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Ann Thorac Surg 2002;74:S1870-S1872
© 2002 The Society of Thoracic Surgeons
a Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany
* Address reprint requests to Dr Karck, Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, D-30623, Hannover, Germany
e-mail: karck{at}thg.mh-hannover.de
Presented at the Aortic Surgery Symposium VIII, May 2–3, 2002, New York, NY.
Abstract
BACKGROUND: Neurologic complications remain one of the major concerns in surgery on the descending thoracic and thoracoabdominal aorta. The impact of preoperative spinal angiography on postoperative neurologic outcome was assessed.
METHODS: Between September 1993 and December 1999, 109 patients (mean age, 58.2 years; range, 24 to 77) underwent preoperative spinal angiography: 50 (45.9%) for aneurysm and 59 (54.1%) for chronic dissection. Sixty-one patients (56.0%) underwent replacement of the descending thoracic aorta whereas the thoracoabdominal aorta was replaced in 48 (44.0%) patients. All intercostal or lumbar arteries that had previously been visualized as the origin of the great radicular artery (GRA) were preserved.
RESULTS: The origin of the GRA was located by spinal angiography in 65 of the 109 patients (59.6%). It was found between level T-5 and L-3 and on the left side in 75.4% (49 of 65) patients. In patients with aneurysms, it was identified less frequently (48%) compared with patients with chronic dissection (69.5%,p = 0.02). The overall operative mortality rate was 5.5% (6 of 109 patients). There were 7 patients (6.4%) with postoperative paraplegia. In 3 of them the origin of the GRA had been reimplanted.
CONCLUSIONS: Even in patients with an identified and subsequently reimplanted GRA, postoperative paraplegia could not always be prevented. Spinal angiography has no impact on the neurologic outcome of thoracic and thoracoabdominal aortic replacement.
Paraplegia is a disastrous complication of surgery on the descending and thoracoabdominal aorta. The great anterior radicular artery (GRA) has been suggested as the most important arterial feeding vessel of the thoracolumbar region of the spinal cord [1]. We routinely subjected our patients undergoing elective surgery on the descending or thoracoabdominal aorta to spinal angiography in order to identify the GRA [2]. This report summarizes the results of this examination with regard to its impact on postoperative neurologic outcome.
Patients and methods
Patient population
Between September 1993 and December 1999, 109 patients underwent preoperative spinal angiography before descending and thoracoabdominal aortic replacement according to the neuroradiological technique described previously [3]. Patient-related preoperative variables are summarized in Table 1.
In 61 patients (56%), aortic pathology was limited to the descending aorta whereas the thoracoabdominal segment was affected in 48 patients (44%). On the basis of the classification by Crawford and associates [3] of thoracoabdominal aortic aneurysm (TAAA) extent, 8 aneurysms were extent I, 14 were extent II, 22 were extent III, and 4 were extent IV.
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Definitions
Operative mortality included deaths within the patients’ entire hospital stay or within 30 days after the operation if they were discharged from the hospital. All patients who died after operation had records of evaluation for neurologic injury before death. Paraplegia was defined as a permanent and complete inability to move the lower extremities, and paraparesis as an incomplete paralysis with potential reversibility.
Statistical methods
Data were analyzed using the Statview statistical software package. Continuous variables are summarized as mean ± standard deviation. Categorical variables are summarized as the absolute frequencies or as a percentage. Between-group comparisons were performed with the 
2. A p value less than 0.05 was considered significant.
Results
Spinal angiographical results
The origin of the GRA was located by spinal angiography in 65 of 109 patients (59.6%). It was found between T-5 and L-3, and the most common source was the left 11th intercostal artery (16 of 65, 24.6%). In the majority of the patients, it was identified on the left side of the respective intercostal or lumbar artery (49 of 65 patients, 75.4%) and between T-8 and L-2 (62 of 65 patients, 95.4%).
The rate of identification in patients with aneurysms (24 of 50 patients, 48.0%) was lower than that in patients with aortic dissection (42 of 59 patients, 71.2%, p = 0.02). In patients with thoracoabdominal aortic pathology, it was found less frequently (22 of 48 patients, 45.8%), when compared with patients with disease limited to the descending aorta (43 of 61 patients, 70.5%; p = 0.009). The detection rate of the GRA in thoracoabdominal aneurysms was 62.5% (Crawford type I), 7.1% in type II, 63.3% in type III, and 50% in type IV aneurysms. No other variables including sex, previous descending or abdominal aortic surgery, Marfan’s syndrome, hypertension, or coronary heart disease had an influence on the detection of GRA.
