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Ann Thorac Surg 2001;72:481-486
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Descending thoracic aortic aneurysm: surgical approach and treatment using the adjuncts cerebrospinal fluid drainage and distal aortic perfusion

^a Department of Cardiothoracic and Vascular Surgery, The University of Texas at Houston Medical School, Memorial Hermann Hospital, Houston, Texas, USA

Address reprint requests to Dr Safi, Department of Cardiothoracic and Vascular Surgery, UTH Medical Center, 6410 Fannin St, Suite 450, Houston, TX 77030
e-mail: hazim.i.safi{at}uth.tmc.edu

Presented at the Forty-seventh Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 9–11, 2000.

	Abstract

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Background. Neurologic deficit (paraplegia or paraparesis) remains a significant morbidity in the repair of descending thoracic aortic aneurysm.

Methods. Between February 1991 and February 2000, we operated on 182 patients for descending thoracic aortic aneurysm. For the purpose of this study—to identify the impact of the combined adjuncts distal aortic perfusion and cerebrospinal fluid (CSF) drainage on neurologic outcome—we selected the 148 of 182 nonemergent patients who had received conventional treatment (simple cross-clamping with or without adjuncts). The mean patient age was 61 years, and 49 of the 148 (33%) patients were women. Nine of the 148 patients (6%) had acute type B dissections. We compared the results of 105 of the 148 patients (71%) who received the combined adjuncts of CSF drainage and distal aortic perfusion with the remaining 43 (29%) patients who underwent repair using the simple cross-clamp with or without the addition of a single adjunct.

Results. Overall 30-day mortality was 13 of 148 patients (8.8%). Overall early neurologic deficit was 4 of 148 (2.7%): 1 of 105 (0.9%) patients who had received distal aortic perfusion and CSF drainage, versus 3 of 43 (7%) in all other patients (p < 0.04).

Conclusions. In our practice the use of the combined adjuncts of CSF drainage and distal aortic perfusion has all but eliminated the incidence of immediate postoperative neurologic deficit in nonemergent patients with aneurysms of the descending thoracic aorta.

	Introduction

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Repair of descending thoracic aortic aneurysms remains a surgical challenge. Since inception of repair techniques, the need for spinal cord protection has been of paramount importance. Although surgical adjuncts, such as the Gott shunt and distal aortic perfusion, were used in the earlier days of descending thoracic aortic aneurysm repair, these adjuncts were often reported to have either little effect on spinal cord protection [1–3] or adverse effects on survival [4]. Emphasis was placed on the speed with which operations were completed. This emphasis created a dilemma in carrying out an operation that often requires more than 30 minutes, because that is the time generally accepted as the margin for spinal cord safety. The incidence of neurologic deficit from the 1970s into the 1980s was reported at 3% to 10% [3].

Today the incidence of neurologic deficit has dropped significantly. Surgeons currently disagree over which particular adjunct provides superior spinal cord protection, but the general consensus is that adjuncts are necessary and may be the reason for the decline in neurologic complications [5–9]. In our practice we have noted the greatest degree of success with the combination of cerebrospinal fluid (CSF) drainage and distal aortic perfusion. This was first demonstrated in thoracoabdominal aortic aneurysm repair [10] and later in descending thoracic aortic aneurysm operations [11]. Intercostal artery reimplantation and moderate hypothermia have also played significant roles [12]. The purpose of this study was to examine the significant factors in the prevention of neurologic deficit during nonemergent repair of descending thoracic aortic aneurysms with the combination of the adjuncts distal aortic perfusion and CSF drainage.

	Material and methods

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Patients
Between February 1991 and February 2000, 182 patients underwent graft repair of descending thoracic aortic aneurysms. We excluded from this study 26 (12.6%) of 182 patients who had involvement of the transverse aortic arch that precluded placement of a proximal clamp and who were treated using profound hypothermic circulatory arrest. Emergent patients had either free or contained rupture and were hemodynamically unstable, and all underwent simple cross-clamp repair. Consequently, 8 emergent patients were also excluded from analysis, as their inclusion in the comparison group would have created an immediate bias.

The 148 patients who underwent nonemergent repair of descending thoracic aortic aneurysms were analyzed with respect to the impact of adjuncts. Patient characteristics at the time of repair are listed in Table 1. There were 99 men (67%) and 49 women (33%). Patient age ranged from 8 to 85 years (mean 61 years). One hundred five patients received the spinal cord adjuncts of distal aortic perfusion and CSF drainage described below. The remaining 43 patients were operated on with simple cross-clamp alone (11 patients) or received the single adjunct of either distal aortic perfusion (28 patients) or CSF drainage (4 patients).

