:162-7. [PMID: 10925224 DOI: 10.1016/s1010-7940(00)00499-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE To determine the efficacy of a single-clamp technique in preventing spinal cord ischemia during repair of aneurysms of the descending thoracic aorta. PATIENTS AND METHODS From January 1989 to May 1999, 132 consecutive patients (91 men and 41 women, aged 31-86 years), with aneurysms of the descending thoracic aorta underwent repair using a single-clamp technique and temporary partial distal exsanguination. The diseased aortic segment was replaced with a Dacron graft. Blood was re-infused from an auto-transfusion device, and the segmental vessels were over-sewn but not implanted into the graft. RESULTS The average aortic cross-clamp time was 26.4 min (range, 11-67 min) for the overall group and 37.4 min for patients who had spinal cord complications. An average of 2066 ml of blood was auto-transfused (range, 450-6100 ml). During the first 30 postoperative days, 17 patients (12.9 %) died. Eleven patients (8.3%) had spinal cord dysfunction, six patients (4.5%) had lower-extremity paraparesis, and five patients (3.8%) had paraplegia. Nine patients (6.8%) had renal failure necessitating hemodialysis. Other complications included bleeding in 15 cases (11.4%), respiratory failure in 12 cases (9.1%), wound-related sequelae in five cases (3.8%), distal embolism in five cases (3.8%), and bowel ischemia in two cases (1.5%). CONCLUSION The single-clamp technique yielded an acceptable complication rate, and the mortality was comparable to that seen after the use of more complex methods. For satisfactory results, the cross-clamp time should not exceed 30 min.
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Affiliation(s)
- D A Cooley
- Texas Heart Institute at St. Luke's Episcopal Hospital, P.O. Box 20345, MC 3-258, Houston, TX 77225-0345, USA
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Parrino PE, Kron IL, Ross SD, Shockey KS, Fisher MJ, Gaughen JR, Kallmes DF, Kern JA, Tribble CG. Retrograde venous perfusion with hypothermic saline and adenosine for protection of the ischemic spinal cord. J Vasc Surg 2000; 32:171-8. [PMID: 10876220 DOI: 10.1067/mva.2000.105003] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Spinal cord injury and the resultant postoperative paraplegia are devastating complications of thoracic aortic surgery, for which no widely accepted protective interventions exist. We hypothesized that retrograde venous perfusion-cooling of the spinal cord with a hypothermic saline and adenosine solution would protect it from ischemic injury caused by thoracic aortic occlusion. METHODS Adult domestic swine of either sex (weight range, 20 to 30 kg) were intubated and ventilated. A left thoracotomy was performed. The accessory hemiazygous vein was divided, and a catheter was inserted distally. The aorta was clamped at the left subclavian artery. The venous catheter was not used in the animals in the control group (n = 7); in the animals in the experimental group (n = 7), a cold (4 degrees C) saline and adenosine solution was infused into the accessory hemiazygous vein. After 30 minutes, the clamp and catheter were removed, and the chest was closed. A blinded observer evaluated the animals' hind-leg motor activity 24 hours later. The Tarlov scale was used: 0, complete paralysis; 1, minimal movement; 2, stands with assistance; 3, stands alone; 4, weak walk; 5, normal gait. The animals' rectal temperatures were measured at the end of the experiment, and blood pressure was measured throughout. Two other groups were studied to assess the effect of the intervention on spinal cord temperature. RESULTS The animals in the control group had a mean Tarlov score of 1.7 +/- 0.6; the animals in the experimental group had a mean Tarlov score of 4.9 +/- 0.1 (P <.01). The animals in the experimental group had a significantly greater drop in spinal cord temperature than those in the control group (4. 05 +/- 0.6 degrees C vs 0.58 +/- 0.12 degrees C; P <.01). No significant difference in rectal temperatures was found, nor did any arrhythmias or hypotensive episodes occur in either group. Perfusion of the spinal cord was confirmed with angiography by using this approach. CONCLUSION Retrograde venous perfusion-cooling of the spinal cord with a hypothermic saline and adenosine solution protects the cord from ischemic injury caused by clamping of the thoracic aorta.
