Abstract:Background: Paraplegia is adevastating complication of open descending (DTAA) and thoracoabdominal aortic aneurysm (TAAA) repair. Despite major advances in imaging and surgical techniques, paraplegia continues to be problematic. We present our experience with routine application of enhanced imaging techniques to detect the anterior spinal artery (ASA) before DTAA and TAAA repair. Methods: We retrospectively reviewed 177 patients with DTAA and TAAA who underwent imaging to detect the ASA before open surgical re… Show more
“…Various intraoperative protective strategies besides CSFD were applied to reduce the incidence of SCI. Our standard spinal cord protection regimen includes preoperative identification of the origin of the spinal artery by dual-energy CT scan 9 with intraoperative preservation of intercostal arteries, routine use of spinal drain, left atrial–femoral artery bypass (with an oxygenator), 10 intraoperative motor evoked potential monitoring, and maintenance of systolic blood pressure >125 mm Hg from 2 hours postoperatively onward. These intraoperative strategies were adopted in each patient on individual basis according to the surgeon's discretion ( Table 3 ).…”
Section: Resultsmentioning
confidence: 99%
“…We did not evaluate the patency of reconstructed spinal arteries postoperatively. 9 Figure 1 Visualization and 3-dimensional reconstruction of the anterior spinal artery (ASA) using a special dual-intensity Yale technique, which is part of our standard spinal cord protection regimen. The artery of Adamkiewicz is shown, arising from the 12th intercostal artery and joining the ASA.…”
Objective: We present our experience with routine application of the cerebrospinal fluid (CSF) drain (CSFD) during open aortic repair.Methods: We retrospectively reviewed 100 patients with descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) or who underwent CSFD insertion before open repair between 2006 and 2017. All CSFDs were inserted by the cardiovascular anesthesia team. The goal was to keep intracranial pressure<10 mm Hg during the surgical procedure by draining CSF at a rate of 20 to 30 mL/h. Postoperatively, CSFD was set to maintain the lumbar pressure <10 mm Hg to reduce the risk of postoperative paraplegia. CSFD was part of our standard cord protection regimen.Results: The mean patient age was 65.4 AE 11.7 years, and 60 (60%) were male. A CSFD was successfully inserted in all patients. The mean hospital length of stay was 11.9 AE 11.8 days, and hospital mortality was 6%. Postoperative transient paresis was observed in 4 patients (4%), and permanent paraplegia was seen in 2 (2%). CSFDrelated complications were reported in 14 patients (14%). Complications included persistent CSF leakage and blood-tinged CSF with and without intracranial hemorrhage and spinal cutaneous fistula in 7 (7%), 9 (9%), and 1 (1%), respectively. Longterm survival was excellent (68.4% at 10 years).Conclusions: CSFD is a safe practice when applied routinely as an adjunct strategy to prevent paraplegia in surgical management of DTAA and TAAA. We feel that this contributed to good early and late clinical results. (JTCVS Techniques 2021;6:1-8)Three-dimensional reconstruction of the anterior spinal artery (T12) using the dual-intensity Yale technique.
“…Various intraoperative protective strategies besides CSFD were applied to reduce the incidence of SCI. Our standard spinal cord protection regimen includes preoperative identification of the origin of the spinal artery by dual-energy CT scan 9 with intraoperative preservation of intercostal arteries, routine use of spinal drain, left atrial–femoral artery bypass (with an oxygenator), 10 intraoperative motor evoked potential monitoring, and maintenance of systolic blood pressure >125 mm Hg from 2 hours postoperatively onward. These intraoperative strategies were adopted in each patient on individual basis according to the surgeon's discretion ( Table 3 ).…”
Section: Resultsmentioning
confidence: 99%
“…We did not evaluate the patency of reconstructed spinal arteries postoperatively. 9 Figure 1 Visualization and 3-dimensional reconstruction of the anterior spinal artery (ASA) using a special dual-intensity Yale technique, which is part of our standard spinal cord protection regimen. The artery of Adamkiewicz is shown, arising from the 12th intercostal artery and joining the ASA.…”
Objective: We present our experience with routine application of the cerebrospinal fluid (CSF) drain (CSFD) during open aortic repair.Methods: We retrospectively reviewed 100 patients with descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) or who underwent CSFD insertion before open repair between 2006 and 2017. All CSFDs were inserted by the cardiovascular anesthesia team. The goal was to keep intracranial pressure<10 mm Hg during the surgical procedure by draining CSF at a rate of 20 to 30 mL/h. Postoperatively, CSFD was set to maintain the lumbar pressure <10 mm Hg to reduce the risk of postoperative paraplegia. CSFD was part of our standard cord protection regimen.Results: The mean patient age was 65.4 AE 11.7 years, and 60 (60%) were male. A CSFD was successfully inserted in all patients. The mean hospital length of stay was 11.9 AE 11.8 days, and hospital mortality was 6%. Postoperative transient paresis was observed in 4 patients (4%), and permanent paraplegia was seen in 2 (2%). CSFDrelated complications were reported in 14 patients (14%). Complications included persistent CSF leakage and blood-tinged CSF with and without intracranial hemorrhage and spinal cutaneous fistula in 7 (7%), 9 (9%), and 1 (1%), respectively. Longterm survival was excellent (68.4% at 10 years).Conclusions: CSFD is a safe practice when applied routinely as an adjunct strategy to prevent paraplegia in surgical management of DTAA and TAAA. We feel that this contributed to good early and late clinical results. (JTCVS Techniques 2021;6:1-8)Three-dimensional reconstruction of the anterior spinal artery (T12) using the dual-intensity Yale technique.
