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Ann Thorac Surg 1999;67:1931-1934
© 1999 The Society of Thoracic Surgeons

Left heart bypass reduces paraplegia rates after thoracoabdominal aortic aneurysm repair

^a Department of Surgery, Baylor College of Medicine, The Methodist Hospital, Houston, Texas, USA

Address reprint requests to Dr Coselli, Department of Surgery, Baylor College of Medicine, The Methodist Hospital, 6560 Fannin, #1100, Houston, TX 77030
e-mail: jcoselli{at}bcm.tmc.edu

Presented at the Aortic Surgery Symposium VI, April 30–May 1, 1998, New York, NY.

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Background. The optimal strategy for spinal cord protection during thoracoabdominal aortic aneurysm (TAAA) repair remains unclear. We evaluated the protective effect of left heart bypass (LHB) during repair of extensive TAAAs.

Methods. During a 12-year period, 710 patients had repair of extent I or II TAAAs. Left heart bypass was used in 312 (43.9%) patients. This group was retrospectively compared with 398 (56.1%) patients who had operations without LHB.

Results. The overall 30-day survival rate was 94.8% (673 patients). In 42 patients, (6.0%) paraplegia or paraparesis developed. In patients with extent I TAAAs, paraplegia and paraparesis rates in LHB (6 of 123, 4.9%) and non-LHB (9 of 246, 3.7%) groups were similar (p = 0.576) despite longer aortic clamp times in the former group. In patients with extent II TAAAs, the LHB group had a lower incidence of paraplegia or paraparesis (9 of 189, 4.8%) compared with the non-LHB group (18 of 137, 13.1%; p = 0.007).

Conclusions. Left heart bypass reduced the risk of paraplegia and paraparesis in patients who had repair of extent I and II TAAAs.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
In addition to the inherent morbidity of postoperative paraplegia and paraparesis (P/P), these neurologic sequelae substantially reduce long-term survival after thoracoabdominal aortic aneurysm (TAAA) repair [1]. Panneton and Hollier’s [2] extensive review of the literature reported an overall 21% incidence of P/P after surgical repair of extensive (Crawford extents I and II) TAAAs. The optimal strategy for spinal cord protection, therefore, remains a major focus of investigation [3].

We used distal aortic perfusion via left heart bypass (LHB) as an adjunct for spinal cord protection with increasing frequency during the past 12 years, and currently we use it routinely during extensive TAAA repairs. Although recent clinical data [4, 5] have lent support to the use of LHB during TAAA repair, those studies combined LHB with cerebral spinal fluid drainage: no large study has focused on LHB alone, so we evaluated the protective effect of LHB during repair of extensive TAAAs.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Between January 1986 and March 1998, 1,100 patients had graft repair of TAAAs. Extensive aneurysms (extents I and II) were repaired in 710 (64.5%) patients, of whom 49 (6.9%) presented with rupture, 38 (5.4%) had acute dissection, and 205 (28.9%) had chronic dissection. The 11 patients (1.5%) who had preoperative P/P were excluded from calculations regarding postoperative neurologic deficits.

Surgical technique
All operations were done by the senior author (JSC); the standardized surgical technique has been described elsewhere [6]. With regard to spinal cord protection, a combination of moderate heparinization, permissive mild hypothermia, sequential aortic clamping, and aggressive reattachment of critical intercostal arteries (T8 to L1) was used consistently throughout the entire series. Left heart bypass was used in 312 (43.9%) cases; 398 (56.1%) operations were done without LHB. Spinal evoked potentials were not monitored, and cerebro-spinal fluid drainage was not used routinely.

In operations with LHB, the perfusion circuit consisted of an outflow cannula in the left atrium, an inflow cannula in either the femoral artery (122 cases, 39.1%) or distal aorta (190 cases, 60.9%), -inch polyvinylchloride tubing, and a centrifugal pump. For selective visceral and renal perfusion, balloon perfusion catheters were connected to the outflow limb using a three-way stopcock. No blood reservoir, heat exchanger, or oxygenator was incorporated in the circuit. A detailed technical report describing our methods for using LHB during TAAA repair was published recently [7].