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Affiliation(s)
- P E Parrino
- Departments of Surgery, Division of Thoracic and Cardiovascular Surgery, and Radiology, University of Virginia Health Sciences Center, Charlottesville, VA 22908, USA
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Cambria RP, Davison JK, Carter C, Brewster DC, Chang Y, Clark KA, Atamian S. Epidural cooling for spinal cord protection during thoracoabdominal aneurysm repair: A five-year experience. J Vasc Surg 2000; 31:1093-102. [PMID: 10842145 DOI: 10.1067/mva.2000.106492] [Citation(s) in RCA: 137] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We developed and applied a method for providing regional spinal cord hypothermia with epidural cooling (EC) during thoracoabdominal aneurysm (TAA) repair. Preliminary results indicated significant reduction in spinal cord ischemic complications (SCI), compared with historical controls, and a 5-year experience with EC was reviewed. METHODS From July 1993 to September 1998, 170 patients with thoracic aneurysms (n = 14; 8.2%) or TAAs (types I and II, n = 83 [49%]; type III, n = 66 [39%]; type IV, n = 7 [4.1%]) were treated with EC. An earlier aneurysm resection was noted in 44% of patients, an emergent operation was noted in 20% of patients, and an aortic dissection was noted in 16% of patients. The EC was successful (mean cerebrospinal fluid [CSF] temperature at cross-clamp, 26.4 +/- 3 degrees C) in 97% of cases, with all 170 patients included in an intention-to-treat analysis. The operation was performed with a clamp/sew technique (98% patients) and selective (T(9) to L(1) region) reimplantation of intercostal vessels. Clinical and EC variables were examined for association with operative mortality and SCI by means of the Fischer exact test, and those variables with a P value less than.1 were included in multivariate logistic regression analysis. RESULTS The operative mortality rate was 9.5% and was weakly associated (P =.07) with SCI; postoperative cardiac complications (odds ratio [OR], 35. 3; 95% CI, 5.3 to 233; P <.001) and renal failure (OR, 32.2; 95% CI, 6.6 to 157; P <.001) were the only independent predictors of postoperative death. SCI of any severity occurred in 7% of cases (type I/II, 10 of 83 [12%]; all other types, 2 of 87 [2.3%]), versus a predicted (Acher model) incidence of 18.5% for this cohort (P =. 003). Half the deficits were minor, with good functional recovery, and devastating paraplegia occurred in three patients (2.0%). Independent correlates of SCI included types I and II TAA (OR, 8.0; 95% CI, 1.4 to 46.3; P =.021), nonelective operation (OR, 8.3, 95% CI, 1.8 to 37.7; P =.006), oversewn T(9) to L(2) intercostal vessels (OR, 6.1; 95% CI, 1.3 to 28.8; P =.023), and postoperative renal failure (OR, 23.6; 95% CI, 4.4 to 126; P <.001). These same clinical variables of nonelective operations (OR, 7.7; 95% CI, 1.4 to 41.4; P =.017), oversewn T(9) to L(2) intercostal arteries (OR, 9.7; 95% CI, 1.5 to 61.2; P =.016), and postoperative renal failure (OR, 20.8; 95% CI, 3.0 to 142.1; P =.002) were independent predictors of SCI in the subgroup analysis of high-risk patients, ie, patients with type I/II TAA. CONCLUSION EC has been effective in reducing immediate, devastating, total paraplegia after TAA repair. A strategy that combines the neuroprotective effect of regional cord hypothermia, avoiding the sacrifice of potential spinal cord blood supply, and postoperative adjuncts (eg, avoidance of hypotension, CSF drainage) appears necessary to minimize SCI after TAA repair.
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Affiliation(s)
- R P Cambria
- Division of Vascular Surgery and Vascular Anesthesia, Department of Surgery and Anesthesia, Massachusetts General Hospital and the Harvard Medical School, Boston 02114, USA
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Carrel TP, Berdat PA, Robe J, Gysi J, Nguyen T, Kipfer B, Althaus U. Outcome of thoracoabdominal aortic operations using deep hypothermia and distal exsanguination. Ann Thorac Surg 2000; 69:692-5. [PMID: 10750745 DOI: 10.1016/s0003-4975(99)01542-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Operation of the descending and thoracoabdominal aorta may be affected by a significant perioperative morbidity, mainly because of ischemic damage of the spinal cord and malperfusion of the abdominal organs. METHODS A comparative analysis was performed on two consecutive series of patients operated between 1982 and 1998. Group 1 consisted of 90 patients operated with moderate hypothermic left heart bypass. Group 2 included 38 patients operated using deep hypothermic cardiopulmonary bypass and a period of circulatory arrest while performing the proximal anastomosis and distal exsanguination during confection of the distal anastomosis. RESULTS Main demographic factors and causes of the aortic disease were similar in both groups. Early mortality was significantly higher in the group of patients with aortic cross-clamping (15 of 90, 16%) than in those operated with circulatory arrest (2 of 38, 5.2%), p < 0.001. Paraplegia occurred in 8 patients in the group operated with mild hypothermia (8.8%) but in only 1 patient (2.6%) when deep hypothermia had been used. CONCLUSIONS In our experience, deep hypothermia combined with distal exsanguination significantly improved the early postoperative outcome after operation of the descending and thoracoabdominal aorta. This technique allowed easy confection of proximal and distal anastomoses, and the duration of the operation was not prolonged significantly through this approach.