“…Any identified spinal artery is spared or reimplanted at the time of surgery. 4 ) At the end of the surgical procedure, the left subclavian artery is transected and connected to blood flow via a separate 8- or 10-mm Dacron graft originating from the new aortic graft or the native aorta.…”
Background Both open and endovascular treatments of descending thoracic aortic aneurysms require a secure proximal landing zone. This may be difficult to achieve when the dilatation extends proximally to the left subclavian level. Clamping above the aneurysm may be difficult. In the case of an endovascular approach, achieving a suitable landing zone may require extensive extra-anatomic debranching, which is not without complications and limitations.
Methods We describe a modification of the traditional elephant trunk procedure that represents a “stand-alone” elephant trunk. Under deep hypothermic circulatory arrest, the aorta is transected between the left carotid and left subclavian arteries. A simple, noninverted elephant trunk is placed through the distal cut aorta. The two ends are sewn back together, incorporating the lip of the elephant trunk in the anastomosis. We review our experience in five patients who underwent this procedure.
Results All 5 patients (4 males, 1 female) aged 41 to 68 (mean, 57 years) tolerated the Stage 1 stand-alone elephant trunk procedure well, without mortality, stroke, or bleeding. The Stage 2 descending aortic replacements were performed at a mean of 6.7 months after Stage 1. There was no Stage 2 mortality, stroke, or bleeding. One patient died 8 years later of cardiac cause, and the remaining are alive and well.
Conclusion A stand-alone elephant trunk procedure is safe and straightforward and provides an excellent proximal foundation for subsequent open (or potentially endovascular) descending aortic replacement.
“…Our paraplegia rates were low (three patients). Routine visualization of the anterior spinal artery before repair may have contributed to these low paraplegia rates 26 . Utilization of a spinal drain to keep the lumbar pressure at 5–12 mmHg postoperatively in descending, thoracoabdominal, and thoracic endovascular aortic repair has been shown effective in reducing the risk of spinal cord injury 27 …”
Section: Commentmentioning
confidence: 99%
“…Routine visualization of the anterior spinal artery before repair may have contributed to these low paraplegia rates. 26 Utilization of a spinal drain to keep the lumbar pressure at 5-12 mmHg postoperatively in descending, thoracoabdominal, and thoracic endovascular aortic repair has been shown effective in reducing the risk of spinal cord injury. 27 An important point to consider has to do with choosing an appropriate length of the ET (10-15 cm) to avoid thrombus around the graft yet permit easy accessibility at Stage II.…”
Purpose
Diffuse mega‐aorta is challenging. Prior studies have raised concerns regarding the safety of the open two‐stage elephant trunk (ET) approach for extensive thoracic aortic aneurysm (TAA), specifically in regard to interstage mortality. This study evaluates the safety of the two‐stage ET approach for management of extensive TAA.
Methods
Between 2003 and 2018, 152 patients underwent a Stage I ET procedure by a single surgeon (mean age 64.5 ± 14.8). Second stage ET procedure was planned in 60 patients (39.4%) and to‐date has been performed in 54 patients (90%). (in the remaining patients, the ET was prophylactic for the long‐term, with no plan for near‐term utilization).
Results
In‐hospital mortality after the Stage I procedure was 3.3% (5/152). In patients planned for Stage II, the median interstage interval was 5 weeks (range: 0–14). Of the remaining six patients with planned, but uncompleted Stage II procedures, five patients expired from various causes in the interval period (interstage mortality of 8.3%). There were no cases of aortic rupture in the interstage interval. Stage II was completed in 58 patients (including four unplanned) with a 30‐day mortality of 10.3% (6/58). Seven patients developed strokes after Stage II (12%), and three patients (5.1%) developed paraplegia.
Conclusions
The overall mortality, including Stage I, interstage interval, and Stage II was 18.6%. This substantial cumulative mortality for the open two‐staged ET approach for the treatment of extensive TAA appears commensurate with the severity of the widespread aortic disease in this patient group. Fear of interstage rupture should not preclude the aggressive Two‐Stage approach to the management of extensive TAA.
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