Spinal Ischemia in Thoracic Aortic Procedures: Impact of Radiculomedullary Artery Distribution Fabian A. Kari, MD, Karin Wittmann, DVM, Sonja Krause,

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Spinal Ischemia in Thoracic Aortic Procedures: Impact of Radiculomedullary Artery Distribution Fabian A. Kari, MD, Karin Wittmann, DVM, Sonja Krause, MS, Babak Saravi, MS, Luisa Puttfarcken, MS, Katharina Förster, DVM, Bartosz Rylski, MD, Sven Maier, CCP, Ulrich Göbel, MD, PhD, Matthias Siepe, MD, Martin Czerny, MD, PhD, Friedhelm Beyersdorf, MD, PhD The Annals of Thoracic Surgery Volume 104, Issue 6, Pages 1953-1959 (December 2017) DOI: 10.1016/j.athoracsur.2017.05.031 Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

The Annals of Thoracic Surgery 2017 104, 1953-1959DOI: (10. 1016/j The Annals of Thoracic Surgery 2017 104, 1953-1959DOI: (10.1016/j.athoracsur.2017.05.031) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Anatomic details of intraspinal collateralization [10]. View is from behind, with 2 pedicles of spinal column and 2 dorsal processes removed. Two pairs of lateral processes are visible (latProc). Anterior radiculomedullary arteries (ARMAs) augment anterior spinal artery (ASA) from right and left sides (asterisks). The dorsal segmental arteries (SAinflow) branch into either 2 vessels, which contribute to the system of epidural arcades (EpiA), or into 3 vessels, in which case they give rise in addition to an ARMA. The vertical black arrow indicates the further vertical course of the ASA. The Annals of Thoracic Surgery 2017 104, 1953-1959DOI: (10.1016/j.athoracsur.2017.05.031) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Maximum distance between any 2 anterior radiculomedullary arteries (ARMAs) within the borders of “stent-grafted” or “replaced” aortic segment (vertical yellow bar). Horizontal yellow line is lower border of treated aortic segment. Black arrows mark short distance of just 1 segment in example animal (left) and long distance of 3 segments between 2 ARMAs in another example animal (right). ASA = anterior spinal artery; Bas = basilar artery; C = cervical; dAo = descending thoracic aorta; L = lumbar; LSA = left subclavian artery; T = thoracic; tSA = thoracic segmental arteries; Vert = vertebral artery. Sacral segments not illustrated. The Annals of Thoracic Surgery 2017 104, 1953-1959DOI: (10.1016/j.athoracsur.2017.05.031) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Maximal distance between end of simulated stent-grafted aortic segment (vertical yellow bar) and first thoracic anterior radiculomedullary artery (ARMA). Horizontal yellow line is lower border of treated aortic segment. Black arrows mark short distance of 0 segments in example animal (left) and long distance of 2 segments from end of treated aortic segment to first thoracic ARMA in another animal (right). ASA = anterior spinal artery; Bas = basilar artery; C = cervical; dAo = descending thoracic aorta; L = lumbar; LSA = left subclavian artery; tSA = thoracic segmental arteries; T = thoracic; Vert = vertebral artery. Sacral segments not illustrated. The Annals of Thoracic Surgery 2017 104, 1953-1959DOI: (10.1016/j.athoracsur.2017.05.031) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Regional spinal cord blood flow (SCBF) at baseline, immediately after operation, and after 3 hours of observation in groups with small and large maximum distances between any 2 thoracic anterior radiculomedullary arteries (tARMAs). Small ARMA-free distances protected from significant SCBF drop during procedure and were prerequisite for reactive postoperative hyperemia. (ARMA = anterior radiculomedullary artery.) The Annals of Thoracic Surgery 2017 104, 1953-1959DOI: (10.1016/j.athoracsur.2017.05.031) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Regional spinal cord blood flow at baseline immediately after operation and after 3 hours of observation. Left, group 0; right, group ≥1. Reactive global hyperemia is less pronounced in group ≥1 and along segments T8, T9, and T10 (lowest treated segments); no regional hyperemia was detectable in group ≥1. (ARMA = anterior radiculomedullary artery; postop = postoperative.) The Annals of Thoracic Surgery 2017 104, 1953-1959DOI: (10.1016/j.athoracsur.2017.05.031) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Supplemental Figure 1 The Annals of Thoracic Surgery 2017 104, 1953-1959DOI: (10.1016/j.athoracsur.2017.05.031) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Supplemental Figure 2 The Annals of Thoracic Surgery 2017 104, 1953-1959DOI: (10.1016/j.athoracsur.2017.05.031) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions