Surgery for acquired heart disease looking for the artery of adamkiewicz: A quest to minimize paraplegia after operations for aneurysms of the descending thoracic and thoracoabdominal aorta

Abstract

All patients undergoing resection of thoracic or thoracoabdominal aneurysms at Mount Sinai Hospital since November 1993 had spinal cord function monitored with somatosensory-evoked potentials as part of a multimodality approach to reducing spinal cord injury. In the segment to be resected, each pair of intersegmental vessels was sequentially clamped, and they were subsequently sacrificed only if no change in somatosensory evoked potentials occurred within 8 to 10 minutes after occlusion. Adjunctive protective measures included mild hypothermia (31 degrees to 33 degrees C), distal perfusion, corticosteroids, maintenance of high normal blood pressures, avoidance of nitroprusside, and cerebrospinal fluid drainage. Ninety-five consecutive patients operated on since 1993 (group II) were compared with 138 earlier patients (group I). Preoperative characteristics such as age, sex, etiology of aneurysm, emergency operation, and reoperation did not differ between groups, nor did operative variables such as incidence of rupture and extent of resection. Group I had slightly more smokers and slightly fewer hypertensive individuals. Group II patients had a significantly better outcome with respect to in-hospital mortality (10.5% vs 18%, p = 0.045) and paraplegia (2% vs 8%, p = 0.008). By multivariate analysis, rupture and diabetes were associated with significantly higher in-hospital mortality, and smoking greatly increased the incidence of paraplegia. The extent of the aneurysm was a major determinant of mortality and paraplegia. The low paraplegia rate in group II was achieved without reattachment of a single intercostal or lumbar artery. No patient with fewer than 10 intersegmental arteries severed had paraplegia, and spinal cord ischemia was reversible in three patients after adjunctive maneuvers were performed to improve perfusion, suggesting that spinal cord blood supply is unlikely to depend on a single "artery of Adamkiewicz."

Surgery for rare aneurysm associated with colorectal cance

“…However, the risk of operation is also unmanageable. The risk of spinal cord injury, particularly in operations on the descending aorta [9] , is also significant. As a result of surgical risk and expense, our patient elected for conservative treatment for his aneurysm 8 years ago.…”

Optimal Preoperative Imaging of Spinal Cord Blood Supply: Fig 1.

“…Apart from the segmental supply to the AKA, there are alternative routes by which the anterior spinal axis might be supplied. From our own experience 2 and that of others, 3 we know that spinal cord function is not always crucially dependent on segmental supply directly connecting to the AKA. Collaterals can substitute the spinal cord supply to maintain spinal cord function.…”

“…Collaterals can substitute the spinal cord supply to maintain spinal cord function. 3 Recently, these collateral pathways have been visualized with MR angiography (MRA) 2 (Fig 1) and correlated with intraoperative spinal cord motor-evoked potentials. It is interesting to note in this study that when the segmental supply to the AKA was inside the cross-clamped aortic region and connecting collaterals originating from outside the cross-clamped aortic area were noticed, this had a predictive value of 97% for stable spinal cord function.…”

Spinal Cord Protection for Descending or Thoracoabdominal Aortic Aneurysm Repair

“…They reported that quick oversewing of the intercostal arteries with CSF drainage and naloxone administration could help reduce the incidence of spinal cord injury. Griepp et al [80] also showed that reattachment could be avoided by ligating the intercostal arteries before aortic cross-clamping while monitoring somatosensory evoked potential. These reports suggest that existing collateral vessels might improve the perfusion pressure.…”