Thoracoabdominal aneury

sm surgery and the risk of

paraplegia: intraoperative
neuroprotection
Present by Ri 顏廷珊
2003/4/14
Anatomy review: spinal cord blood
supply
 Aorta intercostal
arteries
One anterior spin
al artery: supply ve
ntral 2/3 spinal cor
d
Two posterior art
ery: supply dorsal
1/3 spinal cord
 Upper 2/3 of anterior
spinal artery is continu
ous and has constant
caliber
 In lower thoracic rege
nt, it decreased in cali
ber, and there is often
one large intercostal b
ranch which supple thi
s segment artery of
Admakiewicz (ARM)
 75% in T9-T12
 Crawford classification
 Type I: proximal
descending to upper
abdominal aorta
 Type II: proximal
descending to the
below the renal
arteries
 Type III: distal half to
the abdominal aorta
 Type IV: most or all
abdominal aorta
 Strategies for prevention of spinal
cord ischemic injury
1. Identification of critical vessels and
intercostal artery anastomosis
2. Distal aortic perfusion
3. CSF drainage
4. Spinal cord evoked potential monito
ring
5. Hypothermia
6. Ischemic precondition
Intercostal arteries anastomosis
 When more than 9 pairs of intercosta
l arteries are ligated the incidence
of paraplegia increases 29 folds
 T9-L1 most risky, exp. T11 and T1
2

Safi et al. importance of intercostal artery reattachment during thoracoabdominal aortic

aneurysm repair, J Vasc Surg 27: 58-68, 1998
 Identification of critical vessels
 Pre-op evaluation:

1. angiography controversial ?!
2. MRA being advantageous, may re
duce spinal cord injury and operatio
n time
Strategies for spinal cord protection during descending thoracic and t
horacoabdominal aortic surgery: up-to-date experimental and cl
inical result, Scand Cardiovasc J 36, 136-160, 2002
 Identification of critical vessels
 Intra-op evaluation:
1. Monitoring evoked potential no convinc
ing evidence showing benefit
Griepp et al.

1. Hydrogen electrode technique  still in e

xperimental studies, but the results are e
ncouraging
Svensson et al.

1. Doppler ultrasonography  in dogs ??

Shibata et al.
Effects of clamping the descending
thoracic aorta
 The risk of ischemic damage to the s
pinal cord with normothermic simple
aortic clamping directly related to t
he clamping time
 the risk of paraplegia begins to incre
ase after 30 min, rise dramatically af
ter 40 min
Hilgenberg AD et al, Blunt traumatic rupture of the thoracic aorta, An
n Thorac Surg 53:233-239, 1992
Effects of clamping the descending
thoracic aorta
 proximal to the clamp increase in the arterial
pressure  increase in afterload  hypertension
in brain and stimulation of aortic receptors  in
crease CSF pressure
 Distal to the clamp hypotension  hypoperfusi
on
 a spinal cord perfusion pressure > 60 mmHg to
maintain cord function

Hilgenberg AD, spinal cord protection for thoracic aortic surgery, Cardiology Clinic, Vol 1
7:4: 1999
 Distal aortic perfusion
1. Passive shunt:
proximal to distal aorta, femoral vein to f
emoral artery, left atrial to femoral arter
y
 provide suboptimal blood flow and per
fusion pressure (< 40 mmHg)

Hilgenberg AD, spinal cord protection for thoracic aortic surgery, Cardiology Cl
inic, Vol 17:4: 1999
 Distal aortic perfusion
 Partial bypass:
left atrium
centrifugal pump
distal aorta or
femoral artery
 maintain proximal
artery systolic
pressure 100-140
mmHg, distal artery
mean pressure 70
mmHg
 CSF drainage
 Spinal cord perfusion pressure= spinal art
ery blood pressure – CSF pressure
 Intra-op protection inconclusive
 Reverse delayed onset paraplegia post-op!
 Currently accepted principles:
maintaining a CSF pressure at 10-12 mmH
g and continuing the CSF drainage for 24-
72 hours post-op

Zvara: thoracoabdominal aneurysm surgery and the risk of paraplegi

a: contemporary practice and future direction, J American society
of Extra-corpo technology, 2002:34:11-17
 Spinal cord evoked potential
monitoring
 Somatosensory cortical evoked potential
1. Most common, good clinical results for intra-op
guidance
2. Posterior tibial or peroneal nerves posterior a
nd lateral columns of spinal cord scalp
3. Detection if there are changes in latency or amp
litude
4. Not directly monitor the function of anterior col
umn but the posterior and lateral column
5. Post-op paraplegia may occur despite unchange
d intra-op SEPs
Strategies for spinal cord protection during descending thoracic and t
horacoabdominal aortic surgery: up-to-date experimental and cl
inical result, Scand Cardiovasc J 36, 136-160, 2002
 Spinal cord evoked potential
monitoring
 Motor evoked potential
1. Motor cortex or spinal cord proximal to th
e clamping site  lower spinal cord, perip
heral nerves or muscle
2. Affected by many anesthetic drugs: propof
ol, NO, BZD…
3. No good correlation monitoring the whit
e matter of the anterior column rather tha
n gray matter
4. Monitoring of MEPs is and extremely sensi
tive and fast method to detect the occurre
nce of intra-op SCI
 Spinal cord evoked potentials
 An electrode inserted in the epidural space
and recorded by another electrode, or dire
ct stimulation of the cord
 Yamamoto et al.: lumbar descending ESP
was the most reliable method for predictin
g post-op neurologic outcome
 Fan et al: significantly correlated with regi
onal spinal cord blood flow at the lumbar s
egment
 Hypothermia
 Neuroprotection: reduce spinal cord meta
bolic rate, decrease CSF neurotransmitter
level
 Systemic hypothermia
1. Deep hypothermic circulatory arrest (18
C) the best condition for repair, for 45-
60 min
Kouchoukos et al. hypothermic bypass and circulatory arrest for operation of th
e desc. Thoracic and thoracoabdominal aorta. Ann Thoracic Surg.1995; 6
0:67-77
1. Moderate hypothermia(29-31C) reduce
spinal cord ischemic injury
Svensson et al. reduction of neurologic injury after high-risk thoracoabdominal
aortic operation. Ann Thoracic Surg. 1998; 66: 132-8
 Hypothermia
 Regional hypothermia
1. Epidural injection of iced saline with
monitoring and drainage of CSF s
pinal cord temperature 25-28C  g
ood clinical results
Cambria et al. Epidural cooling for spinal cord protection during thoracoabdom
inal anuerysm repair: a 5-year experience, J Vasc Surg. 2000; 31:1093-
102

