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Ann Thorac Surg 1998;66:132-138
© 1998 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Reduction of neurologic injury after high-risk thoracoabdominal aortic operation¹

^a The Center for Aortic Surgery and Departments of Department of Thoracic and Cardiovascular Surgery, Lahey Hitchcock Clinic, Burlington, Massachusetts, USA
^b Department of Anesthesiology, Lahey Hitchcock Clinic, Burlington, Massachusetts, USA
^c Department of Neurology, Lahey Hitchcock Clinic, Burlington, Massachusetts, USA
^d Department of Biomathematics, M. D. Anderson Cancer Center, Houston, Texas, USA

Accepted for publication March 2, 1998.

Address reprint requests to Dr Svensson, Center for Aortic Surgery, Department of Thoracic and Cardiovascular Surgery, Lahey Hitchcock Clinic, 41 Mall Rd, Burlington, MA 01805

	Abstract

Top Footnotes Abstract Introduction Patients and methods Results Comment References

 
Background. Of all aortic operations, thoracoabdominal aortic repairs have the highest risk of spinal cord neurologic injury, manifest by lower limb paraplegia or paraparesis. Cerebrospinal fluid drainage combined with intrathecal papaverine (CSFDr + IP) may reduce the risk and severity of neurologic injury. The objective of this study was to evaluate the effect of CSFDr + IP to prevent neurologic injury after high-risk thoracoabdominal aneurysm repairs.

Methods. We screened 64 patients before operation with descending thoracic or thoracoabdominal aneurysms for possible inclusion in a prospective, randomized study. Thirty-three patients with high-risk type I and II thoracoabdominal aneurysms met inclusion criteria and 17 were randomly assigned to CSFDr + IP and 16 to the control group. The study was terminated early after interim analysis revealed a significant difference.

Results. Of 64 patients screened, 2 patients died after operation (3.1%, 2/64); both were in the randomized study (6%, 2/33), and neither had a neurologic injury. Neurologic injury developed in 2 CSFDr + IP patients and 7 control patients (p = 0.0392). Control patients also had lower postoperative motor strength scores (p = 0.0340). On multivariate analysis, risk factors for neurologic injury included (p < 0.05) longer cross-clamp time, failure to actively cool with bypass, and postoperative hypotension, whereas CSFDr + IP was protective. Logistic regression showed that CSFDr + IP and active cooling significantly reduced the risk of injury and that the two combined modalities were additive. Of 64 patients screened, only 2 (3%) had a permanent neurologic deficit preventing ambulation.

Conclusions. For high-risk thoracoabdominal aneurysms, CSFDr + IP was effective in reducing the incidence and severity of neurologic injury. Active cooling may be further additive to CSFDr + IP protection, although this needs to be confirmed in a larger study.

	Introduction

Top Footnotes Abstract Introduction Patients and methods Results Comment References

 
Ever since the aorta was first cross-clamped for aortic repairs, paralysis of the lower limbs has been a potential and feared complication. The incidence of spinal cord neurologic injury after aortic operations, defined as either paraparesis or paraplegia of the lower limbs, either permanent or transient, is approximately 0.25% for elective infrarenal abdominal aortic aneurysms and up to 48% for extensive high-risk Crawford type II thoracoabdominal aneurysms [1], the latter extending from the proximal descending thoracic to the infrarenal abdominal aorta. In patients with the highest risk type II thoracoabdominal aneurysms, neurologic injury rates in hospital survivors of up to 41% were reported by Cox and colleagues [2] and a paraplegia rate of up to 21% in the study by Gilling-Smith and colleagues [3]. The risk of neurologic injury is also high in patients presenting with aortic rupture whether in the abdominal aorta (2.5%), descending thoracic aorta (18%), or thoracoabdominal aorta (22%, 26%) [4–6].

