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Ann Thorac Surg 2002;73:1023-1024
© 2002 The Society of Thoracic Surgeons

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Correspondence

Spinal cord protection during descending aortic aneurysm repair: Reply

^a Department of Cardiothoracic and Vascular Surgery, The University of Texas at Houston Medical School, Hermann Memorial Hospital, 6410 Fannin, Suite 450, Houston, TX 77030, USA

e-mail: hazim.j.safi{at}uth.tmc.edu

To the Editor

We appreciate the interest in our manuscript [1] and the comments made by Dr Kazui. He and his colleagues advocate the use of distal aortic perfusion for most thoracic aortic repairs and reserve cerebrospinal fluid (CSF) drainage for the more extensive aneurysms, such as type II thoracoabdominal aortic aneurysm. In their opinion, CSF drainage may not be necessary for procedures in which cross-clamp periods are less than 30 to 40 minutes.

From a practical standpoint, it is difficult to predict when an operation will require more than 30 minutes for repair. In our analysis group of 148 patients undergoing repair of descending thoracic aortic aneurysm, 77 (52.0%) required cross-clamp periods longer than 30 minutes. Moreover, 82 patients (55.4%) had a type C descending thoracic aortic aneurysm (entire descending thoracic aorta) and 24 (16.2%), type B (from the sixth thoracic vertebrae to the diaphragm). In 71 patients (48.0%), there was either acute or chronic dissection. Descending thoracic aortic aneurysm repair that involved either dissection or reimplantation of the intercostal arteries accounted for the longer aortic cross-clamp periods in our series. The aortic cross-clamp time and consequently the degree of spinal cord protection required could not be determined until the aneurysm was opened. If the necessity for CSF drainage suddenly became apparent, it would be difficult to insert a drain midway through the procedure.

Two patients with an aortic cross-clamp time of less than 30 minutes sustained a neurologic deficit; in 1 of them, the aortic cross-clamp time was 18 minutes. Although studies have greatly assisted us in establishing risk factors, it is impossible to predict each incidence of neurologic deficit. For this reason, we have adopted the routine combined use of CSF drainage and distal aortic perfusion for repair of all nonruptured thoracic aneurysms.

We are in full agreement with Dr Kazui on the importance of CSF dynamics. We are currently analyzing these data and their relationship to spinal cord perfusion. We also commend Dr Kazui and colleagues for their outstanding results in descending thoracic aortic aneurysm repair. In their experience, success appears to be firmly linked to the use of the adjunct distal aortic perfusion. Likewise, we have been influenced by our success. Our current technique has evolved over the past 10 years to include CSF drainage and distal aortic perfusion, which we have found to provide substantial protection against neurologic deficit.

References

1. Estrera A.L., Rubenstein F.S., Miller C.C., III, Huynh T.T.T., Letsou G.V., Safi H.J. Descending thoracic aortic aneurysm: surgical approach and treatment using the adjuncts cerebrospinal fluid drainage and distal aortic perfusion. Ann Thorac Surg 2001;72:481-486.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Anthony L. Estrera Hazim J. Safi Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Estrera, A. L. Articles by Safi, H. J. Search for Related Content PubMed Articles by Estrera, A. L. Articles by Safi, H. J. Related Collections Cerebral protection Related Article