HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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): Marc A.A.M. Schepens Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Schepens, M. A.A.M. Articles by Boezeman, E. H. Search for Related Content PubMed PubMed Citation Articles by Schepens, M. A.A.M. Articles by Boezeman, E. H.

Ann Thorac Surg 1999;67:1963-1967
© 1999 The Society of Thoracic Surgeons

Impact of left heart bypass on the results of thoracoabdominal aortic aneurysm repair

^a Departments of Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
^b Department of Anesthesiology and Intensive Care, St. Antonius Hospital, Nieuwegein, The Netherlands
^c Department of Clinical Neurophysiology, St. Antonius Hospital, Nieuwegein, the Netherlands

Address reprint requests to Dr Schepens, Department of Cardiothoracic Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands

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

	Abstract

Top Abstract Introduction Patients and methods Results Comment Appendix 1 References

 
Background. This study evaluated the role of left heart bypass on the results of thoracoabdominal aortic aneurysm (TAAA) operations.

Methods. Two hundred fifty-eight patients had surgical repair of a thoracoabdominal aortic aneurysm between 1981 and 1998 using the inlay technique. Simple cross-clamping was used in 47.7% and left heart bypass (atriodistal) in 52.3%. Further surgical technique was identical: liberal intercostal or lumbar artery reimplantation, cerebrospinal fluid drainage (since 1989), administration of a renal cooling solution, permissive mild hypothermia, and no pharmacologic protection. Both univariate and multivariate analysis were used.

Results. The hospital mortality rate was 10.1% overall: 14.6% in the cross-clamp group, and 5.9% in the bypass group (p = 0.02). The risk of hospital death increased with aneurysm rupture (odds ratio 5.6) and when the patient needed postoperative dialysis (odds ratio 7.5). The use of left heart bypass had a mild protective effect on hospital death (odds ratio 0.56). The incidence of postoperative renal failure requiring dialysis was 8.3% overall: 10.9% in the cross-clamp group, and 5.9% in the bypass group (p = 0.16). After multivariate analysis, a longer operative procedure (odds ratio 1.01 per minute) and a longer reappearance time of blue dye in the urine (odds ratio 1.05 per minute) increased the risk of dialysis, whereas the use of atriodistal bypass reduced that risk (odds ratio 0.08). Paraplegia or paraparesis occurred in 10.9% of patients overall: 13.2% in the cross-clamp group, and 8.8% in the bypass group (p = 0.27). After logistic regression, rupture increased the risk of paraplegia or paraparesis (odds ratio 3.2) and dissection reduced it (odds ratio 0.23).

Conclusions. The use of atriodistal bypass is beneficial in patients who had thoracoabdominal aortic aneurysm repair. Hospital mortality rates, postoperative dialysis, and paraplegia/paraparesis were reduced.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Appendix 1 References

 
The surgical repair of thoracoabdominal aortic aneurysms (TAAA) is associated with significant morbidity. Peripheral neurologic deficit, paraplegia or paraparesis (P/P), is the most devastating complication. Paraplegia occurs in 6% to 40%, and kidney failure in 5% to 17% of patients [1, 2]. Most cases in early series were treated without adjuncts, but subsequently surgeons have tried to protect end organs from prolonged ischemic periods. Although various adjuncts initially were used with limited success, recently some objective data have become available that support the use of left heart bypass for this surgical procedure [3–7]. The purpose of this retrospective analysis was to establish whether left heart bypass influenced mortality and morbidity rates after repair of TAAA.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Appendix 1 References

 
Between February 1981 and March 1998, 264 patients had TAAA repair. Six patients were omitted from the analysis because extracorporeal circulation and deep hypothermia were used because of extension of the aneurysm into the aortic arch. Patient ages ranged from 28.8 to 81.9 years (mean, 65.4 years). Aneurysmal extent was classified as described by Crawford [1]. Simple cross-clamping was used in 123 patients (47.7%) and left heart bypass with the Biomedicus pump in 135 (52.3%). Associated preoperative, intraoperative, and postoperative variables are given in Appendix 1.

Our operative technique has been described in detail [8–10]. Before 1987 we used only simple cross-clamping, and since 1987 mainly left heart bypass (except in type IV TAAA). Spinal cord protection consists of liberal reattachment of all patent intercostal/lumbar vessels between T8 and L2. There has been a recent tendency also to reimplant more proximally located vessels [5]. Cerebrospinal fluid (CSF) drainage (using two catheters, one at L3–L4 and another at L4–L5) was introduced in 1989. CSF drainage was used intraoperatively and continued 3 days postoperatively, keeping the CSF pressure at or below 10 mm Hg; the amount of CSF drained was unlimited. Intrathecal papaverine, intravenous naloxone, thiopental, and methylprednisolone were not used. Somatosensory (since 1987) [10] and motor (since 1994) evoked potentials were used in all patients who had elective operations. No patient received intravenous heparin.

Distal aortic perfusion was typically conducted from the left atrium (through the left atrial appendage or in redo surgery through the left upper or lower pulmonary vein) to the left common femoral artery, either directly or using a small piece of 8-mm Dacron prosthesis anastomosed end-to-side to the left common femoral artery. Only occasionally was the left common iliac artery or abdominal aorta used as an inflow port. The Biomedicus centrifugal pump was primed with 500 mL normal saline solution, 5,000 units of heparin, and 100 mL (20%) albumin. All tubing and cannulas were heparin-coated except the heat exchanger. Rectal temperature was allowed to decrease to 32°C to achieve mild hypothermia. In the bypass group, rewarming was started using the built-in heat exchanger after the spinal cord and all abdominal organs were reperfused. The distal aortic clamp was moved down in a sequential fashion to allow continued retrograde perfusion during reattachment of side arteries. For the distal anastomosis, sometimes left heart bypass was stopped and an open anastomosis was done.

When the renal arteries were accessible and included in the aneurysmal segment, renal cooling was administered through patent ostia in both groups (100 mL/minute of 4°C Ringer’s acetate containing 12 g/L mannitol over 3 minutes, repeated every 30 minutes).

All arteries were reimplanted, either individually or together in a patch, directly into the main aortic graft or occasionally through a separate tube graft. When heavy atherosclerosis or calcification made suturing of the vessels hazardous, an endarterectomy of the surrounding aortic wall was done to make suturing safer.

Some essential patient characteristics of the cross-clamp group and the bypass group are listed in Table 1. Of note, the cross-clamp group included a significantly greater proportion of patients with important risk factors for postoperative mortality and morbidity, including atherosclerotic aneurysms, renal insufficiency, and rupture, but significantly fewer patients with more extensive type II aneurysms.

	Results

Top Abstract Introduction Patients and methods Results Comment Appendix 1 References

 
The overall hospital mortality rate was 10.1% (26 of 258): 14.6% (18/123) in the cross-clamp group versus 5.9% (8/135) in the bypass group (p = 0.02). On univariate analysis, the use of simple cross-clamping (p = 0.02), age over 75 years (p = 0.02), preoperative serum creatinine over 200 µmol/L (p = 0.002), a severely reduced left ventricular ejection fraction (p = 0.0002), rupture (p = 0.0001), postoperative dialysis (p = 0.0001), the delayed reappearance of blue dye in the urine (p = 0.03), CSF drainage (p = 0.05), and early reintervention (p = 0.03) were all associated with a higher hospital mortality rate (Appendix). On multivariate analysis, rupture (p = 0.0005, odds ratio 5.6, 95% confidence interval [CI] 2.1 to 14.5) and postoperative dialysis (p = 0.0002, odds ratio 7.5, 95% CI 2.7 to 21.1) were the only variables predictive of hospital death. A beneficial influence of left heart bypass was seen (odds ratio 0.56, 95% CI 0.2 to 1.4) but did not reach significance (p = 0.23, goodness-of-fit ² of the model p = 0.8).

Postoperative dialysis was necessary in 21 of 253 patients (8.3%): 10.9% in the cross-clamp group (13 of 119) and 5.9% in the bypass group (8 of 134, p = 0.16). After univariate analysis, rupture (p = 0.01), age over 75 years (p = 0.03), a longer reappearance time of blue dye in the urine (p = 0.0001), a duration of repair longer than 360 minutes (p = 0.05), no CSF drainage (p = 0.02), and early postoperative reintervention (p = 0.002) were associated with postoperative dialysis. After logistic regression, the longer the reappearance time of blue dye in the urine (p = 0.03, odds ratio 1.05 per minute, 95% CI 1.01 to 1.09), and the longer the duration of repair (p = 0.007, odds ratio 1.01 per minute, 95% CI 1.00 to 1.02), the higher the risk of dialysis. The use of atriodistal bypass significantly reduced the risk of dialysis (p = 0.02, odds ratio 0.08, 95% CI 0.01 to 0.6, goodness-of-fit ² p = 0.55).