Other studies have reported that the risk of neurologic injury may be reduced by cerebrospinal fluid (CSF) drainage [7–9], and either atriofemoral bypass or cardiopulmonary bypass [4, 10–13], particularly if active cooling is added [10–12, 14–16]. A previous prospective randomized study evaluated CSF drainage alone to reduce the risk of neurologic injury [1] but failed to show any significant benefit of CSF drainage. The study has been criticized, however, because the volume of CSF drained was limited to 50 mL during aortic cross-clamping, CSF was not allowed to freely drain by gravity, and CSF drainage was not continued after the operation [1, 7, 9]. Nevertheless, there was a trend toward a lower incidence of neurologic injury in patients with CSF drainage who had postoperative hemodynamic instability (p = 0.08) [1]. A previous normothermic animal experiment in Chacma baboons showed that the combination of CSF drainage and intrathecal papaverine (CSFDr + IP) dilated the anterior spinal artery, increased spinal cord blood flow, and prevented neurologic injury [17]. Initial studies in humans showed that CSFDr + IP was safe and could possibly reduce the risk of neurologic injury [12, 18]. We wished to evaluate in a prospective, randomized study whether the combination of CSFDr + IP was effective in reducing the incidence and the severity of neurologic injury.

	Patients and methods

Top Footnotes Abstract Introduction Patients and methods Results Comment References

 
Institutional Review Board permission was obtained from Baylor College of Medicine, Methodist Hospital, and Veterans’ Administration Medical Center (Houston, TX); and Lahey Hitchcock Medical Center (Burlington, MA) for performing the study. The Institutional Review Board approval included a request for interim analysis of safety and efficacy. For a prospective randomized study of patients undergoing high-risk Crawford type I or type II thoracoabdominal aneurysm repairs, a sample size of 100 patients was required based on an event rate of 25% in the control group and 5% in the CSFDr + IP group ( = 0.05, ß = 0.2, power = 80%, Pearson ² test) [1, 19].

All patients potentially requiring Crawford type I or type II thoracoabdominal repairs subsequent to February 13, 1992, who did not have reasons for exclusion were approached for informed consent to be entered into the study. The reasons for exclusion were the following:

1. Unable to give fully informed voluntary consent.
   
2. Elective cardiopulmonary bypass with full heparinization.
   
3. Previous lower back operation.
   
4. Crawford type III or type IV thoracoaneurysm, namely, aneurysms not originating above the mid-descending thoracic aorta at T-6.
   
5. Repairs not likely to be Crawford type I (repairs extending from the proximal descending thoracic aorta above the sixth rib to the renal arteries) or Crawford type II (repairs from the proximal descending thoracic aorta to below the renal arteries).
   
6. Patients in shock.
   

Thirty-three patients met the criteria. Median age was 66 years (range, 34 to 79 years; quartiles, 61, 72). There were 25 men and 8 women. Patients were block randomized by computer-generated assignment and the use of folded cards within serially numbered opaque envelopes.

Papaverine and cerebrospinal fluid drainage
Papaverine hydrochloride powder was prepared monthly by mixing it with 10% dextrose in water and filtering the solution through a 0.22-µm filter to produce a preservative-free 1% solution [18].

With local anesthesia, a catheter was inserted into the intrathecal space and the tip positioned in the lower thorax [18]. Twenty minutes before aortic cross-clamping, 20 mL of CSF was withdrawn and 3 mL of warmed (37°C) preservative-free papaverine solution (30 mg) was introduced during 5 minutes followed by a slow flush of the catheter with CSF [18]. On aortic cross-clamping, CSF was allowed to drain freely by gravity, and after unclamping, CSF drainage was stopped. Postoperatively, CSF was allowed to freely drain if CSF pressure exceeded 7 to 10 cm H₂O.

Surgical technique
The technique of thoracoabdominal aneurysm repair has been previously described in detail [1, 5, 6, 8, 9, 14]. Briefly, through a thoracoabdominal incision with division of the costal margin, the diaphragm was divided and the aorta exposed. Atriofemoral bypass was established by cannulating the left atrium and the femoral artery. The proximal aorta was then cross-clamped and the aorta repaired. When feasible, aortic segments were sequentially cross-clamped to maintain both proximal and distal perfusion [12, 14–16]. Intercostal and lumbar arteries below T6 were preserved when possible [12, 14–16]. After 1992, active cooling to a bladder temperature of 29° to 31°C was instituted before aortic cross-clamping by atriofemoral bypass. Active cooling was added because our retrospective analysis of thoracoabdominal aneurysm repairs suggested that active cooling was possibly further protective with atriofemoral bypass [8].