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Affiliation(s)
- T P Carrel
- Clinic for Cardiovascular Surgery and Institute of Anesthesiology, University Hospital Berne, Switzerland.
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Ross SD, Kern JA, Gangemi JJ, St Laurent CR, Shockey KS, Kron IL, Tribble CG. Hypothermic retrograde venous perfusion with adenosine cools the spinal cord and reduces the risk of paraplegia after thoracic aortic clamping. J Thorac Cardiovasc Surg 2000; 119:588-95. [PMID: 10694621 DOI: 10.1016/s0022-5223(00)70141-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We evaluated the utility of retrograde venous perfusion to cool the spinal cord and protect neurologic function during aortic clamping. We hypothesized that hypothermic adenosine would preserve the spinal cord during ischemia. METHODS Six swine (group I) underwent thoracic aortic occlusion for 30 minutes at normothermia. Group II animals underwent spinal cooling by retrograde perfusion of the paravertebral veins with hypothermic (4 degrees C) saline solution during aortic occlusion. The spinal cords of group III animals were cooled with a hypothermic adenosine solution in a similar fashion. Intrathecal temperature was monitored and somatosensory evoked potentials assessed the functional status of spinal pathways. RESULTS Spinal cooling without systemic hypothermia significantly improved neurologic Tarlov scores in group III (4.8 +/- 0.2) and group II (3.8 +/- 0.4) when compared with group I scores (1.3 +/- 0.6) (P <.001). Furthermore, 5 of the 6 animals in group III displayed completely normal neurologic function, whereas only one animal in group II and no animals in group I did (P =.005). Somatosensory evoked potentials were lost 10.6 +/- 1.4 minutes after ischemia in group I. In contrast, spinal cooling caused rapid cessation of neural transmission with loss of somatosensory evoked potentials at 6.9 +/- 1.2 minutes in group II and 7.0 +/- 0.8 minutes in group III (P =.06). Somatosensory evoked potential amplitudes returned to 85% of baseline in group III and 90% of baseline in group II compared with only 10% of baseline in group I (P =.01). CONCLUSIONS We conclude that retrograde cooling of the spinal cord is possible and protects against ischemic injury and that adenosine enhances this effect. The efficacy of this method may be at least partly attributed to a more rapid reduction in metabolic and electrical activity of the spinal cord during ischemia.
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Affiliation(s)
- S D Ross
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia Health Sciences Center, Charlottesville, VA 22908, USA
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Parrino PE, Kron IL, Ross SD, Shockey KS, Fisher MJ, Gaughen JR, Kern JA, Tribble CG. Spinal cord protection during aortic cross-clamping using retrograde venous perfusion. Ann Thorac Surg 1999; 67:1589-94; discussion 1594-5. [PMID: 10391260 DOI: 10.1016/s0003-4975(99)00307-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Paraplegia remains a devastating complication following thoracic aortic operation. We hypothesized that retrograde perfusion of the spinal cord with a hypothermic, adenosine-enhanced solution would provide protection during periods of ischemia due to temporary aortic occlusion. METHODS In a rabbit model, a 45-minute period of spinal cord ischemia was produced by clamping the abdominal aorta and vena cava just below the left renal vessels and at their bifurcations. Four groups (n = 8/group) were studied: control, warm saline, cold saline, and cold saline with adenosine infusion. In the experimental groups, saline or saline plus adenosine was infused into the isolated cavae throughout the ischemic period. Clamps were removed and the animals to recovered for 24 hours before blinded neurological evaluation. RESULTS Tarlov scores (0 = paraplegia, 1 = slight movement, 2 = sits with assistance, 3 = sits alone, 4 = weak hop, 5 = normal hop) were (mean +/- standard error of the mean): control, 0.50 +/- 0.50; warm saline, 1.63 +/- 0.56; cold saline, 3.38 +/- 0.26; and cold saline plus adenosine, 4.25 +/- 0.16 (analysis of variance for all four groups, p < 0.00001). Post-hoc contrast analysis showed that cold saline plus adenosine was superior to the other three groups (p < 0.0001). CONCLUSION Retrograde venous perfusion of the spinal cord with hypothermic saline and adenosine provides functional protection against surgical ischemia and reperfusion.
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Affiliation(s)
- P E Parrino
- Department of Surgery, University of Virginia Health Sciences Center, Charlottesville 22908, USA
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