Paraplegia or paraparesis (P/P) occurred in 10.9% (28 of 256) overall: 13.2% in the cross-clamp group (16 of 121), and 8.8% in the bypass group (12 of 135, p = 0.27). Only rupture (p = 0.004) and atherosclerotic origin of the aneurysm (p = 0.03) were associated with P/P after univariate analysis. After stepwise logistic regression, rupture (p = 0.01, odds ratio 3.3, 95% CI 1.3 to 8.0) and nondissection as etiology (p = 0.05, odds ratio 0.23, 95% CI 0.05 to 1.0) remained in the predictive model (goodness-of-fit, ² p = 0.7).

Eight hundred six intercostal arteries were reattached in 251 patients with a mean of 3.2 arteries per patient (range, 0 to 14 per patient). The number of vessels that were reimplanted divided by the number of open intercostal or lumbar arteries between T8 and L2 multiplied by 100 was defined as the intercostal/lumbar artery reimplantation index (excluding patients with no open intercostal arteries in that particular segment). This index ranged from 12.5% to 100%, with a mean of 76%. In type I TAAA, the mean index was 79% (range, 16 to 100), 76% in type II (range, 12 to 100), 73% in type III (range, 25 to 100), and 75% in type IV (range, 50 to 100). In postdissection aneurysms, the mean intercostal/lumbar artery reimplantation index was 72.6% (range, 20 to 100), and it was 77% in the atherosclerotic aneurysms (range, 12 to 100). Chronic dissection was present in 60 patients, and acute dissection in only 3. In the patient group with an intercostal/lumbar reimplantation index higher than 50%, the incidence of P/P was 10.9%, versus 17.8% in the patient group with an index lower than 50% (p = 0.3).

	Comment

Top Abstract Introduction Patients and methods Results Comment Appendix 1 References

 
The influence of atriodistal bypass on mortality and morbidity rates after TAAA surgery has been questioned for several years. Only recently has the beneficial impact of this adjunct on surgical results become clear [3–7]. We feel that our data underscore these findings.

It is obvious from our data that patients with type I and II aneurysms have the highest risk for P/P, although the difference is small. This fact is known from the literature. In previous reports, the incidence of P/P for type II aneurysms has ranged from 9% to 31% [7]. The incidence in this particular group using a multimodality approach (atriodistal bypass, unlimited CSF drainage, and aggressive reattachment of intercostal and lumbar vessels) was 9.1%. If we apply the highly predictive model of Acher [11] (correlation coefficient = 0.997) to our total patient group, the calculated incidence of P/P is 66.2%. The predicted incidence of P/P in the bypass group is 42%, and 24.5% in the cross-clamp group, whereas our results were 8.8% and 13.2%, respectively. If we consider type I and II aneurysms together, the incidence of P/P was 12.6%, whereas the model of Acher predicted 52.4%.

The finding that chronic dissection is a protective factor for P/P is surprising, because most previous reports have shown the contrary. However, the positive association between P/P and chronic dissection had already been disproved by us [9] and recently also by Coselli [3] in a much larger patient group. Acute dissection represents only a minority of patients in the present series, but we believe that acute dissection certainly increases the risk for P/P, which is also influenced by impending rupture.

The benefits of intercostal or lumbar artery reimplantation seem apparent [3, 5, 12]. The difference between the incidence of P/P in the patient group with an intercostal/lumbar artery reimplantation index higher (10.9%) or lower (17.8%) than 50% did not reach statistical significance, however. We still recommend reimplantation of all patent vessels between T8 and L2, and, in addition, more proximally located vessels, because they might be important in the prevention of delayed-onset paraplegia [5].

The association of a longer total aortic cross-clamp time and a higher incidence of P/P did not emerge from our data, which support the findings of Coselli [3], that a decreased incidence of P/P can be achieved despite longer aortic cross-clamp times. Future better and more sophisticated biochemical [13, 14] and neurophysiologic [10, 15] intraoperative monitoring might help us further reduce the incidence of P/P.

Our findings underscore that postoperative dialysis has severe repercussions on outcome, because 38.1% (8 of 21) of the patients who needed dialysis died in the hospital. A further reduction in the incidence of this complication will continue to improve perioperative and long-term results. The reappearance of blue dye in the urine after reperfusion of the kidneys is a reflection of renal damage caused by ischemia and reperfusion. Limitation of the total duration of the repair also seems to be important in preventing renal injury requiring dialysis. Use of atriodistal bypass combined with sequential clamping will reduce renal ischemic time, and this was also found this to be an independent predictor of renal failure in a large series of 1,509 patients [16]

The present study clearly points to a significant benefit of distal arterial perfusion on morbidity from renal failure in thoracoabdominal aortic aneurysm operations and shows a favorable, although not statistically significant, influence on mortality rate and spinal cord complications.