Neurologic evaluation
After the operations, patients were evaluated by observers unaware of the randomization study. In addition, the morning after the operation and daily for the first 5 days, patients’ lower limb motor function was scored by asking the patients to alternately raise each extended straight leg off the bed for at least 5 seconds and grading the responses as follows:

0 = no movement

1 = flicker of movement

2 = able to bend knee to move leg

3 = unable to perform straight-leg raise against gravity, but better leg movement

4 = normal movement and later ambulation.

Patients who displayed any weakness underwent a full examination by a neurologist unaware of the study randomization, and if indicated, a magnetic resonance imaging or computed tomographic scan was performed.

Statistical methods
Statistical analysis was performed according to the intention to treat method as per statistical convention and included 1 patient in the control group who died suddenly before operation because of a probable ruptured aneurysm. One patient in each group in which thoracoabdominal repairs were planned did not have thoracoabdominal incisions and repairs, but descending aortic repairs. Comparison among patients of variables was performed with the Pearson ² test and Student’s t test (Table 1). Other possible protective measures such as distal perfusion, active cooling, sequential repair, and segmental artery reattachment were equally distributed between the groups. The Student’s t test and Kruskal-Wallis test were used for comparison of neurologic injury events and motor scores between the two groups. Spearman correlation and logistic regression were used to evaluate treatment effects. The stepwise logistic regression model was determined using all variables. Data were analyzed using BMDP software (BMDP Statistical Software, Inc, Los Angeles, CA). Late follow-up was obtained by a detailed questionnaire, office visits, or contacting referral physicians, and was evaluated by Kaplan-Meier analysis.

	Results

Top Footnotes Abstract Introduction Patients and methods Results Comment References

 
Excluding type III and type IV thoracoabdominal aneurysms, 64 patients underwent descending or thoracoabdominal operations during the period ending December 28, 1996, of whom 33 were eligible for the study. Seventeen patients were assigned to CSFDr + IP and 16 to the control group. Seven patients with type I or type II thoracoabdominal aneurysms were excluded for the following reasons: heparinization, 3; shock, 3 (1 also stroke); stroke, 1; and back operations, 1. There were two postoperative hospital deaths (2/33, 6%), one in each group, at 12 days (respiratory failure and adult respiratory distress syndrome) and at 5 days (retrograde dissection of the ascending aorta with rupture) for an overall 94% (31/33) hospital survival rate. These were the only two 30-day hospital deaths in the total series of repairs (3.1%, 2/64) for an overall survival rate of 96.9%. On late follow-up, all study hospital survivors are alive for a 94% 3-year survival by Kaplan-Meier analysis.

A neurologic injury developed in two of the CSFDr + IP patients (2/17, 11.8%) and 7 of the control patients (7/16, 43.8%, p = 0.0392, Pearson ²). The lowest mean motor score was 3.88 in the CSFDr + IP group and 3.25 in the control group (p = 0.0340, Student’s t test; p = 0.17, Kruskal-Wallis test) (Fig 1).

View larger version (9K): [in this window] [in a new window]   Fig 1. Dot plot of postoperative lower limb motor function score counts. The vertical lines indicate the medians, the xs indicate the means. (CSFDr + IP = cerebrospinal fluid drainage plus intrathecal papaverine.)

View larger version (20K): [in this window] [in a new window]   Fig 2. Logistic regression curves showing relationship of aortic cross-clamp time and risk of neurologic injury. The intercept coefficient was -9.6101 (standard error, 4.3416), for cerebrospinal fluid drainage plus intrathecal papaverine (CSFDr + IP) the coefficient was -3.98798 (standard error, 1.8375; p = 0.039), the active cooling coefficient was -6.3827 (standard error, 2.9143; p = 0.037), and the coefficient for clamp time was 0.15174 (standard error, 0.06591; p = 0.029). (No Cooling = no active cooling or CSFDr + IP.)

The univariate differences between uninjured patients and patients with neurologic injury are shown in Table 1. On multivariate analysis of all variables, the following variables significantly affected the incidence of neurologic injury: intercostal ischemia time (p = 0.0022), no active cooling (p = 0.0036), postoperative hypotension (p = 0.0414), and CSFDr + IP (p = 0.0100).

