Surgery for acquired heart disease looking for the artery of adamkiewicz: A quest to minimize paraplegia after operations for aneurysms of the descending.

Slides:

Advertisements

Similar presentations

The risk of ischemic spinal cord injury in patients undergoing graft replacement for thoracoabdominal aortic aneurysms Klaus Grabitz, MD, Wilhelm Sandmann,

Advertisements

Acute traumatic aortic aneurysm: The Duke experience from 1970 to 1990

Thoracoabdominal Aneurysm Repair: A 20-Year Perspective

Paraplegia after extensive thoracic and thoracoabdominal aortic aneurysm repair: Does critical spinal cord ischemia occur postoperatively? Christian.

Direct Spinal Cord Perfusion Pressure Monitoring in Extensive Distal Aortic Aneurysm Repair Christian D. Etz, MD, PhD, Gabriele Di Luozzo, MD, Stefano.

Thoracic and Thoracoabdominal Aneurysm Repair: Is Reimplantation of Spinal Cord Arteries a Waste of Time? Christian D. Etz, MD, James C. Halstead, MA.

Prospective Study of the Natural History of Thoracic Aortic Aneurysms

Randall B. Griepp, MD, Eva B. Griepp, MD

The “first generation” of endovascular stent-grafts for patients with aneurysms of the descending thoracic aorta Michael D. Dake, MD, D.Craig Miller,

Visceral vessel relocation techniques

Acute traumatic aortic aneurysm: The Duke experience from 1970 to 1990

Prevention of postoperative paraplegia during thoracoabdominal aortic surgery1 Yukio Kuniyoshi, MD, PhD, Kageharu Koja, MD, PhD, Kazufumi Miyagi, MD,

Open Surgical Repair of 2286 Thoracoabdominal Aortic Aneurysms

Randomized comparison of cold blood and cold crystalloid renal perfusion for renal protection during thoracoabdominal aortic aneurysm repair Scott A.

Surgical treatment of thoracoabdominal aortic aneurysms by simple crossclamping: Risk factors and late results Marc A.A.M. Schepens, MD, Jo J.A.M. Defauw,

Clinical outcomes of different surgical approaches for proximal descending thoracic aneurysm involving the distal arch Hyun-Chel Joo, MD, Young-Nam Youn,

Extensive deployment of the stented elephant trunk is associated with an increased risk of spinal cord injury Jorge Flores, MD, PhD, Takashi Kunihara,

Outcomes of 3309 thoracoabdominal aortic aneurysm repairs

Indications for aortic replacement

Lobe-specific extent of systematic lymph node dissection for non–small cell lung carcinomas according to a retrospective study of metastasis and prognosis

David L. Reich, MD, Suzan Uysal, PhD, Martin Sliwinski, PhD, M

Subtypes of acute aortic dissection

Surgical treatment of the dilated ascending aorta: when and how?

Axillary Cannulation Significantly Improves Survival and Neurologic Outcome After Atherosclerotic Aneurysm Repair of the Aortic Root and Ascending Aorta

Is the bentall procedure for ascending aorta or aortic valve replacement the best approach for long-term event-free survival? Christian Hagl, MD, Justus.

Comparison of perioperative myocardial protection with nifedipine versus nifedipine and metoprolol in patients undergoing elective coronary artery bypass.

Charles Acher, MD The Journal of Thoracic and Cardiovascular Surgery

Defining risk and identifying predictors of mortality for open conversion after endovascular aortic aneurysm repair Salvatore T. Scali, MD, Adam W. Beck,

Can retrograde perfusion mitigate cerebal injury after particulate embolization? A study in a chronic porcine model Tatu Juvonen, MD, PhDa, Donald J.

Operative mortality rates for intact and ruptured abdominal aortic aneurysms in Michigan: An eleven-year statewide experience Dolores J. Katz, MPH, James.

Preservation of intercostal arteries during thoracoabdominal aortic aneurysm surgery: A retrospective study Scott D. Ross, MD, Irving L. Kron, MD, Patrick.

Diabetes and evidence of atherosclerosis are major risk factors for adverse outcome after elective thoracic aortic surgery Christian Hagl, MD, Jan D.