Outcome variables
All preoperative, intraoperative, and postoperative data were gathered prospectively and entered into a database. Preoperative characteristics included dissection (acute and chronic), rupture, Marfan syndrome, renal insufficiency (serum creatinine exceeding 3.0 mg/dL or requiring hemodialysis), and preexisting P/P (lower extremity paralysis or weakness). The predicted incidence of P/P within subgroups was calculated as described by Acher and associates [8]. Intraoperative data included aortic clamp time, intercostal ischemic time, and renal ischemic time. Postoperative complications evaluated included early death, P/P (both immediate and delayed), acute renal failure (serum creatinine exceeding 3.0 mg/dL or requiring hemodialysis), bleeding complications (bleeding requiring reoperation or coagulopathy), stroke, cardiac complications (dysrhythmia, myocardial infarction, or inotropic support exceeding 48 hours), and pulmonary complications (pneumonia or ventilator support exceeding 48 hours).

Statistical analysis
The statistical analysis was done using the SAS (release 6.10; SAS Institute Inc, Cary, NC) and SPSS (release 6.1.3; SPSS Inc, Chicago, IL) systems for Windows. Categoric variables were compared using univariate analysis (Pearson ² test or the Fisher exact test), and ordinal data were compared using Student’s t test. Associations were considered statistically significant when p was less than 0.05.

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
For the entire group of 710 patients, 30-day and in-hospital survival were 94.8% (n = 673) and 91.8% (n = 652), respectively. There were four (0.6%) intraoperative deaths; these patients are excluded in calculations of postoperative morbidity rates. Overall, 42 patients (6.0%) had P/P, 75 patients (10.6%) had renal failure, and 17 (2.4%) had bleeding complications. Data comparing patients who had operation with versus without LHB are given in Table 1.

Extent II TAAAs
Among the patients with extent II TAAAs, both groups had similar predicted P/P rates. The LHB group had more cases of chronic dissection but fewer cases of ruptured aneurysm. A longer mean aortic clamp time associated with a shorter mean intercostal ischemic time was again noted in the LHB group. The incidence of P/P was strikingly lower in the LHB patients (4.8% versus 13.1%, p = 0.007). The frequencies of all other complications, including early mortality rate, were similar between the two groups.

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Although several reports [9–15] advocate the use of LHB to minimize spinal cord ischemia during TAAA repair, conclusions regarding its role in this setting are difficult to substantiate because of several common limitations, including failure to report data for descending thoracic and TAAAs separately, lack of comparative data for LHB and non-LHB patients, and limited information regarding TAAA extent and the presence of dissection or rupture, which are critical factors in evaluating a study population’s risk of developing P/P [8]. Two recent retrospective comparative studies, however, suggested a potential benefit to using LHB during repair of extensive TAAAs (Table 2). The 1995 study by Bavaria and colleagues [5] found substantial reduction in postoperative P/P in 26 patients who survived operations with LHB; however, statistical significance was not achieved because of the sample size. More recently, Safi and associates [4] found a similar decrease in P/P rates with LHB; this benefit was statistically significant in patients with extent II TAAAs. Unfortunately, both studies also used cerebro-spinal fluid drainage in the LHB groups; therefore, clear conclusions regarding the individual benefits of either adjunct are difficult to support.

The marked reduction in P/P in our extent II patients who had aortic repairs using LHB was achieved despite significantly longer aortic clamp times. Similarly, although LHB did not reduce the P/P rate in extent I patients, the incidence did remain stable despite a significantly longer aortic clamp time in the LHB group. We believe that, by reducing intercostal ischemic time, LHB allows the aorta to be clamped safely for a longer time. This adjunct is especially beneficial in patients with acute dissection or Marfan syndrome, conditions in which a fragile aortic wall requires meticulous suturing to assure hemostasis.

Although this series was retrospective, it found that LHB conferred protection in patients who had repair of extensive TAAAs. Verification of the proposed benefits of LHB as well as other adjuncts will require continuous reevaluation. To optimize such studies, detailed data regarding TAAA extent, rupture, and the presence of acute or chronic dissection should be reported routinely.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
We acknowledge Autumn Jamison for providing database management, statistical analysis, and invaluable assistance with manuscript preparation.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Joseph S. Coselli Scott A. LeMaire Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Coselli, J. S. Articles by LeMaire, S. A. Search for Related Content PubMed PubMed Citation Articles by Coselli, J. S. Articles by LeMaire, S. A.