One patient had two GRAs: one on the right at T-8 and another one on the left at L-2. Seventeen of the 65 patients (26.1%) with an identified GRA presented with additional intersegmental collaterals feeding this vessel. Collaterals were identified more frequently if the GRA was found in the segment to be operated (p = 0.034). No other preoperative variables including sex, previous descending or abdominal aortic surgery, Marfan’s syndrome, hypertension, coronary heart disease, or dissection were positively correlated with the identification of collaterals. Likewise among patients in whom the origin of the GRA was identified before surgery, the existence of collaterals was not correlated with paraplegia or paraparesis.
No complications from the angiographic investigations, either neurologic or related to the puncture site, were encountered.
Surgical results
Intraoperative and postoperative results are summarized in Table 2. The operative mortality rate was 5.5% (6 of 109 patients). All deaths occurred from multiorgan failure after replacement of the thoracoabdominal aorta (6 of 48 patients, 12.5%). Duration of ECC was shorter in patients with GRA detection (p = 0.04). The number of levels of reimplanted intersegmental arteries (ISA) was somewhat larger in patients with GRA detection, although this difference may have been due to chance (p = 0.07).
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There were 7 patients (6.3%) with postoperative paraplegia. Six patients had undergone replacement of the thoracoabdominal aorta, and 1 patient had his descending aorta replaced. The patient with paraplegia after descending aortic replacement underwent mitral valve replacement for mitral regurgitation as a concomitant procedure. In 3 of the 7 patients with paraplegia the GRA was detected preoperatively.
Comment
The role of the GRA for maintenance of spinal cord blood supply is controversial [5]. In this study, preoperative identification of the GRA had no impact on the incidence of severe postoperative neurologic complications after descending or thoracoabdominal aortic replacement. This result indicates the importance of other risk factors such as perioperative hypotension, duration of intraoperative spinal cord ischemia or thromboembolism of collaterals to the anterior spinal artery.
ISA reattachment during descending and thoracoabdominal replacement is a blind maneuver unless preoperative localization of intersegmental vessels truly critical to spinal cord blood supply is available. For this reason we tried to reimplant ISAs suggested to be important by preoperative angiography. However, analysis of the operative reports indicates that a variable number of other ISAs were implanted additionally. Thus the operative strategy of the surgeon remained largely unaffected by the results of preoperative spinal angiography. This may explain why the number of ISAs that were reimplanted or preserved was not significantly different between the groups with and without identification of the GRA. Moreover no significant differences in occurrence of paraplegia were found between the two groups.
The detection rate of GRA was 59.6% in this series. This result is comparable with previous reports from other institutions [6–9]. It implies that the GRA is not always patent in the diseased aorta, particularly in the presence of a large mural thrombus.
Identification of the origin of the GRA may provide information about the vascular topography of an individual’s spinal cord perfusion system. We believe that this is theoretically an important first step in the reduction of neurologic complications after descending or thoracoabdominal aortic replacement. Conversely, the results of this study suggest that preoperative spinal angiography for identification of the GRA is not justified since this knowledge did not completely prevent postoperative paraplegia. Because of the potential benefit of additional information about individual spinal cord blood supply, however, we are currently evaluating less invasive means of detecting the GRA, such as MRI imaging, before descending or thoracoabdominal aortic replacement.
References
This article has been cited by other articles:
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  E. Apostolakis and K. Akinosoglou Is preoperative demonstration of Adamkiewicz's artery a clinical reality in acute aortic dissection? Eur. J. Cardiothorac. Surg., October 1, 2007; 32(4): 684 - 685. [Full Text] [PDF]
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C. D. Etz, T. M. Homann, K. A. Plestis, N. Zhang, M. Luehr, D. J. Weisz, G. Kleinman, and R. B. Griepp Spinal cord perfusion after extensive segmental artery sacrifice: can paraplegia be prevented? Eur. J. Cardiothorac. Surg., April 1, 2007; 31(4): 643 - 648. [Abstract] [Full Text] [PDF]
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 K. Yoshioka, H. Niinuma, S. Ehara, T. Nakajima, M. Nakamura, and K. Kawazoe MR Angiography and CT Angiography of the Artery of Adamkiewicz: State of the Art RadioGraphics, October 1, 2006; 26(suppl_1): S63 - S73. [Abstract] [Full Text] [PDF]
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M. Toyama, A. Usui, T. Akita, and Y. Ueda A vascular tube for intercostal artery reimplantation Eur. J. Cardiothorac. Surg., March 1, 2006; 29(3): 413 - 415. [Abstract] [Full Text] [PDF]
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 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]
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 G. Iannelli, F. Piscione, L. Di Tommaso, M. Monaco, M. Chiariello, and N. Spampinato Thoracic aortic emergencies: impact of endovascular surgery Ann. Thorac. Surg., February 1, 2004; 77(2): 591 - 596. [Abstract] [Full Text] [PDF]
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