Retrograde cerebral perfusion enhances cerebral protection during prolonged hypothermic circulatory arrest: a study in a chronic porcine model Tatu Juvonen,

Lars G. Svensson, MD, PhD, E. Stanley Crawford, MD †, Kenneth R

Support Your Specialty

T. Carrel, MD, M. Pasic, MD, U. Niederhäuser, MD, M. Turina, MD

Extended aortic replacement for acute type a dissection with the tear in the descending aorta Terushisa Kazui, MD, Yukihiko Tamiya, MD, Toshiaki Tanaka,

Marfan syndrome: The variability and outcome of operative management

Impact of distal aortic and visceral perfusion on liver function during thoracoabdominal and descending thoracic aortic repair Hazim J. Safi, MD, Charles.

Predicting the Risk of Paraplegia After Thoracic and Thoracoabdominal Aneurysm Repair Stefano Zoli, MD, Fabian Roder, MS, Christian D. Etz, MD, PhD,

Combined use of cerebral spinal fluid drainage and naloxone reduces the risk of paraplegia in thoracoabdominal aneurysm repair C.W. Acher, MD, M.M. Wynn,

Paraplegia After Thoracoabdominal Aortic Aneurysm Repair: Is Dissection a Risk Factor? Joseph S. Coselli, Scott A. LeMaire, Luiz Poli de Figueiredo,

Yuji Tachimori, MD, Hoichi Kato, MD, Hiroshi Watanabe, MD

Spinal Cord Perfusion and Protection During Descending Thoracic and Thoracoabdominal Aortic Surgery: The Collateral Network Concept Randall B. Griepp,

Natural history of thoracic aortic aneurysms: indications for surgery, and surgical versus nonsurgical risks John A Elefteriades, MD The Annals of Thoracic.

Late neurological recovery of paraplegia after endovascular repair of an infected thoracic aortic aneurysm Barend M.E. Mees, MD, PhD, Frederico Bastos.

Surgical management of infective endocarditis associated with cerebral complications Kiyoyuki Eishi, MD, Kouhei Kawazoe, MD, Yoshihiro Kuriyama, MD, Yoshitsugu.

Kara H. V. Kvilekval, MD, Jonathan P. Yunis, MD, Robert A

Aspects of the spinal cord circulation as assessed by intrathecal oxygen tension monitoring during various arterial interruptions in the pig Lennart.

Gastrointestinal complications after descending thoracic and thoracoabdominal aortic repairs: A 14-year experience Paul E. Achouh, MD, Ken Madsen, MD,

A new predictive model for adverse outcomes after elective thoracoabdominal aortic aneurysm repair Scott A LeMaire, MD, Charles C Miller, PhD, Lori D.

E.Stanley Crawford, M.D., Ralph W. DeNatale, M.D.

Repair of Thoracoabdominal Aortic Aneurysms in Octogenarians

Staged repair significantly reduces paraplegia rate after extensive thoracoabdominal aortic aneurysm repair Christian D. Etz, MD, PhD, Stefano Zoli,

The fate of the distal aorta after repair of acute type A aortic dissection James C. Halstead, MA (Cantab), MB, BChir, MRCS (Eng), Matthias Meier, MD,

Heart transplantation in patients with previous cardiac operations:

Michael A. Coady, MD, John A. Rizzo, PhD, Graeme L

Quantitative electroencephalography: A method to assess cerebral injury after hypothermic circulatory arrest Craig K. Mezrow, MSa (by invitation), Peter.

Reoperation for aneurysmal disease of the ascending aorta in patients with concomitant aortic valve incompetence Matthias Karck, MDa, Joachim Cremer,

Thoracoabdominal Aneurysm Repair: A 20-Year Perspective

Branch graft patency after open repair of thoracoabdominal aortic aneurysms Nicholas T. Kouchoukos, MD, Alexander Kulik, MD, MPH, Catherine Castner, RN,

Natural history of descending thoracic and thoracoabdominal aneurysms

Hazim J Safi, MD, Charles C Miller, PhD The Annals of Thoracic Surgery

Operative Strategy for Descending and Thoracoabdominal Aneurysm Repair With Preoperative Demonstration of the Adamkiewicz Artery Kojiro Furukawa, MD,

Minimally invasive direct coronary artery bypass, percutaneous transluminal coronary angioplasty, and stent placement for left main stenosis William.

Perioperative renal function and thoracoabdominal aneurysm repair: Where do we go from here? Leonard N. Girardi, MD The Journal of Thoracic and Cardiovascular.