1. Local cold packing in animal study

 ??
Ueno et al,
 Ischemic precondition
 The natural physiologic process where by s
hort, sublethal events of ischemia to an or
gan initiate a protective cellular process by
which the organ is protected from a subse
quent, usually lethal ischemic insult.
 Mechanism: unclear, Probably mediated b
y production of heat shock protein 70 and
110/105, adenosine receptors, alpha agoni
st, and potassium-dependent ATP channel
s
Zvara: thoracoabdominal aneurysm surgery and the risk of paraplegia: conte
mporary practice and future direction, J American society of Extra-corpo te
chnology, 2002:34:11-17
 Ischemic precondition
 Zvara et al.: 3min precondition event 3
0 min  12 min ischemia spinal cord pr
otection!
 Munyao et al.: 12.5 min precondition eve
nt  12 hours  30 min ischemia, better
results than 24 hours delay
 Clinical debates:

No known optimal timing !!

Strategies for spinal cord protection during descending thoracic and thoracoabd
ominal aortic surgery: up-to-date experimental and clinical result, Scand
Cardiovasc J 36, 136-160, 2002
 Pharmacological protection
 Stabilize cellular membranes : Ca channel
blocker, MgSO4
 Decrease neurologic metabolic activity: ke
tamine
 Scavenge free radicals: allopurinal
 Reduce intracellular edema: mannitol
 Decrease inflammation: glucocorticoids

 Currently there is no convincing data rega

rding the efficacy of any of these drugs !
 T.H Webb and G.M Williams, JHH
thoracic abdominal aneurysm repair: cardiovascular surg 7
(6):573-585, 1999
 JHH repair technique
1. Pre-op spinal angiography: successfully l
ocalized in ~60% of patients, ¾ from left
side, 80% form T9-T12
2. CSF drain
3. Epidural spinal electrode for continuous s
pinal cord evoked potential and standard
peripheral somatosensory evoked potenti
al monitoring
 Bypass with a centrifugal blood pump and heat ex
changer:
Proximal inf. Pulmonary vein with tip in left atri
um
Distal left femoral artery
 Moderate hypothermia: systemic cooling to 32C
 Segmental clamping and repair: spinal artery isch
emia for 10-15 min, visceral and renal ischemia f
or 15-40 min, no significant hypotension occured
 Reimplantation of pre-op localized spinal artery
 CSF drainage was continued for 72 h post-op
 Result
 1993-1997,145 cases, 62% Crawford
I or II, 26 % dissection, 9% rupture
 SCI: 5.8 %(Paraplegia/ paraparesis
=3.6%/ 2.2%)
 Mortality: 11%
 Discussion
 No cord events developed in p’t with
successful pre-op localization of spin
al arteries and had critical intercostal
vessels reimplanted.
 No pre-op localization, no succesful l
ocalization  even reimplantation of
lower intercostal vessels  high risk
of cord event
 Pre-op localization of critical vessels
Richard P, Cambria MD et al (MGH), Thoracoabdominal an
eurysm repair: results with 337 operation performed over a
15-year interval: Ann of Surg: 236(4): 471-479
 MGH repair technique
1. Clamp and sew
2. Distal perfusion only in highly selected p’ts ( co
mplexity in surgery, significant renal insufficienc
y)
3. Regional hypothermia with epidural cooling (26
C)
4. Reimplantation of patent T9-L1 intercostal vess
els
5. Continuous CSF drainage after restoration of lo
wer extremity perfusion and discontinuation of
EC, for 48-72 hr
 Result
 1987-2001, 337 cases, 44% Crawfor
d I or II, 24.3%urgent cases
 SCI: 11.4% (Paraplegia/ paraparesis
=6.6%/ 4.8%)
 Mortality: 8.3%
 Discussion
 Multivariate analysis of variables
associated with SCI
variable P value
TAA type I/II vs III/IV 0.039
Aneurysm rupture 0.034
Total cross clamp times 0.0019
Patent critical zone intercostal sa 0.031
crifice(T9-L1)
Intra-op hypotension 0.028
 Distal perfusion only in highly selecti
ve patients mostly rely on neuropr
otective strategies.
 Hypothermia (Epidural Cooling) is th
e best method of cord protection.
 An aggressive posture of intercostal r
evasculization has in our view been c
onclusively proven to be benefit.