Strategies to Manage Paraplegia Risk After Endovascular Stent Repair of Descending Thoracic Aortic Aneurysms

Cheung, Albert T.; Pochettino, Alberto; McGarvey, Michael L.; Appoo, Jehangir J.; Fairman, Ronald M.; Carpenter, Jeffrey P.; Moser, William; Woo, Edward Y.; Bavaria, Joseph E.

doi:10.1016/j.athoracsur.2005.04.027

Cited by 234 publications

(166 citation statements)

References 22 publications

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“…Existing experience with endovascular stent-graft repair of isolated descending thoracic aortic aneurysms indicates that spinal cord ischemia remains a serious complication, with a reported frequency that ranges from 0% to 12.0% [2,[6][7][8][9][10][11][12][13][14][15][16][17] (Table 5).…”

Section: Discussionmentioning

confidence: 99%

Spinal cord ischemia after elective endovascular stent-graft repair of the thoracic aorta☆

Kawaharada

Morishita

Kurimoto

et al. 2007

European Journal of Cardio-Thoracic Surgery

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Background: We reviewed our experience to investigate the determinants of paraplegia/paraparesis after endovascular stent-graft repair of the thoracic aorta, to assess the influence of the artery of Adamkiewicz (ARM) detected by preoperative magnetic resonance angiography (MRA) and to identify patients at risk. Methods: Over a 5-year period (March 2001-June 2006, 149 patients underwent elective endovascular stentgraft repair of the descending thoracic aorta. Patient demographics and perioperative factors relating to the endovascular procedure were evaluated by using univariate statistical analyses. To assess the influence of the ARM in the thoracolumbar region, patients in whom ARM was detected by preoperative MRA were divided into two groups: patients who had occlusion of the intercostal artery for ARM due to stent-graft (group A, n = 33) and patients who had patency of the intercostal artery for ARM following stent-graft (group B, n = 38). Results: Five (3.6%) of the 144 patients had paraparesis/paraplegia. Two of these five patients had previously undergone operation for total arch replacement with elephant trunk and one had surgery for descending aortic repair. Univariate analyses identified only prior aortic surgery as a significant risk factor ( p = 0.04). Paraparesis/paraplegia rates were 10% (three patients) in group A and 0% in group B ( p = 0.09). Conclusion: Prior thoracic aortic replacement was found to be a significant predictor of spinal cord ischemia, and therefore vigilance is needed regarding occlusion of the intercostal artery for ARM detected prior to stent-graft repair. #

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Section: Discussionmentioning

confidence: 99%

Spinal cord ischemia after elective endovascular stent-graft repair of the thoracic aorta☆

Kawaharada

Morishita

Kurimoto

et al. 2007

European Journal of Cardio-Thoracic Surgery

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“…For example, in the case of hypotension, fluid resuscitation and pressor support are used to sustain mean arterial pressure at ≥90 mm Hg. 10 In suspected embolization, anticoagulation or antithrombotics can be used. Anticoagulation has been used in the case of dissection but there are no randomized controlled studies of radicular artery dissection.…”

