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Ann Thorac Surg 1999;67:1937-1939
© 1999 The Society of Thoracic Surgeons

Spinal cord protection in descending thoracic and thoracoabdominal aortic repair

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

Address reprint requests to Dr Safi, Baylor College of Medicine, The Methodist Hospital, 6550 Fannin, Suite 1603, Houston, TX 77030;
e-mail: hsafi{at}bcm.tmc.edu

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

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. During simple cross-clamp repair of the descending thoracic or thoracoabdominal aorta, the likelihood of neurologic complications increases greatly after only 30 minutes of spinal cord ischemia. At greatest risk are patients with type II thoracoabdominal aortic aneurysms.

Methods. We reviewed our experience of simple cross-clamp repair and procedures accompanied by adjuncts, paying particular attention to the outcome of patients who had type II thoracoabdominal aortic aneurysms. Between February 1991 and March 1998, 508 patients had descending thoracic and thoracoabdominal aortic repair, 255 (50.2%) of whom received the adjuncts of cerebrospinal fluid drainage and distal aortic perfusion.

Results. Fifteen patients died on the day of operation and could not be evaluated for neurologic deficit. The overall incidence of neurologic deficit was 33 of 493 patients (6.7%). In patients who received adjuncts, neurologic deficit occurred in 9 of 247 (3.6%) overall; in types I and II it was 8 of 164 (4.9%), and in type II alone, 7 of 87 (8.1%). Neurologic deficit in simple cross-clamp patients was 24 of 246 (9.8%) overall; in types I and II it was 15 of 99 (15.2%), and in type II alone, 13 of 44 (29.6%).

Conclusions. With the surgical adjuncts of cerebrospinal fluid drainage and distal aortic perfusion, the probability of neurologic deficit is lowered appreciably.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
In 1986, Crawford and associates [1], recognizing the correlation between aneurysm extent and patient outcome, defined four significant types of thoracoabdominal aortic aneurysm (TAAA). This classification system has been used in statistical analyses in the ensuing 12 years, and studies have repeatedly found that having a type II TAAA is the most important single risk factor for neurologic deficit [1–9]. In our previous experience, patients with type II TAAA were approximately five times more likely to have postoperative neurologic deficit than patients with other types of aneurysms (p < 0.001). In multivariate analyses, which separate the effects of type II aneurysms from other risk factors mathematically, we found independent odds of developing neurologic deficit to be as high as 15:1 (p < 0.0001) [4].

Aneurysms extending from the sixth intercostal space to above the renal arteries are most often labeled type I, but on occasion type II according to the original Crawford classification. Designating aneurysms of this region of the thoracoabdominal aorta as type V (Fig 1) will help us to further refine the analysis of study results and possibly shed new light on the cause of neurologic complications as well as the success or failure of surgical adjuncts.

View larger version (45K): [in this window] [in a new window]   Fig 1. Thoracoabdominal aortic aneurysm classification. Type I, from below the left subclavian artery to above the celiac axis, or opposite the superior mesenteric and above the renal arteries. Type II, from below the left subclavian and including the infrarenal abdominal aorta to the level of the aortic bifurcation. Type III, from the sixth intercostal space tapering to just above the infrarenal abdominal aorta to the iliac bifurcation. Type IV, from the 12th intercostal space, tapering to above the iliac bifurcation. Type V, from the sixth intercostal space, tapering to just above the renal arteries.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

Between February 1991 and March 1998, we operated on 508 patients for descending thoracic or thoracoabdominal aortic repair. We reviewed our experience before 1992 using simple cross-clamp repair and compared it with operation accompanied by adjuncts after 1992, paying particular attention to the outcome of patients with type II TAAA. Fifteen patients died on the day of operation and could not be evaluated for neurologic deficit. There were 315 men (63.9%) and 178 women. Median age was 67 years (range, 8 to 88 years). Among these patients, hypertension was the most prevalent of associated diseases, occurring in 363 of 493 of the patients (73.6%). Of 247 (50.1%) patients who had adjunct procedures, (35.2%) had highest risk type II TAAA.

The patient characteristics of the simple cross-clamp patients treated before 1992 were generally similar to that of adjunct patients, with the following significant exceptions: fewer women had adjunct procedures (31.2% versus 41.1%, p < 0.03); more chronic dissection occurred in patients who had adjunct procedures (35.0% versus 15.9%, p < 0.001); and more patients who had adjunct procedures had type II TAAA (35.2% versus 17.9%, p < 0.001).

