Ann Thorac Surg 2009;88:265-267. doi:10.1016/j.athoracsur.2008.09.016
© 2009 The Society of Thoracic Surgeons
Case Reports
A Modified Technique for Preventing Spinal Cord Ischemia During Type II Thoracoabdominal Aneurysm Repair
Keun Her, MD,
ChangWoo Choi, MD,
JaeWook Lee, MD,
HwaKyun Shin, MD,
YongSoon Won, MD*
Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Bucheon Hospital, Gyeonggi-do, Republic of Korea
Accepted for publication September 3, 2008.
* Address correspondence to Dr Won, Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Bucheon Hospital, 1174 Jung dong, Wonmi-gu, Bucheon-si, Gyeonggi-do, 420-767, Republic of Korea (Email: hkleh{at}naver.com).
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Abstract
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A 51-year-old man required replacement of the thoracoabdominal aorta due to a type II thoracoabdominal aortic aneurysm. We tailored and plicated the aortic aneurysm to make a closed tube. All of the intercostal arteries and lumbar arteries were reimplanted using a closed tube constructed with an aneurysmoplasty to the main aortic graft, using this tube to protect the spinal cord. The closed tube maintained blood flow to the intercostal and lumbar arteries, and no neurologic deficits developed.
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Introduction
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Paraparesis and paraplegia are major complications of surgical repair of thoracic and thoracoabdominal aneurysms. Despite advances in anesthetic and surgical techniques, the rate of paraplegia and paraparesis varies between 5% and 40% [1]. Shortening the duration of spinal cord ischemia and reimplanting as many intercostal and lumbar arteries as possible, regardless of whether they feed the Adamkiewicz or great radicular artery, may be critical. We reimplanted these arteries to the aortic graft using a closed tube constructed by an aneurysmoplasty.
A 51-year-old man was diagnosed with a type II thoracoabdominal aortic aneurysm. He had had the ascending aorta replaced 3 years earlier because of an acute aortic dissection type A, and he had been followed-up at 6-month intervals with computed tomography. We planned an elective operation for the thoracoabdominal aortic aneurysm. Under cerebrospinal fluid drainage, a double-lumen endotracheal tube was used for anesthesia and the left femoral artery and vein were exposed for cardiopulmonary bypass. After the descending thoracic and abdominal aortas were completely exposed through a left thoracoabdominal incision, a proximal aortic clamp was applied just below the left subclavian artery, and then the distal aortic clamp was applied approximately 2 cm distal to the proximal aortic clamp. After aortic clamping, partial cardiopulmonary bypass was started to preserve the visceral organs and thoracolumbar spinal cord. The aorta was then divided between the clamps and the proximal anastomosis was performed using a standard Dacron graft (DuPont, Wilmington, DE) in an end-to-end fashion; then another aortic clamp was reapplied just above the celiac trunk with a bevel to include as many lumbar arteries in the aortic aneurysm as possible. As a result of this distal aortic clamping, the aneurysm was isolated from the blood supply and opened longitudinally. All of the intercostals and lumbar arteries were identified, and then the aneurysmal free wall on the opposite side of the vertebra was trimmed, plicated, and re-closed. As a result, a closed tube approximately 2 cm in diameter, involving the intercostals and lumbar arteries, was constructed using an aneurysmoplasty. The aortic graft and this closed tube were connected with an 8-mm Dacron graft (DuPont) at the midportion of the closed tube (Figs 1 and 2).
After finishing the connection between the aortic graft and closed tube, distal anastomosis of the aortic graft to the aorta was performed at the level of the inferior mesenteric artery with reattachment of the celiac axis, superior mesenteric artery, and both renal arteries in button fashion. The inferior mesenteric artery was sacrificed. The patient was discharged on postoperative day 23. Postoperative magnetic resonance angiography (MRA), performed on the postoperative day 90, revealed patent intercostal and lumbar arteries through the closed tube (Fig 3).
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Fig 1. (Left) Preoperative and (right) postoperative diagrams of the closed tube used to reimplant the intercostal and lumbar arteries at the thoracoabdominal replacement.
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Fig 2. An intraoperative photograph of the closed tube (black arrow) and 8-mm Dacron graft (DuPont, Wilmington, DE) (white arrow) connecting the closed tube to the aortic graft.
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Fig 3. Magnetic resonance angiogram of the aortic graft, patent closed tube (white arrow), and patent 8-mm Dacron graft (DuPont, Wilmington, DE) (black arrow).
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Comment
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The repair of thoracoabdominal aortic aneurysms has substantial morbidity and mortality. Despite maneuvers to reduce this risk, such as distal aortic perfusion, cerebrospinal fluid drainage, elevation of the mean arterial pressure, and intraoperative neuromonitoring, a considerable risk of paraplegia remains [2–4].
The mechanism responsible for postoperative paraplegia remains controversial, although spinal cord ischemia is often held to be principally responsible. Therefore, intraoperative and postoperative maintenance of adequate circulation to the spinal cord is exceedingly important in preventing postoperative neurologic injuries. Consequently, reimplantation of the intercostal and lumbar arteries, including the Adamkiewicz artery, within a short time should improve the neurologic outcome in thoracic and thoracoabdominal aortic repair. Since the size of the intercostal and lumbar arteries does not correspond to that of the Adamkiewicz artery in most cases, preserving all of the intercostal and lumbar arteries within a given level (eg, T8–L1) is important [5]. Some articles have reported various methods for reattaching the intercostal and lumbar arteries [6–8], but these have not been applied widely. Toyama and colleagues [6] reported tailoring the lower descending aorta using automatic sutures, making a vascular tube approximately 2.0 cm in diameter, and anastomosing the end of the vascular tube to the aortic graft. This method is very similar to our technique, although we made a closed tube with plication of the aneurysm and connected this tube to the aortic graft using an 8-mm graft at the midportion of the tube to preserve the even flow of each intercostal and lumbar artery.
Our method has some advantages and disadvantages. First, our technique can achieve complete revascularization of the intercostal and lumbar arteries easily, rapidly, and without selection of which should be reimplanted, but it also risks enlargement or rupture of the vascular tube and thrombus formation in the tube in the late phase. In fact, Toyama and colleagues [6] reported two vascular tube obstructions in four cases. To prevent such thrombus formation or obstruction of the tube, we connected the closed tube to the aortic graft using an 8-mm graft at the midportion of the tube, and the patency of the closed tube in our case was very good postoperatively.
In summary, we believe that our technique may be particularly helpful in providing spinal cord protection in patients who require long segment replacement of the descending thoracic and abdominal aorta.
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References
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Abstract
Introduction