The total volume of CSF drained averaged 447.2 mL (range, 12 to 1157 mL) and included 18.2 mL lost at the time of needle and catheter insertion, 101.8 mL during aortic cross-clamping, and 304.3 mL during subsequent drainage in the intensive care unit. Six of the catheters were inserted at L3-4 and 11 at L4-5. Blood staining in 2 patients resolved on CSF drainage. In 2 patients, CSF could not be drained adequately; however, papaverine was administered without incident. The median postoperative length of CSF drainage was 40.00 hours (range, 2 to 60 hours). There were no complications related to CSF drainage or the use of intrathecal papaverine except for one patient who had a persistent CSF leak that required an epidural blood patch. No patient complained of postoperative headaches, probably because they spent several days lying in bed before ambulation.

Neither of the 2 patients who died had a neurologic injury. Only 1 patient (3.0%), who had acute dissection and a preoperative creatinine level of 3.8 mg/dL, required institution of postoperative hemodialysis. The effect of neurologic injury on prolonged postoperative intubation, intensive care unit stay, and discharge are shown in Table 2. On complete follow-up after discharge, all except 2 patients (94%, 29/31) had recovered and were walking without support. In the total series of 64 repairs, only these 2 patients (3.1%, 2/64) had a permanent neurologic injury preventing ambulation.

	Comment

Top Footnotes Abstract Introduction Patients and methods Results Comment References

The combination of CSFDr + IP significantly reduced the incidence and severity of neurologic injury. In contrast to the previous study [1] of CSF drainage alone to a maximum of 50 mL, the current study added papaverine, drained a larger volume of CSF (mean 447.2 mL) by gravity during aortic cross-clamping rather than by monitoring pressure, and continued CSF drainage during the postoperative period. After neurologic injury, negative neurotrophic proteins that prevent spinal cord healing may be released into the CSF [23]. Thus, because of this and because of preventing excessive CSF pressures, prolonged drainage may enhance spinal cord recovery after ischemia. Previous experiments in animals and initial studies in humans suggested that CSFDr + IP could be protective [12, 17, 18]. In a prospective nonrandomized study of CSFDr + IP in 34 patients [12, 17, 18], none had an early neurologic injury. However, 3 (8.8%) experienced a delayed neurologic injury, two of them transient. In 19 patients who were operated on during the same period but not treated with CSFDr + IP, the incidence of neurologic injury was 42% (p = 0.058). Similarly, Kieffer [9, 22], in a study of 29 patients who underwent thoracoabdominal aneurysm repairs with the use of CSFDr + IP and cardiopulmonary bypass, found that none had a neurologic injury. In the current study, no patients who had atriofemoral bypass combined with CSFDr + IP had a neurologic injury. Cerebrospinal fluid drainage combined with atriofemoral bypass has been reported to also be protective [8]. Thus, the use of atriofemoral bypass with hypothermia and CSFDr + IP appears to offer additive protection against neurologic injury during the period of spinal cord ischemia when the aorta is cross-clamped, but needs to be confirmed in a larger prospective randomized study.

There were no significant adverse effects related to the use of CSFDr + IP. It should be stressed that our solution of papaverine was preservative-free, warmed, and injected slowly for 5 minutes, followed by slow injection of CSF to flush the catheter [17, 18] to prevent a hypotensive sympathetic response.

Any comparison of this prospective randomized study to other retrospective series should be done with caution. In some studies the definition of neurologic injury is not stated, or subgroups of high-risk patients are excluded [1, 14]. Only one [1] has scored postoperative motor strength and noted that most of the neurologic injury events, as in the current study (7/9) were transient. These were associated with considerably prolonged intubation, intensive care unit stay, hospital stay, and resultant additional use of resources.

The hospital and late survival rate of 94% in the randomized patients and the 30-day survival rate of 96.9% in the total series of patients compares favorably with recent results reported by Crawford’s group (96% 30-day survival, 86% 1-year survival) [1], Coselli and colleagues [6] (92.6% in-hospital), Cambria and colleagues [20] (90% 60-day survival), Safi and colleagues [8] (96% 30-day survival), and Kouchoukos and colleagues [10] (91.2% 30-day survival). However, 30-day survival rates of 65% [2] or hospital survival rates of 72% [3] have been published recently. The potential for severe morbidity, respiratory failure, multiple-organ failure, and death is clearly great in these extensive operations. Nevertheless, with a team approach of dedicated anesthesiologists, surgeons, nurses, perfusionists, neurologists, intensivists, nephrologists, cardiologists, and pulmonologists, improved results can be achieved.

