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Ann Thorac Surg 2001;72:486
© 2001 The Society of Thoracic Surgeons
a Department of Thoracic Surgery, Hospital of the University of Pennsylvania, 6 Silverstein, 3400 Spruce St, Philadelphia, PA 19104, USA
This paper documents the results of 148 patients operated on for thoracic (ie, not thoracoabdominal aneurysms) aneurysms between February 1991 and February 2000. This study excluded all emergency procedures requiring an open proximal aortic arch, or hypothermic technique, or the inability to place a proximal cross-clamp. This is a fairly straightforward and simple retrospective study.
The fundamental findings corroborate the relentless findings by most groups this decade performing thoracic aortic surgery, namely that the addition of distal aortic perfusion with cerebrospinal fluid (CSF) drainage has more spinal cord protection than a straight cross-clamp or any single adjunct alone. However, the series presented by Borst and colleagues1 showed similar results with LA-FA bypass alone (mortality 3%, paraplegia 2.3%).
The only statistically significant finding in this series is that the combination of distal aortic perfusion with CSF drainage provided protection against paraplegia compared to a control group. The control group actually consisted of three subsets of patients: straight cross-clamping, CSF drainage alone, and distal aortic perfusion alone.
The authors present a fairly large series of elective descending thoracic aortic procedures. There are not too many thoracic aortic surgery groups capable of supplying these numbers from a single institution.
A proposed classification scheme nicely delineates anatomically distinct higher risk thoracic aneurysms versus lower risk thoracic aneurysms and this classification should be considered in all future papers and reviews on descending thoracic aneurysms. The data identified that it was Type C aneurysms (ie, aneurysms from the subclavian artery to the diaphragm) that produced paraplegia in this series. Type A and Type B descending aneurysms had no cases of neurological deficit. Importantly, the statistical analysis also revealed that age, gender, dissection, intercostal reattachment, and chronic obstructive pulmonary disease did not effect the incidence of paraplegia.
The information regarding paraplegia differences between Types A, B, and C descending thoracic aneurysms are important, although this does not quite reach statistical significance at p equal to 0.07. This will become more important in the future, as many descending thoracic aortic aneurysms will probably be repaired using endovascular stent grafting technology. During endograft procedures, the following question always arises; How far from the aneurysm can we land the device at "distal and proximal" landing zones. There is a dilemma as the stent graft seal is better if the landing zone is further away from the true aneurysm, however, as this study implies, the risk of paraplegia is also greater as more of the descending thoracic aorta is covered. We may want to think twice before we "pave" via endovascular stents, the full descending aorta if it’s not absolutely necessary.
This series shows, that in expert hands, a relatively low incidence of paraplegia (approximately 1% to 2%) can be attained in elective descending thoracic aortic aneurysm surgery using LA-FA bypass and CSF drainage.
References
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