Cardiac function is a risk factor for paralysis in thoracoabdominal aortic replacement

Acher, Charles W.; Wynn, Martha M.; Hoch, John R.; Kranner, Paul W.

doi:10.1016/s0741-5214(98)70261-7

Cited by 77 publications

(56 citation statements)

References 33 publications

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“…Even in such environments, operative mortality is generally in the 10% range, and spinal cord ischemic complications (SCI) remain in the 5% to 15% range. [1][2][3][4][5][6][7][8][9] Indeed, efforts to minimize the risk of SCI have been the principal impetus for the variety of operative strategies and protective adjuncts used during surgery. Clearly, there is no consensus on the major variants of operative approach (e.g., with or without some form of distal aortic perfusion) designed to minimize SCI, as reviewed elsewhere.…”

Section: Discussionmentioning

confidence: 99%

Thoracoabdominal Aneurysm Repair: Results With 337 Operations Performed Over a 15-Year Interval

Cambria¹,

Clouse²,

Davison³

et al. 2002

Annals of Surgery

335

221

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ObjectiveTo review perioperative results and late survival after thoracoabdominal aneurysm repair (TAA), in particular to assess the impact over time of epidural cooling (EC) on spinal cord ischemic complications (SCI). Summary Background DataA variety of operative approaches and protective adjuncts have been used in TAA to minimize the major complications of perioperative death and SCI. There is no consensus with respect to the optimal approach. MethodsFrom January 1987 to November 2001, 337 consecutive TAA repairs were performed by a single surgeon. Clinical features included prior aortic grafts in 97 (28.8%) and emergent operation in 82 (24.6%), including rupture in 46 (13.6%) and dissection in 63 (19%). Operative management consisted of a clamp/sew technique with adjuncts in 93%. EC (since July 1993) to prevent SCI was used in 194 (57.6%) repairs. Variables associated with the end points of operative mortality and postoperative SCI were assessed with the Fisher exact test and logistic regression; late survival was estimated with the Kaplan-Meier method. ResultsOperative mortality was 8.3% and was associated with nonelective operation, intraoperative hypotension, total transfusion requirement, and the postoperative complications of paraplegia, renal failure, and pulmonary insufficiency. Postoperative renal failure and transfusion requirement were independent correlates of mortality. SCI of any severity occurred in 38 of 334 (11.4%) operative survivors, with 22/38 (6.6% of cohort) sustaining total paraplegia. EC reduced the risk of SCI in patients with types I-III TAA (10.6% vs. 19.8%, P ϭ .04). Independent correlates of SCI over the entire study interval included types I/II TAA, rupture, cross-clamp duration, sacrifice of T9 -L1 intercostal vessels, and intraoperative hypotension. Late survival rates at 2 and 5 years were 81.2 Ϯ 3% and 67.2 Ϯ 5%. ConclusionsEC has decreased the risk of SCI after TAA repair. Decreasing the substantial proportion (nearly 25%) of patients requiring nonelective operation will improve results. Late survival is equal to that after routine AAA repair, indicating that the considerable resource expenditure required for TAA repair is worthwhile.Despite advances in endoluminal grafting for isolated thoracic and infrarenal aortic aneurysm, open operation remains the only feasible treatment option for thoracoabdominal aneurysm (TAA). Since TAA extent is relatively uncommon in the spectrum of degenerative aneurysm disease, experience and clinical reports have been largely concentrated in a modest number of centers. Even in such environments, operative mortality is generally in the 10%

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Section: Discussionmentioning

confidence: 99%

Thoracoabdominal Aneurysm Repair: Results With 337 Operations Performed Over a 15-Year Interval

Cambria¹,

Clouse²,

Davison³

et al. 2002

Annals of Surgery

335

221

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“…35 Comparable results have been achieved in contemporary practice with the use of both clamp/sew and distal perfusion techniques. 4,5,28,36,37 In addition, atriofemoral bypass will provide easily titratable mechanical unloading of the left ventricle, and this may be desirable in patients with antecedent aortic valvular dysfunction or significant degrees of left ventricular dysfunction.…”

Section: Open Surgical Repairmentioning

confidence: 99%

“…6 Another negative predictor reported in the literature is advanced age, although we found that overall functional status is more important than chronological age per se. 4,32,56 The presence of increasing numbers of comorbid conditions can naturally be expected to increase overall operative risk. Individual series have demonstrated increased operative risks in patients with antecedent coronary artery disease, significant COPD, and, in particular, preoperative renal insufficiency.…”

Section: Conrad and Cambria Management Of Thoracoabdominal Aneurysms 843mentioning

confidence: 99%

“…4 -7,30,32,57 Significant antecedent dysfunction in these respective organ systems increases the risks of organ-specific complications after operation, and patients who sustain major neurological deficits, postoperative renal failure, and cardiopulmonary complications have a significantly increased risk of operative mortality. 4,6,32,38,56 …”