	Appendix 1

Top Abstract Introduction Patients and methods Results Comment Appendix 1 References

 
Univariate analysis of the association between preoperative, intraoperative, and postoperative variables and hospital mortality rate, incidence of paraplegia or paraparesis, and dialysis

Variable No. Hospital Mortality Paraplegia/Paraparesisa Dialysisb No. % Odds Ratio p No. % Odds Ratio p No. % Odds Ratio p Sex Male 190 18 9.5 1 0.591 21 11.1 1 0.843 17 9.1 1 0.421 Female 68 8 11.7 1.3 7 10.3 0.9 4 5.9 0.6 Age (y) 75 233 20 8.6 1 0.015 28 12.1 1 0.066 16 7 1 0.026 > 75 25 6 24 3.3 0 0 0 5 20 3.3 Rupture Yes 38 12 31.6 3.5 0.0001 9 25 3.5 0.004 7 18.4 3.2 0.014 No 220 26 11.8 1 19 8.6 1 14 6.5 1 COPDc Yes 50 7 14 1.5 0.358 6 12 1.1 0.787 6 12.5 1.7 0.284 No 199 19 9.5 1 21 10.6 1 15 7.6 1 Preoperative serum creatinine (µmol/L) 200 243 21 8.6 1 0.002 28 11.6 1 0.178 19 7.8 1 0.225 > 200 15 5 33.3 5.3 0 0 0 2 18.2 2.6 Arterial hypertensionc Yes 198 18 9.1 0.6 0.327 21 10.7 0.9 0.831 14 6.1 2.5 0.128 No 51 7 13.7 1 6 11.7 1 7 14 1 Previous aortic surgery Yes 100 8 8 0.7 0.379 8 8.8 0.63 0.200 6 6.1 0.6 0.319 No 158 18 11.4 1 20 13.3 1 15 9.6 1 Preoperative stroke Yes 32 5 15.6 1.8 0.266 2 6.2 0.5 0.365 3 10 1.3 0.720 No 226 21 9.3 1 26 11.6 1 18 8.1 1 Etiology Dissection 63 7 11.1 1.1 0.754 2 3.2 0.2 0.026 5 8.1 0.9 0.938 Atherosclerosis 195 19 9.7 1 26 13.4 1 16 8.4 1 Left ventricular ejection fractiond Normal 196 14 7.1 1 0.0002 20 10.3 1 0.362 13 6.7 1 0.119 Moderately decreased 43 9 21 3.4 6 13.9 1.4 7 9.7 1.5 Severely decreased 12 3 25 4.3 2 16.6 1.7 1 9.1 1.4 Operative technique CC 123 18 14.6 1 0.021 16 13.2 1 0.268 13 10.9 1 0.155 BIO 135 8 5.9 0.36 12 8.8 0.6 8 5.9 0.5 Type TAAA I 39 1 2.5 1 0.304 5 12.8 1 0.257 3 7.7 1 0.638 II 112 11 9.8 4.2 14 12.5 0.9 9 8.1 1.1 III 71 12 16.9 7.9 7 10.1 0.7 5 7.2 0.9 IV 36 2 5.5 2.2 2 5.5 0.4 4 11.7 1.6 Renal coolinga Yes 212 21 9.9 1 0.771 22 10.4 1 0.529 19 9.0 1 0.379 No 44 5 11.4 1.2 6 13.6 1.3 2 4.8 0.5 Reappearance time of blue dye in the urinee (min) 30 143 11 7.7 1 0.025 16 11.2 1 0.876 4 2.8 1 0.0001 > 30 16 4 25 3.9 2 12.5 1.1 5 33.3 1.7 Intercostal/lumbar artery reimplantation indexf (%) 50 41 5 12.2 1.4 0.494 7 17.1 1.6 0.359 2 5.0 0.8 0.848 > 50 139 12 8.6 1 16 11.6 1 8 5.8 1 Total aortic clamp timeg (min) < 60 20 3 15 1 0.063 3 15 1 0.217 1 5.5 1 0.752 60–120 68 9 13.2 0.86 12 17.6 1.2 5 7.3 1.35 > 120 95 5 5.2 0.31 9 9.5 0.6 5 5.2 0.9 Total duration of the repair (min) 360 146 13 8.9 1 0.641 18 12.3 1 0.520 8 5.6 1 0.046 > 360 103 11 10.7 1.2 10 9.7 0.7 13 12.8 2.5 CSF drainage Yes 95 5 5.2 1 0.05 7 7.4 1 0.170 3 3.2 1 0.024 No 163 21 12.8 2.6 21 12.9 1.8 18 11.3 3.8 Paraplegia/paraparesisa Yes 232 26 11.2 1 0.586 — — — — 19 8.4 1 0.814 No 26 2 7.7 0.6 — — — — 2 7.1 0.8 Dialysisb No 232 16 6.9 1 0.0001 26 11.2 1 0.814 — — — — Yes 21 8 38.1 8.3 2 9.5 0.8 — — — — Early reintervention No 231 18 7.8 1 0.034 24 10.4 1 0.750 15 6.6 1 0.002 Yes 24 5 20.8 3.1 3 12.5 1.2 6 25 4.7