	Results

Top Abstract Introduction Material and methods Results Comment References

 
The incidence of neurologic deficit in the entire group of patients was 33 of 493 (6.7%). Before 1992, and using only simple cross-clamping, the overall incidence of neurologic complications was 24 of 246 patients (9.8%). In contrast, neurologic deficit occurred in 9 of 247 patients (3.6%, p < 0.007) since 1992. Table 1 shows the significant differences in outcome for adjunct versus simple cross-clamp patients. Additionally, 15 of 493 (3%) cases of delayed-onset neurologic deficit occurred overall. This outcome did not appear to be affected by adjunct use (4.5% adjunct versus 1.7% cross-clamp, p > 0.05).

	Comment

Top Abstract Introduction Material and methods Results Comment References

We have also examined the protective qualities of the adjuncts in patients who had more than 45 minutes of cross-clamp time [11]. In that study we again found positive results using adjuncts, with the most significant improvement in outcome in patients with type II TAAA. In the current series, female gender, chronic dissection, and type II TAAA tended to increase risk of neurologic deficit. Nonetheless, the adjunct group fared far better than the cross-clamp group.

Before the introduction of distal aortic perfusion and cerebrospinal fluid drainage, the speed of the operation was directly linked to the probability of a good outcome: cross-clamp time was the critical variable. Cerebrospinal fluid drainage and distal aortic perfusion diminish the significance of cross-clamp time and decrease the incidence of neurologic deficit. The effectiveness of these adjuncts is most striking in patients at highest risk, ie, those with type II TAAA. By using these modalities, proximal anastomosis and reattachment of intercostal and visceral arteries can proceed without haste. We believe that reimplantation of intercostal arteries 8 through 12 is of utmost importance to prevent early and late paraplegia and to increase long-term survival [12]. Spinal cord ischemia, however, continues to pose a great risk to the patient. Ongoing research, best communicated by clear data and a universally used system of aneurysm classification, is critical for continued improvement in aortic repair.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Crawford E.S., Crawford J.L., Safi H.J., et al. Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients. J Vasc Surg 1986;3:389-404.[Medline]
2. 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]
3. Safi H.J., Hess K.R., Randel M., et al. Cerebrospinal fluid drainage and distal aortic perfusion: reducing neurologic complications in repair of thoracoabdominal aortic aneurysm types I and II. J Vasc Surg 1996;23:223-229.[Medline]
4. Safi H.J., Campbell M.P., Miller C.C., III, et al. Cerebral spinal fluid drainage and distal aortic perfusion decrease the incidence of neurological deficit: the results of 343 descending and thoracoabdominal aortic aneurysm repairs. Eur J Vasc Endovasc Sur 1997;13:1-7.
5. Svensson L.G., Crawford E.S., Hess K.R., et al. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg 1993;17:357-370.[Medline]
6. Hollier L.H., Money S.R., Naslund T.C., et al. Risk of spinal cord dysfunction in patients undergoing thoracoabdominal aortic replacement. Am J Surg 1992;164:210-213.[Medline]
7. Schepens M.A.A.M., Defauw J.J.A.M., Hamerlijnck R.P.H.M., et al. Surgical treatment of thoracoabdominal aortic aneurysms by simple cross clamping. J Thorac Cardiovasc Surg 1994;107:134-142.[Abstract/Free Full Text]
8. Coselli J.S. Thoracoabdominal aortic aneurysms: experience with 372 patients. J Card Surg 1994;9:638-647.[Medline]
9. Cox G.S., O’Hara P.J., Hertzer N.R., et al. Thoracoabdominal aneurysm repair: a representative experience. J Vasc Surg 1992;15:780-788.[Medline]
10. Kouchoukos N.T., Lell W.A., Karp R.B., et al. Hemodynamic effects of aortic clamping and decompression with a temporary shunt for resection of the descending thoracic aorta. Surgery 1979;85:25-30.[Medline]
11. Safi H.J., Miller C.C., III, Vinnerkvist A., et al. Effect of extended cross-clamp time during thoracoabdominal aortic aneurysm repair. Ann Thor Surg 1998;66:1204-1209.[Abstract/Free Full Text]
12. Safi H.J., Miller C.C., III, Carr C., et al. The importance of intercostal artery reattachment during thoracoabdominal aortic aneurysm repair. J Vasc Surg 1998;27:58-68.[Medline]

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