View larger version (18K): [in this window] [in a new window]   Fig 1. Cerebrospinal fluid catheter insertion. Cerebrospinal pressure was maintained at less than 10 mm Hg.

View larger version (41K): [in this window] [in a new window]   Fig 2. Distal aortic perfusion through the left common femoral artery and left superior pulmonary vein.

Once adequate hemostasis was obtained, an appropriately sized, woven Dacron tube graft was anastomosed to the proximal aorta with a running polypropylene suture. If patent intercostal arteries were to be reattached, the graft was cut in a beveled fashion and the distal anastomosis completed. Reimplantation of patent, lower intercostal arteries (T8 to T12) was performed routinely except in cases of acute dissection or when technically impossible. The distal anastomosis was then performed with the graft flushed just before its completion. The aortic clamps were slowly removed and suture lines checked for hemostasis. The patient was weaned from bypass once the rectal temperature reached 36°C. Intravenous protamine was administered to reverse the effect of the heparin and the atrial and femoral cannulas were removed.

Postoperatively, the mean arterial pressure was maintained between 80 and 100 mm Hg. Cerebrospinal fluid was drained no more than 20 mL/hour to maintain a CSF pressure of less than 10 mm Hg for 3 days. If a delayed neurologic deficit appeared after removal of the drain, a new CSF drain was reinserted immediately to decrease the CSF pressure, a practice that may lead to prompt resolution of the neurologic deficit [13].

Outcome variables and statistical analysis
Descending thoracic aortic aneurysms were classified according to Figure 3. Type A descending thoracic aortic aneurysms (left subclavian artery to T6) were repaired in 42 patients (28.4%), type B (T6 to the diaphragm) in 24 patients (16.2%), and type C (left subclavian artery to the diaphragm) in 82 patients (55.4%). Aneurysms with dissection were considered acute if an operation was performed in less than 14 days from the onset of pain, and chronic if after 14 days. Postoperative neurologic deficit was defined as paraplegia or paraparesis observed upon the patient awakening from anesthesia, regardless of severity. Those patients who developed paraplegia or paraparesis after a period of normal neurologic function were classified as having had a delayed neurologic deficit. Patients who sustained cerebral infarction identified by a thorough neurologic examination and computed tomographic scan of the head, were excluded from the neurologic deficit group. Operative mortality was defined as death occurring within 30 days of an operation.

View larger version (41K): [in this window] [in a new window]   Fig 3. Descending thoracic aortic aneurysms are classified as type A, left subclavian artery to T6 (A); type B, T6 to the diaphragm (B); or type C, left subclavian artery to the diaphragm (C).

	Results

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The 30-day mortality for elective repair of the descending thoracic aortic aneurysm was 8.8% (13 of 148 patients). The 30-day mortality for emergent repair was 25%. Age, aortic dissection, and aortic clamp time were not significant with regard to neurologic deficit (Table 1). The incidence of cerebral vascular accident for repair of descending thoracic aneurysms was 2.7%, and renal failure was 7.2%.

The overall rate of neurologic deficit was 2.7% (4 of 148 patients). There were no cases of neurologic deficit in aneurysm types A or B. All 4 patients with neurologic deficit had aneurysms of the entire descending thoracic aorta classified as type C (p = 0.7). The rate of immediate neurologic deficit was 0.9% (1 of 105 patients) in those patients whose aneurysms were repaired using the combination of distal aortic perfusion and CSF drainage versus 7.0% (3 of 43 patients) in the comparison group (p < 0.04). Within the comparison group, two cases of neurologic deficit were observed in patients who received distal aortic perfusion (2 of 28 patients), and one case in a patient who underwent simple clamp and sew technique alone (1 of 11 patients). No cases of neurologic deficit were observed in the 4 patients who received CSF drainage alone. Two cases of delayed neurologic deficit were observed, one in the combined adjunct group and one in the comparison group (p = NS).

Intercostal artery reattachment was performed in 59 cases (40.1%), but did not demonstrate a benefit for protection against neurologic deficit (p = 0.55). The aortic cross-clamp periods for each aneurysm type (A, B, C) were 33, 27, and 33 minutes, respectively (p = NS).

	Comment

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Neither distal aortic perfusion nor CSF drainage used individually proved to be exceptionally effective in the previous era of descending thoracic aortic aneurysm repair [14, 15]. More contemporary series, however, have demonstrated the benefit of these adjuncts on the incidence of neurologic deficit [16–18].

