Ann Thorac Surg 2005;79:1249
© 2005 The Society of Thoracic Surgeons
Original article: Cardiovascular
INVITED COMMENTARY
R. Scott Mitchell, MD
Department of Cardiothoracic Surgery, Stanford University Medical Center, Falk CVRC, 300 Pasteur Dr, Stanford, CA 94305
(E-mail: rsmitch{at}stanford.edu).
This report by Flores and colleagues documents excellent results for reoperative procedures in a difficult group of patients, namely thoraco-abdominal aneurysm repair in patients who had previously experienced abdominal aneurysm repair. There was no operative mortality, and only 3 patients with neurologic injury, a stroke in 1, and neurogenic bladder and monoparesis in 1 patient each. Adjuncts for spinal cord protection included distal perfusion with sequential clamping in 11 patients, deep hypothermia in 6 patients to allow an open proximal anastamosis, 2 patients with proximal moderate hypothermia and distal perfusion at 18°C, and 1 patient with visceral perfusion from a catheter placed in the proximal aortic segment. Cerebrospinal fluid drainage and evoked sensory potential monitoring was used in all patients. Preoperative identification of the blood supply to the anterior spinal artery by muli-detector row computed tomography was possible in an unspecified number of patients. Intercostal artery (ICA) reimplantation was performed in 10 patients (four ICA pairs were implanted in 5 patients, three pairs in 3 patients, and two pairs in 2 patients, ranging from T-3 to L-2). All of these patients had at least one ICA pair reconstructed between T-9 and T-12. Prevention of back bleeding from patent ICAs was accomplished with balloon catheters during aortic and branch vessel reconstruction. Naloxone and methylprednisolone were also administered.
Although these are excellent results, the strategy for spinal cord protection is complex and all inclusive, and it is difficult to discern which modality or modalities are effective. For example, it would be helpful to know which ICA reconstructions were based on loss of sensory evoked potentials during sequential clamping and which were performed based on findings from computed tomographic angiography. Although the authors state that they use a strategy of selective ICA reimplantation, 10 of 18 patients underwent multiple ICA reimplantations, and we have no information as to the number of patent ICAs that were ligated and not reimplanted. Many aortic surgeons have produced similarly good results without sensory evoked potentials and CTA imaging of the anterior spinal artery. It would be helpful to know if limiting ICA reimplantation to intercostals identified by CTA would be sufficient. Such a bold strategy, if successful, could significantly limit operation times and bleeding complications.
Related Article
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Risk of Spinal Cord Injury After Operations of Recurrent Aneurysms of the Descending Aorta
- Jorge Flores, Norihiko Shiiya, Takashi Kunihara, Kenji Matsuzaki, and Keishu Yasuda
Ann. Thorac. Surg. 2005 79: 1245-1249.
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