^a Excludes intraoperative deaths (n = 2).

^b Excludes patients on preoperative chronic dialysis (n = 6).

^c Data missing for 9 patients.

^d Data missing for 7 patients.

^e Data available for 159 patients.

^f Data available for 180 patients.

^g Data available for 183 patients.

COPD = chronic obstructive pulmonary disease; CSF = cerebrospinal fluid drainage.

	References

Top Abstract Introduction Patients and methods Results Comment Appendix 1 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. Livesay J.J., Cooley D.A., Ventemiglia R.A., et al. Surgical experience in descending thoracic aneurysmectomy with and without adjuncts to avoid ischemia. Ann Thorac Surg 1985;39:37-46.[Abstract]
3. Coselli J.S., LeMaire S.A., de Figueiredo L.P., Kirby R.P. Paraplegia after thoracoabdominal aortic repair: is dissection a risk factor?. Ann Thorac Surg 1997;63:28-36.[Abstract/Free Full Text]
4. 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]
5. Safi H.J., Miller C.C., Carr C., Iliopoulos D.C., et al. Importance of intercostal artery reattachment during thoracoabdominal aortic aneurysm repair. J Vasc Surg 1998;27:58-68.[Medline]
6. Safi H.J., Miller C.C., Yawn D.H., et al. Impact of distal aortic and visceral perfusion on liver function during thoracoabdominal and descending thoracic aortic repair. J Vasc Surg 1998;27:145-153.[Medline]
7. 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]
8. Schepens M.A., Defauw J.J., Hamerlijnck R.P., et al. Surgical treatment of thoracoabdominal aortic aneurysms by simple cross-clamping. J Thorac Cardiovasc Surg 1994;107:134-142.[Abstract/Free Full Text]
9. Schepens M.A., Defauw J.J., Hamerlijnck R.P., Vermeulen F.E. Use of a left heart bypass in the surgical repair of thoracoabdominal aortic aneurysms. Ann Vasc Surg 1995;9:327-338.[Medline]
10. Schepens M.A., Boezeman E.H., Hamerlijnck R.P., et al. Somatosensory evoked potentials during exclusion and reperfusion of critical aortic segments in thoracoabdominal aortic aneurysm surgery. J Cardiac Surg 1994;9:692-702.[Medline]
11. Acher C.W., Wynn M.M., Hoch J.R., et al. Combined use of cerebral spinal fluid drainage and naloxone reduces the risk of paraplegia in thoracoabdominal aneurysm repair. J Vasc Surg 1994;19:236-248.[Medline]
12. Svensson L.G., Hess K.R., Coselli J.S., Safi H.J. Influence of segmental arteries, extent, and atriofemoral bypass on postoperative paraplegia after thoracoabdominal aortic operations. J Vasc Surg 1994;20:255-262.[Medline]
13. Brock M.V., Redmond M., Ishiwa S., et al. Clinical markers in CSF for determining neurologic deficits after thoracoabdominal aortic aneurysm repairs. Ann Thorac Surg 1997;64:999-1003.[Abstract/Free Full Text]
14. Van Dongen E.P., Ter Beek H.T., Boezeman E.H., et al. Normal serum concentrations of S-100 protein and changes in cerebrospinal fluid concentrations of S-100 protein during and after thoracoabdominal aortic aneurysm surgery: is S-100 protein a biochemical marker of clinical value in detecting spinal cord ischemia?. J Vasc Surg 1998;27:344-346.[Medline]
15. De Haan P., Kalkman C.J., de Mol B.A., et al. Efficacy of transcranial motor-evoked myogenic potentials to detect spinal cord ischemia during operations for thoracoabdominal aneurysms. J Thorac Cardiovasc Surg 1997;113:87-101.[Abstract/Free Full Text]
16. Svensson L.G., Crawford E.S., Hess K.R., et al. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg 1993;17:367-367.