There are weaknesses in this study. First, the operating team was not blinded to the procedure. In the study of CSF drainage alone [1], this was initially attempted, but was impossible to successfully implement. Nevertheless, in this study, postoperative observers were unaware of the randomization and its possible outcomes in an attempt to reduce the risk of bias. Second, the study was terminated early because of the statistically significant difference that was reached after one-third of the patients had been entered. Termination was advised by the IRB because of the ethical problems with continuing the study. Ideally, from a statistical viewpoint, the study should have enrolled a total of 100 patients to prevent an alpha error, although the period of enrollment would have to have been considerably extended to increase accrual, and with extension, clinical relevance may have been lost. In most studies of neurologic injury, Crawford type I and type II thoracoabdominal aneurysms are uncommon, and with the exception of reports from Crawford’s group [1, 4, 5], and former associates Coselli and colleagues [6] and Safi and coworkers [8], the numbers in most reports are small. If the study had continued, the difference probably would have become stronger, but it may also not have been borne out in a larger series. Furthermore, continuation of the study would have entailed significant changes in the protocol if innovative experimental techniques, such as local cooling methods [24], including epidural cooling [20], had been added to the procedure.

Because most patients (96.9% or 62/64) in the current series survived operation, this devastating neurologic injury that was frequently previously associated with death has become of increasing paramount importance to patients, their families, providers, and insurance companies. Nevertheless, with current methods, this risk was reduced to 2.9% (1/34, transient deficit) in patients operated on since June 1994, with none in the CSFDr + IP group. In the entire series of repairs, only 3.1% (2/64) had a neurologic injury that prevented them from walking after recovery from the operation. Continued research is needed to further reduce the risk of all complications.

	Footnotes

Top Footnotes Abstract Introduction Patients and methods Results Comment References

 
¹This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/annals

	References

Top Footnotes Abstract Introduction Patients and methods Results Comment References

 