Joseph S Coselli, MD, Lori D Conklin, MD, Scott A LeMaire, MD

Hazim J. Safi, MD, Anthony L. Estrera, MD, Charles C

Moderate hypothermia, with partial bypass and segmental sequential repair for thoracoabdominal aortic aneurysm Steven M. Frank, MD, Stephen D. Parker,

Descending thoracic and thoracoabdominal aortic aneurysms: “Busted”

Presentation transcript:

Surgery for acquired heart disease looking for the artery of adamkiewicz: A quest to minimize paraplegia after operations for aneurysms of the descending thoracic and thoracoabdominal aorta Randall B. Griepp, MDa, M.Arisan Ergin, MD, PhDa, Jan D. Galla, MD, PhDa, Steven Lansman, MD, PhDa, Nguyen Khan, MDa, Cid Quintana, MDa, Jock McCollough, MDa, Carol Bodian, PhDb The Journal of Thoracic and Cardiovascular Surgery Volume 112, Issue 5, Pages 1202-1215 (November 1996) DOI: 10.1016/S0022-5223(96)70133-2 Copyright © 1996 Mosby, Inc. Terms and Conditions

Fig. 1 Comparison of group I and group II patients with regard to etiology of aneurysms. Group I includes all patients operated on between January 1986 and October 1993. Group II includes all patients operated from November 1993, at which time SSEP monitoring and various modifications of surgical technique were initiated, until February 1996. There were 82 atherosclerotic aneurysms in group I versus 59 in group II; 38 dissections in group I versus 25 in group II; and 18 aneurysms with diverse other causes in group I versus 11 in group II. Statistical analysis showed that proportion of aneurysms of each type did not differ significantly between groups, suggesting that differences in outcome are unlikely to arise from differences in underlying lesions in each group, rather than from differences in operative strategy. The Journal of Thoracic and Cardiovascular Surgery 1996 112, 1202-1215DOI: (10.1016/S0022-5223(96)70133-2) Copyright © 1996 Mosby, Inc. Terms and Conditions

Fig. 2 Comparison between group I and group II patients (defined in Fig. 1 and in text) with respect to extent of aneurysms, categorized according to conventional classification schemes for assessing risk of spinal cord injury after operation. Thoracic aneurysms were defined as those aneurysms that end above the diaphragm and are therefore associated with low risk of spinal cord injury; 92 patients in group I and 55 in group II had such aneurysms. Thoracoabdominal aneurysms include all lesions extending from the descending aorta into the abdomen and are most likely to result in spinal cord injury: 46 patients in group I and 40 in group II had aneurysms thus classified. Crawford I and II aneurysms are those that fit into groups defined by Stanley Crawford; these are the subset of thoracoabdominal aneurysms in which paraplegia is most likely to develop after operation. There were 18 Crawford I and six Crawford II aneurysms in Group I, for a total of 24; there were 20 Crawford I and seven Crawford II aneurysms in group II, for a total of 27. The p value indicates that proportions of patients falling into these conventional categories of aneurysm extent—which define risk of spinal cord injury—did not differ significantly between groups I and II, making it valid to compare incidence of paraparesis and paraplegia after operation. The Journal of Thoracic and Cardiovascular Surgery 1996 112, 1202-1215DOI: (10.1016/S0022-5223(96)70133-2) Copyright © 1996 Mosby, Inc. Terms and Conditions

Fig. 3 Comparison between group I and group II patients (defined in Fig. 1 and in text) with respect to extent of aneurysms defined by number of intersegmental (intercostal and lumbar) vessels severed during aneurysm operation, which we propose as a more accurate way of defining risk of postoperative spinal cord injury. Seventy patients in group I and 36 patients in group II had fewer than seven arteries sacrificed; 46 patients in group I and 36 in group II had fewer than 11 vessels cut, and 22 patients in group I and 21 in group II had 11 or more arteries cut, putting them into the group at highest risk. The proportion of patients with more extensive aneurysms appears slightly greater in group II, but this difference was not statistically significant, as indicated by the p value. The Journal of Thoracic and Cardiovascular Surgery 1996 112, 1202-1215DOI: (10.1016/S0022-5223(96)70133-2) Copyright © 1996 Mosby, Inc. Terms and Conditions