Section: Treatmentmentioning

confidence: 99%

Evaluation of a Patient With Spinal Cord Infarction After a Hypotensive Episode

Vongveeranonchai

Zawahreh

Strbian

et al. 2014

Stroke

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A 72-year-old man with past medical history significant for peripheral vascular disease, bilateral carotid stenosis, hypertension, dyslipidemia, and heavy tobacco use developed sudden severe chest pain and received sublingual nitroglycerin with pain resolution. The patient was able to walk to the ambulance, but on arrival in the emergency room had a systolic blood pressure of 60 mm Hg, which was thought to be secondary to nitroglycerin. He was given intravenous fluids. A few hours later, he complained of being unable to move his legs and was found to be paraplegic with urinary retention and a T4 sensory level to pain and temperature with preserved light touch, vibration, and joint position sense. Additional intravenous fluids resulted in minimal improvement. Emergent MRI of the spine was nondiagnostic, but a follow-up MRI the next day showed abnormal signal intensity within the anterior gray matter on T2-weighted images from the T2 through T5 level, with corresponding signal on diffusion weighted imaging. A computed tomography of the chest showed no aortic dissection. Cardiac telemetry and echocardiogram were unremarkable. A fasting low density lipoprotein was 120. He was treated with intravenous fluids, aspirin 81 daily, an increased statin dose, and eventually discharged to an acute rehabilitation facility. Six month later, his lower extremity strength had improved. He was able to walk 45 feet with a wheeled walker and required intermittent urinary catheterization. DiscussionAcute spinal cord infarction (SCI) is uncommon, accounting for 1.2% of stroke admissions and 5% to 8% of acute myelopathies.1 The vast majority of spinal infarcts involve the anterior spinal artery (ASA) and have distinct clinical features because of sparing of the posterior columns. These patients have preserved posterior column function despite loss of pain and temperature with bilateral lower extremity weakness. Recognizing spinal cord ischemia early is critical so that the processes causing ischemia can be addressed to limit SCI. Vascular Anatomy of the Spinal CordTo understand the mechanisms of spinal cord ischemia, one must first understand the vascular supply of the cord, which leaves the thoracic cord particularly vulnerable to ischemia (Figure). There is a single ASA and 2 or 4 posterior spinal arteries (PSAs). The ASA is derived from branches of the vertebral arteries arising at the level of the foramen magnum. Segmental vessels at the level of each spinal nerve roots divide into anterior and posterior radicular arteries. At variable levels these course medially and anastomose with either the ASA or the PSAs. During development the majority of anterior radicular arteries regress leaving only 4 to 8 arteries to feed into the ASA. Fewer anastomoses make this territory more susceptible to ischemia. In the cervical cord the anterior radicular arteries are branches of the vertebral and ascending cervical arteries. In the rostral thoracic cord they are branches of the deep and ascending cervical arteries. In the middle and lower thorac...

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“…Cases with acute neurologic events were subjected to further NIHSS and ASIA exams along with a detailed neurologic consultation and examination along with appropriate neuroimaging to confirm the existence of spinal or brain ischemia and exclude peripheral nerve or muscle injury. If an episode of spinal ischemia was detected intraoperatively or postoperatively, our institution's standard protocol was followed to attempt to reverse ongoing ischemia (Cheung et al, 2002(Cheung et al, , 2005McGarvey etal., 2007).…”

Section: Experimental Procedures Surgical Proceduresmentioning

confidence: 99%

Biomarker evidence for mild central nervous system injury after surgically-induced circulation arrest

et al. 2008

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Previously, we identified 14-3-3 β and ζ isoforms and proteolytic fragments of α-spectrin as proteins released from degenerating neurons that also rise markedly in cerebrospinal fluid (CSF) following experimental brain injury or ischemia in rodents, but these proteins have not been studied before as potential biomarkers for ischemic central nervous system injury in humans. Here we describe longitudinal analysis of these proteins along with the neuron-enriched hypophosphorylated neurofilament H (pNFH) and the deubiquitinating enzyme UCH-L1 in lumbar CSF samples from 19 surgical cases of aortic aneurysm repair, 7 involving cardiopulmonary bypass with deep hypothermic circulatory arrest (DHCA). CSF levels of the proteins were near the lower limit of detection by Western blot or enzyme-linked fluorescence immunoassay at the onset of surgical procedures, but increased substantially in a subset of cases, typically within 12-24 hours. All cases involving DHCA were characterized by >3-fold elevations in CSF levels of the two 14-3-3 isoforms, UCH-L1, and pNFH. Six of 7 also exhibited marked increases in α-spectrin fragments generated by calpain, a protease known to trigger necrotic neurodegeneration. Among cases involving aortic cross-clamping but not DHCA, the proteins rose in CSF preferentially in the subset experiencing acute neurological complications. Our results suggest the neuron-enriched 14-3-3β, 14-3-3ζ, pNFH, UCH-L1, and calpain-cleaved α-spectrin may serve as a panel of biomarkers with clinical potential for the detection and management of ischemic central nervous system injury, including for mild damage associated with surgically-induced circulation arrest.

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Strategies to Manage Paraplegia Risk After Endovascular Stent Repair of Descending Thoracic Aortic Aneurysms

Cited by 234 publications

References 22 publications

Spinal cord ischemia after elective endovascular stent-graft repair of the thoracic aorta☆

Spinal cord ischemia after elective endovascular stent-graft repair of the thoracic aorta☆

Evaluation of a Patient With Spinal Cord Infarction After a Hypotensive Episode

Biomarker evidence for mild central nervous system injury after surgically-induced circulation arrest

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