1. Crawford E.S., Svensson L.G., Hess K.R., et al. A prospective randomized study of cerebrospinal fluid drainage to prevent paraplegia after high-risk surgery on the thoracoabdominal aorta. J Vasc Surg 1991;13:36-45.[Medline]
2. Cox G.S., O’Hara P.J., Hertzer N.R., Piedmonte M.R., Krajewski L.P., Beven E.G. Thoracoabdominal aneurysm repair: a representative experience. J Vasc Surg 1992;15:780-787.[Medline]
3. Gilling-Smith G.L., Worswick L., Knight P.F., Wolfe J.H.N., Mansfield A.O. Surgical repair of thoracoabdominal aortic aneurysm: 10 years’ experience. Br J Surg 1995;82:624-629.[Medline]
4. Svensson L.G., Crawford E.S., Hess K.R., Coselli J.S., Safi H.J. Variables predictive of outcome in 832 patients undergoing repairs of the descending thoracic aorta. Chest 1993;104:1248-1253.[Free Full Text]
5. Svensson L.G., Crawford E.S., Hess K.R., Coselli J.S., Safi H.J. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg 1993;17:357-370.[Medline]
6. Coselli J.S., LeMaire S.A., Poli de Figueiredo L., Kirby R.P. Paraplegia after thoracoabdominal aortic aneurysm repair: is dissection a risk factor?. Ann Thorac Surg 1997;63:28-36.[Abstract/Free Full Text]
7. Acher C.W., Wynn M.M., Hoch J.R., Popic P.M., Turnipseed W.D. Combined use of spinal fluid drainage and naloxone reduces risk of neurologic deficit in the repair of thoracoabdominal aneurysms. J Vasc Surg 1994;19:236-248.[Medline]
8. Safi H.J., Bartoli S., Hess K.R., et al. Neurologic deficit in patients at high risk with thoracoabdominal aortic aneurysms: the role of cerebral spinal fluid drainage and distal aortic perfusion. J Vasc Surg 1994;20:434-443.[Medline]
9. Marstrand Workshop Group. Thoracoabdominal aortic aneurysms with special reference to technical problems and complications. Eur J Vasc Surg 1993;7:725-730.[Medline]
10. Kouchoukos N.T., Daily B.D., Rokkas C.K., et al. Hypothermic bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg 1995;60:67-77.[Abstract/Free Full Text]
11. Najafi H. Descending aortic aneurysmectomy without adjuncts to avoid ischemia. 1993 update. Ann Thorac Surg 1993;55:1042-1045.[Abstract/Free Full Text]
12. Svensson L.G., Patel V., Robinson M.F., Ueda T., Roehm J.O., Jr, Crawford E.S. Influence of preservation or perfusion of intraoperatively identified spinal cord blood supply on spinal motor evoked potentials and paraplegia after aortic surgery. J Vasc Surg 1991;13:355-365.[Medline]
13. Lawrie G.M., Earle N., DeBakey M.E. Evolution of surgical techniques for aneurysms of the descending thoracic aorta: twenty-nine years experience with 659 patients. J Card Surg 1994;9:648-661.[Medline]
14. Svensson L.G., Crawford E.S. Aortic dissection and aortic aneurysm surgery: clinical observations, experimental investigations, and statistical analyses. Part III. Curr Probl Surg 1993;30:1-172.[Medline]
15. Svensson L.G., Hess K.R., Coselli J.S., Safi H.R. Influence of segmental arteries, extent, and atrio-femoral bypass on postoperative paraplegia after thoracoabdominal aortic aneurysm repairs. J Vasc Surg 1994;20:255-262.[Medline]
16. Svensson L.G., Hess K.R., Coselli J.S., Safi H.J. Influence of segmental arteries and distal aortic perfusion on postoperative paraplegia after thoracoabdominal aortic operations. J Vasc Surg 1994;20:255-262.[Medline]
17. Svensson L.G., Von Ritter C.M., Groenveld H.T., et al. Cross-clamping of the thoracic aorta: influence of aortic shunts, laminectomy, papaverine, calcium channel blockers, allopurinol, and superoxide dismutase on spinal cord blood flow and paraplegia in baboons. Ann Surg 1986;204:38-47.[Medline]
18. Svensson L.G., Stewart R.W., Cosgrove D.M., et al. Intrathecal papaverine for the prevention of paraplegia after operation on the thoracic or thoracoabdominal aorta. J Thorac Cardiovasc Surg 1988;96:823-829.[Abstract]
19. Fleiss J.L. Statistical methods for rates and proportions, 2nd ed. New York: John Wiley and Sons, 1981:41.
20. Cambria R.P., Davison J.K., Zanetti S., et al. Clinical experience with epidural cooling for spinal cord protection during thoracic and thoracoabdominal aneurysm repair. J Vasc Surg 1977;25:234-243.
21. Cooley D.A., Baldwin R.T. Technique of open distal anastomosis for repair of descending thoracic aortic aneurysms. Ann Thorac Surg 1992;54:932-936.[Abstract/Free Full Text]
22. Kieffer E. Surgical treatment of aneurysms of the thoraco-abdominal aorta. Rev Prat 1991;41:1793-1797.[Medline]
23. Schnell L., Schneider R., Kolbeck R., Barde Y.-A. Neurotrophin-3 enhances sprouting of corticospinal tract during development and after adult spinal cord lesion. Nature 1994;367:170-173.[Medline]
24. Acosta-Rua G.J. Treatment of traumatic paraplegic patients by localized cooling of the spinal cord. J Iowa Med Soc 1970;60:326-328.[Medline]

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				T. Miyairi, Y. Kotsuka, M. Ezure, M. Ono, T. Morota, H. Kubota, K. Shibata, K. Ueno, and S. Takamoto Open stent-grafting for aortic arch aneurysm is associated with increased risk of paraplegia Ann. Thorac. Surg., July 1, 2002; 74(1): 83 - 89. [Abstract] [Full Text] [PDF]

				J. S. Coselli, S. A. LeMaire, L. D. Conklin, C. Koksoy, and Z. C. Schmittling Morbidity and mortality after extent II thoracoabdominal aortic aneurysm repair Ann. Thorac. Surg., April 1, 2002; 73(4): 1107 - 1116. [Abstract] [Full Text] [PDF]