Fig. 4 Comparison between group I and group II patients (defined in Fig. 1 and in text) with respect to use of distal perfusion during repair of thoracic and thoracoabdominal aneurysms. Eighty-four patients in group I versus 56 in group II had partial bypass, 35 in group I versus 36 in group II had HCA, and 19 in group I versus three in group II had no distal bypass. Although the proportion of patients who had partial perfusion—distal perfusion without HCA—was the same in both groups, there were significant differences in proportions of group I and group II patients who underwent HCA and in whom no distal perfusion was used. This results in a highly significant difference between groups, as indicated by the p value, with respect to distal perfusion methods, which reflects acknowledged differences in surgical techniques between groups. The Journal of Thoracic and Cardiovascular Surgery 1996 112, 1202-1215DOI: (10.1016/S0022-5223(96)70133-2) Copyright © 1996 Mosby, Inc. Terms and Conditions

Fig. 5 Comparison between group I and group II patients (defined in Fig. 1 and in text) with respect to minimum temperatures recorded during sacrifice of intersegmental arteries and during aortic crossclamping. Patients who had HCA are excluded from both groups. As indicated by p values, both esophageal and rectal temperatures were slightly but significantly lower in group II patients, in whom a greater emphasis was placed on minimizing spinal cord metabolism during operation. The Journal of Thoracic and Cardiovascular Surgery 1996 112, 1202-1215DOI: (10.1016/S0022-5223(96)70133-2) Copyright © 1996 Mosby, Inc. Terms and Conditions

Fig. 6 Comparison between group I and group II patients (defined in Fig. 1 and in text) with respect to in-hospital mortality after aneurysm resection. All includes all patients in each group; other categories are conventional classifications reflecting aneurysm extent, as defined in Fig. 2. There is a significantly lower mortality after operation among patients undergoing operation more recently (group II) when all patients are included: 25 patients in group I died, versus 10 in group II. When smaller numbers of patients in other categories are compared, however, differences are not significant; 10 patients with thoracic aneurysms died in group I versus three in group II; 15 with thoracoabdominal aneurysms in group I died versus seven in group II; and nine with Crawford I and II aneurysms died in group I versus five in group II. The Journal of Thoracic and Cardiovascular Surgery 1996 112, 1202-1215DOI: (10.1016/S0022-5223(96)70133-2) Copyright © 1996 Mosby, Inc. Terms and Conditions

Fig. 7 Comparison between group I and group II patients (defined in Fig. 1 and in text) with respect to in-hospital mortality after aneurysm resection. When classified by extent of aneurysm as defined by number of intersegmental vessels severed, the more recent group II patients had a significantly lower mortality, not only overall (p = 0.03) but also in operations involving seven to 10 severed intersegmental arteries; nine patients in group I died versus one in group II (p = 0.02). Eleven patients in group I with more than 10 intersegmental vessels severed died, versus six patients in group II, and in the group with the smallest number of intersegmental vessels cut, there were five deaths in group I and three in Group II. The Journal of Thoracic and Cardiovascular Surgery 1996 112, 1202-1215DOI: (10.1016/S0022-5223(96)70133-2) Copyright © 1996 Mosby, Inc. Terms and Conditions

Fig. 8 Comparison between group I and group II patients (defined in Fig. 1 and in text) with respect to paraplegia after resection of descending thoracic and thoracoabdominal aneurysms. Rate of spinal cord injury is significantly lower among group II patients overall (11 patients in group I versus two in Group II), and also if thoracoabdominal aneurysms or Crawford I and II aneurysms are considered separately. Two patients with thoracic aneurysms in group I had spinal cord injury, versus none in group II; nine with thoracoabdominal aneurysms had paraplegia in group I, whereas only two in group II had paraplegia. In group I, five patients with Crawford I and three with Crawford II aneurysms had paraplegia; in Group II, only two patients in the Crawford I and II group, both with Crawford II aneurysms, had spinal cord injury. The Journal of Thoracic and Cardiovascular Surgery 1996 112, 1202-1215DOI: (10.1016/S0022-5223(96)70133-2) Copyright © 1996 Mosby, Inc. Terms and Conditions

Fig. 9 Comparison between group I and group patients (defined in Fig. 1 and in text) with respect to paraplegia after resection of descending thoracic and thoracoabdominal aneurysms. When extent of aneurysm is defined by number of intersegmental vessels severed, group II patients show significantly lower rates of paraplegia in each category: only two patients in group II with more than 10 vessels severed had spinal cord injury, whereas in group I paraplegia developed in six of the patients with most extensive aneurysms, an additional four in the intermediate group, and one in the group with very few intersegmental arteries cut. The Journal of Thoracic and Cardiovascular Surgery 1996 112, 1202-1215DOI: (10.1016/S0022-5223(96)70133-2) Copyright © 1996 Mosby, Inc. Terms and Conditions