We believe that the combination of these two adjuncts may provide significant spinal cord protection. This defense against spinal cord ischemia is achieved during aortic cross-clamping by creating a balance between decreased distal aortic pressure and increased CSF pressure [11, 19]. Specifically, the decrease in distal aortic pressure causes a decrease in the spinal artery pressure. A concomitant rise in CSF pressure can lead to "spinal cord compartment syndrome" [20], resulting in further spinal cord ischemia. By draining the excess CSF, pressure is reduced, relieving the compartment syndrome and augmenting perfusion to the spinal cord (Fig 4). At the same time, distal aortic perfusion increases the distal aortic pressure and increases perfusion pressure of the spinal cord [21].

View larger version (27K): [in this window] [in a new window]   Fig 4. (A) Dynamics of aortic cross-clamp: cerebrospinal fluid (CSF) pressure increases and distal aortic (DAo) pressure decreases. (B) Dynamics of aortic cross-clamp with adjuncts: CSF pressure decreases and DAo pressure increases, thus increasing perfusion pressure of the spinal cord.

Although neurologic deficit has been directly linked to the aortic ischemic period in the simple cross-clamp technique, we found no correlation in the current series between aortic cross-clamp time and neurologic deficit; two neurologic deficits were noted in patients with cross-clamp times longer than 30 minutes and two in patients with aortic cross-clamp times of less than 30 minutes (p = 0.62). In the analysis by Safi and coworkers [21], distal aortic perfusion was shown to negate the effect of more than 40 minutes of aortic cross-clamp time on neurologic deficit. Similar to this previous series, the use of the combined adjuncts appears to negate the effect of prolonged ischemic time.

Reattachment of the lower (T8 to T12) intercostal arteries was previously shown to reduce the risk of neurologic deficits during thoracoabdominal aortic aneurysm repair [12]. Although we emphasize the importance of intercostal artery reattachment in descending thoracic aortic repair, its significance to spinal cord protection was inconclusive (p = 0.55). This finding may have been due to the low number of patients who had intercostal artery reattachment (40.1%).

Limitations of this study included the retrospective nature of the analysis. In addition, the method selection was nonrandomized. Although the overall number of neurologic deficits was small, the advantage of distal aortic perfusion and CSF drainage may prove to be more evident in a future larger series.

The use of the combined adjuncts of distal aortic perfusion and CSF drainage was performed safely and significantly reduced the rate of neurologic deficit during nonemergent repair of descending thoracic aortic aneurysms. Because classification of descending thoracic aortic aneurysms may have prognostic significance, future studies reporting outcomes of repair should include this classification scheme for risk analysis and accurate reporting.

	Acknowledgments

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We thank Amy Wirtz Newland for her editorial assistance.

	Discussion

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DR DARRYL S. WEIMAN (Memphis, TN): I would like to ask, when you use left atrial to femoral bypass, how much heparin do you give in the circuit?

DR ESTRERA: We give 1 mg/kg

DR WEIMAN: Some people are not using any heparin.

DR ESTRERA: That is correct. Since 1995, Dr Safi has been using moderate heparinization, since he has had some cases in which the circuit thrombosed. In general, circuit flows between 800 and 1,800 cc/minute are utilized during left atrial to femoral bypass. In some situations, however, circuit flows may decrease, and thus flows of less than 500 cc/minute are more of a concern for thrombosis.

DR CHARLES WILLEKES (Muskegon, MI): A very nice paper. I have two questions. First, when you set up partial left heart bypass, when do you make your decision to go on total bypass if you cannot place a proximal clamp? Second, you say that you use only two adjuncts, yet you reattach intercostal arteries T8 to T12; do you not consider intercostal reattachment as another adjunct?

DR ESTRERA: We do consider intercostal artery reattachment an adjunct. But in this study, we evaluated 148 patients and we compared only the combined adjuncts of distal aortic perfusion and cerebrospinal fluid drainage with no combined adjuncts. Intercostal artery reattachment was used in both groups, but was performed only in 40% of the cases. Remember that not all cases required reattachment, therefore the numbers were relatively small. Thus, possibly because of the relatively low number of intercostal reattachments, this was not significant. Dr Safi, however, has previously shown with thoracoabdominal aortic aneurysms that intercostal artery reattachment was significant.

The decision to utilize total cardiopulmonary bypass when we cannot place a proximal clamp is made at the time of opening the chest. For us, it is simple to add a venous cannula in the left groin, if need be.

	References

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