				E. A. Hessel Bypass Techniques for Descending Thoracic Aortic Surgery Seminars in Cardiothoracic and Vascular Anesthesia, November 1, 2001; 5(4): 293 - 320. [Abstract] [PDF]

				A. L. Estrera, C. C. Miller III, T. T.T. Huynh, E. Porat, and H. J. Safi Neurologic outcome after thoracic and thoracoabdominal aortic aneurysm repair Ann. Thorac. Surg., October 1, 2001; 72(4): 1225 - 1231. [Abstract] [Full Text] [PDF]

				N. T. Kouchoukos, P. Masetti, C. K. Rokkas, S. F. Murphy, and E. H. Blackstone Safety and efficacy of hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta Ann. Thorac. Surg., September 1, 2001; 72(3): 699 - 708. [Abstract] [Full Text] [PDF]

				K. Shibata, S. Takamoto, Y. Kotsuka, T. Miyairi, T. Morota, K. Ueno, and H. Sato Doppler ultrasonographic identification of the critical segmental artery for spinal cord protection Eur J Cardiothorac Surg, September 1, 2001; 20(3): 527 - 532. [Abstract] [Full Text] [PDF]

				S. Kazama, Y. Miyoshi, M. Nie, H. Imai, Z. B. Lin, A. Kurata, and M. Machii Protection of the spinal cord with pentobarbital and hypothermia Ann. Thorac. Surg., May 1, 2001; 71(5): 1591 - 1595. [Abstract] [Full Text] [PDF]

				S. A. LeMaire, C. C. Miller III, L. D. Conklin, Z. C. Schmittling, C. Koksoy, and J. S. Coselli A new predictive model for adverse outcomes after elective thoracoabdominal aortic aneurysm repair Ann. Thorac. Surg., April 1, 2001; 71(4): 1233 - 1238. [Abstract] [Full Text] [PDF]

				L. K. von Segesser, B. Marty, X. Mueller, P. Ruchat, P. Gersbach, F. Stumpe, and A. Fischer Active cooling during open repair of thoraco-abdominal aortic aneurysms improves outcome Eur J Cardiothorac Surg, April 1, 2001; 19(4): 411 - 416. [Abstract] [Full Text] [PDF]

				T. Kunihara, S. Sasaki, N. Shiiya, T. Miyatake, N. Mafune, and K. Yasuda Proinflammatory cytokines in cerebrospinal fluid in repair of thoracoabdominal aorta Ann. Thorac. Surg., March 1, 2001; 71(3): 801 - 806. [Abstract] [Full Text] [PDF]

				I. Y. P. Wan, G. D. Angelini, A. J. Bryan, I. Ryder, and M. J. Underwood Prevention of spinal cord ischaemia during descending thoracic and thoracoabdominal aortic surgery Eur J Cardiothorac Surg, February 1, 2001; 19(2): 203 - 213. [Abstract] [Full Text] [PDF]

				P. de Haan, I. Vanicky, M. J. H. M. Jacobs, O. Bakker, J. Lips, S. A.G. Meylaerts, and C. J. Kalkman Effect of ischemic pretreatment on heat shock protein 72, neurologic outcome, and histopathologic outcome in a rabbit model of spinal cord ischemia J. Thorac. Cardiovasc. Surg., September 1, 2000; 120(3): 513 - 519. [Abstract] [Full Text] [PDF]

				D. A. Cooley, A. Golino, and O. H. Frazier Single-clamp technique for aneurysms of the descending thoracic aorta: report of 132 consecutive cases Eur J Cardiothorac Surg, August 1, 2000; 18(2): 162 - 167. [Abstract] [Full Text] [PDF]

				P. Mastroroberto and M. Chello EMERGENCY THORACOABDOMINAL AORTIC ANEURYSM REPAIR: CLINICAL OUTCOME J. Thorac. Cardiovasc. Surg., September 1, 1999; 118(3): 477 - 481. [Abstract] [Full Text] [PDF]

				L. G. Svensson An approach to spinal cord protection during descending or thoracoabdominal aortic repairs Ann. Thorac. Surg., June 1, 1999; 67(6): 1935 - 1936. [Abstract] [Full Text] [PDF]

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