This article has been cited by other articles:

				Y. Kawanishi, K. Okada, M. Matsumori, H. Tanaka, T. Yamashita, K. Nakagiri, and Y. Okita Influence of Perioperative Hemodynamics on Spinal Cord Ischemia in Thoracoabdominal Aortic Repair Ann. Thorac. Surg., August 1, 2007; 84(2): 488 - 492. [Abstract] [Full Text] [PDF]

				L. K. von Segesser Perfusion techniques during surgery of the thoracic and thoraco-abdominal aorta: the veno-arterial bypass MMCTS, June 19, 2007; 2007(0619): 2535. [Abstract] [Full Text] [PDF]

				Y. Kawanishi, K. Okada, H. Tanaka, T. Yamashita, K. Nakagiri, and Y. Okita The adverse effect of back-bleeding from lumbar arteries on spinal cord pathophysiology in a rabbit model J. Thorac. Cardiovasc. Surg., June 1, 2007; 133(6): 1553 - 1558. [Abstract] [Full Text] [PDF]

				Y. Kawanishi, H. Munakata, M. Matsumori, H. Tanaka, T. Yamashita, K. Nakagiri, K. Okada, and Y. Okita Usefulness of Transcranial Motor Evoked Potentials During Thoracoabdominal Aortic Surgery Ann. Thorac. Surg., February 1, 2007; 83(2): 456 - 461. [Abstract] [Full Text] [PDF]

				A. Kaya, R. H. Heijmen, T. Th. Overtoom, J.-A. Vos, W. J. Morshuis, and M. A. Schepens Thoracic Stent Grafting for Acute Aortic Pathology Ann. Thorac. Surg., August 1, 2006; 82(2): 560 - 565. [Abstract] [Full Text] [PDF]

				P. W.G. Elbers, P. de Haan, I. Vanicky, D. Legemate, and M. Dzoljic Effect of Temporary Visceral Ischemia on Spinal Cord Ischemic Damage in the Rabbit Ann. Thorac. Surg., March 1, 2006; 81(3): 910 - 917. [Abstract] [Full Text] [PDF]

				S. Martin-Suarez, A. Dell'Amore, D. Pacini, E. Angeli, A. Loforte, G. Oppido, and R. Di Bartolomeo Saccular Aneurysm at the Aortic Isthmus Ann. Thorac. Surg., August 1, 2005; 80(2): 744 - 744. [Full Text] [PDF]

				R. G. MacArthur, S. A. Carter, J. S. Coselli, and S. A. LeMaire Organ Protection During Thoracoabdominal Aortic Surgery: Rationale for a Multimodality Approach Seminars in Cardiothoracic and Vascular Anesthesia, June 1, 2005; 9(2): 143 - 149. [Abstract] [PDF]

				D. Kalavrouziotis, R. J.F. Baskett, and J. A.P. Sullivan Pulmonary artery to distal bypass for surgery on the descending thoracic aorta Interactive CardioVascular and Thoracic Surgery, June 1, 2005; 4(3): 170 - 172. [Abstract] [Full Text] [PDF]

				M. Schepens, K. Dossche, W. Morshuis, R. Heijmen, E. van Dongen, H. ter Beek, H. Kelder, and E. Boezeman Introduction of adjuncts and their influence on changing results in 402 consecutive thoracoabdominal aortic aneurysm repairs Eur. J. Cardiothorac. Surg., May 1, 2004; 25(5): 701 - 707. [Abstract] [Full Text] [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]

				T. Wada, H. Yao, T. Miyamoto, S. Mukai, and M. Yamamura Prevention and detection of spinal cord injury during thoracic and thoracoabdominal aortic repairs Ann. Thorac. Surg., July 1, 2001; 72(1): 80 - 84. [Abstract] [Full Text] [PDF]

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): Marc A.A.M. Schepens Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Schepens, M. A.A.M. Articles by Boezeman, E. H. Search for Related Content PubMed PubMed Citation Articles by Schepens, M. A.A.M. Articles by Boezeman, E. H.