Ann Thorac Surg 1998;66:1208-1209
© 1998 The Society of Thoracic Surgeons
Original articles: cardiovascular
invited commentary
Marc A.A.M. Schepens, MD, PhDa
a Department of Cardiothoracic Surgery, St. Antonius Hospital, Koekoekslaan, 3435 CM Nieuwegein, the Netherlands
 |
Invited commentary
|
|---|
 Top
 Invited commentary
|
|---|
Repair of a thoracoabdominal aortic aneurysm is a complex intervention challenging major organ systems during and after the operation. Therefore the operation can be associated with a relatively high incidence of serious complications. The most feared complication is paraplegia. Replacing the whole thoracoabdominal aorta cannot be done in a hurry. If one wants to perform a safe and durable repair without any doubts about each constructed anastomosis, it is necessary that one can proceed in an unhurried fashion.
This article by Dr Safi and associates provides additional evidence that the use of adjuncts, distal aortic perfusion and cerebrospinal fluid drainage, offers the possibility of safely extending total aortic cross-clamp time. Patients having a thoracoabdominal aortic aneurysm are very often vascular cripples with serious associated diseases such as coronary, renal, or cerebrovascular problems. Obtaining a spectacular risk reduction of paraplegia/paraparesis in a type II aneurysm from 38% with simple cross-clamping to 7.3% when adjuncts are used speaks for itself.
Cross-clamp times of greater than 30 minutes will put the patient at risk with regard to neurologic outcome if no adjuncts are used. And who can replace the total thoracoabdominal aorta in less than 30 minutes? No one. Total aortic cross-clamp time depends on the extent of the aneurysm, the number of newly constructed anastomoses, and the technical skills of the surgical team. The last two elements cannot be altered that much, at least if reimplantation of low intercostal vessels is accepted as another aid in the prevention of paraplegia. Thus, only the extension of the cross-clamp time will allow us to perform these interventions, and this is directly related to the use of staged clamping in combination with left heart bypass and cerebrospinal fluid drainage.
From the results of Safi and associates’ work, which is based on sound physiologic principles and which I can underscore based on my own experience in the Netherlands, it seems that surgeons who do not use adjuncts for these interventions on the thoracoabdominal aorta are becoming more and more isolated. Furthermore, I am convinced that the use of distal aortic perfusion combined with sequential aortic clamping allows continuous monitoring of the spinal cord with evoked potentials and substantially unloads the heart in these patients.
There are many steps in the struggle with paraplegia. The one reported here by Safi and coworkers is certainly a major one.