Section: Conrad and Cambria Management Of Thoracoabdominal Aneurysms 843mentioning

confidence: 99%

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Contemporary Management of Descending Thoracic and Thoracoabdominal Aortic Aneurysms: Endovascular Versus Open

Conrad

Cambria

2008

Circulation

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“…1 Patients at greatest risk are those with Crawford types I, II, or emergent dissection. 2,3 Factors postulated to decrease the incidence of paraplegia include decreased aortic cross-clamp time, reimplantation of intercostal arteries, hypothermia, or CSF drainage. 1 The proposed mechanism of the benefit of CSF drainage in paraparesis is reduction of CSF pressure and the improvement in spinal cord perfusion pressure.…”

Section: Reversal Of Paraparesis After Thoracic Aneurysm Repair By Cementioning

confidence: 99%

Reversal of paraparesis after thoracic aneurysm repair by cerebrospinal fluid drainage

Khong

Yang

Doobay

et al. 2000

Can J Anesth/J Can Anesth

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Purpose: To describe a case of reversal of delayed paraparesis, after an elective type I thoracoabdominal aortic aneurysm (TAAA) repair, via cerebrospinal fluid (CSF) drainage.Clinical Features: A 75-yr-old woman developed paraparesis 13 hr after type I TAAA repair. The patient had been given combined regional and general anesthesia. There was no cerebrospinal fluid drain inserted at the time of surgery. The patient was hemodynamically stable throughout the procedure and was transported to the intensive care unit with trachea intubated and lungs ventilated. She demonstrated some initial lower limb paraparesis but had good recovery of limb function three hours after cessation of the epidural infusion. However, five hours and forty-five minutes after stopping the epidural, she was again paraparetic. Peripheral nerve injury, prolonged effects of epidural local anesthetic, and epidural hematoma were ruled out as precipitating factors. Cord ischemia was considered possible and a CSF catheter was inserted. Immediate improvement was seen upon catheter insertion and commencement of drainage, beginning with movement in the left toes and foot. Drainage was performed when the CFS pressure became > 15 mmHg. Motor function in the lower limbs continued to improve with each drainage extending to complete recovery after 40 hr. She was discharged home 11 days after surgery with no neurological deficit.Conclusion: Drainage of CSF was useful in treating a case of post-TAAA neurologic deficit.Objectif : Décrire le cas d'un renversement de paraparésie différée, à la suite d'un drainage du liquide céphalo-rachidien (LCR), survenue après la réparation d'un anévrisme aortique thoraco-abdominal (AATA) de type I.Éléments cliniques : Une femme de 75 ans a été victime d'une paraparésie, 13 h après la réparation d'un AATA de type I. Elle a reçu une anesthésie régionale et générale combinée. À ce moment, on n'avait pas inséré de drain pour le liquide céphalo-rachidien. La patiente a présenté une hémodynamie stable tout au long de l'opération et a été transportée à l'unité des soins intensifs intubée et ventilée. Une paraparésie des membres inférieurs s'est d'abord manifestée, mais une bonne récupération de la fonction est survenue trois heures après le retrait de la perfusion péridurale. Toutefois, cinq heures et quarante-cinq minutes après la fin de la perfusion, la paraparésie est réapparue. Une lésion du nerf périphérique, des effets prolongés de l'anesthésique local péridural et un hématome péridural ont été exclu comme facteurs précipitants possibles. Une ischémie médullaire étant soupçonnée, nous avons inséré un cathéter dans le LCR. Une amélioration immédiate a été observée, dès le début du drainage, par des mouvements des orteils et du pied gauches. Le drainage a été réalisé lorsque la pression du LCR est devenue > 15 mmHg. La fonction motrice des membres inférieurs s'est améliorée avec chaque drainage jusqu'à une récupération complète après 40 h. La patiente a reçu son congé 11 jrs après l'intervention et ne présentait pas de défici...

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Cardiac function is a risk factor for paralysis in thoracoabdominal aortic replacement

Abstract: CSFD and low-dose naloxone significantly reduce the paralysis risk associated with thoracoabdominal aortic replacement. A decrease in the cardiac index with aortic occlusion is a previously unreported variable that defines a subset of patients at higher risk for paralysis.

Cited by 77 publications

References 33 publications

Thoracoabdominal Aneurysm Repair: Results With 337 Operations Performed Over a 15-Year Interval

Thoracoabdominal Aneurysm Repair: Results With 337 Operations Performed Over a 15-Year Interval

Contemporary Management of Descending Thoracic and Thoracoabdominal Aortic Aneurysms: Endovascular Versus Open

Reversal of paraparesis after thoracic aneurysm repair by cerebrospinal fluid drainage

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