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Ann Thorac Surg 2006;82:1677-1678
© 2006 The Society of Thoracic Surgeons
Hamamatsu University School of Medicine, 1–20–1, Handayama, Hamamatsu 431-3192, Japan
(Email: tkazui{at}hama-med.ac.jp).
In this article, the Mount Sinai group [1] raises a provocative issue in claiming that serial sacrifice of as many as 15 intercostal arteries can be safely done with motor-evoked potential (MEP) and somatosensory-evoked potential (SSEP) monitoring during thoracic and thoracoabdominal aortic aneurysm surgery. The authors obtained a remarkable neurologic outcome in a series of 100 patients, with only 2% of the patients experiencing postoperative paraplegia. With such an outstanding result, it is hard to find arguments against their proposed strategy, which should otherwise come to be viewed by many cardiovascular surgeons as rather dangerous in at least some specific situations.
Descending thoracic aortic aneurysm repair without intercostal artery reattachment has been done in the past with acceptable neurologic outcome. The problem with serial sacrifice of intercostals may lie elsewhere, however. In my opinion, it is likely to affect mostly the surgical repair of thoracoabdominal aneurysms, particularly the Crawford type II variety.
The authors mentioned that sacrificing less than nine pairs of intercostal arteries was safe. On most occasions, however, this extensive repair procedure will require the sacrifice of more than nine pairs. In the present series, 13 patients had this extensive variety of aneurysm, and apparently 1 patient, whose intercostal artery sacrifice extended from T3 to L3, developed paraplegia. Analyzed as a separate patient subset, this would make the outcome look similar to that of most other contemporary studies. Thus, it may be argued that the strategy may not be readily applicable for this extensive disease.
We have seen in our experience that the MEP or SSEP waveforms sometimes decrease in amplitude, and even occasionally become flat, as a certain segment of the descending aorta is cross-clamped, thus indicating spinal cord hypoperfusion. It is quite amazing that the authors noticed no such instance in the present series while serial sacrifice of the intercostals was being undertaken. What might be the reason behind such greater tolerance against ischemia for these patients?
The report is going to be published at a time when many cardiovascular surgeons are advocating more strongly than ever the need for preoperative detection of the artery of Adamkiewicz and aggressive reattachment of the intercostals and lumbar arteries. The availability of various noninvasive imaging techniques is making it possible for a higher detection rate of the great radicular artery that has been demonstrated in many recent studies as being critical to the spinal cord arterial supply. This report denies the very existence of any such critical artery. It can be expected that it will stir up a lot of discussion on the issue of spinal cord protection during thoracic and thoracoabdominal aneurysm surgery.
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