Angiographic localization of spinal cord blood supply and its relationship to postoperative paraplegia G.Melville Williams, MD, Bruce A. Perler, MD,

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Presentation transcript:

Angiographic localization of spinal cord blood supply and its relationship to postoperative paraplegia G.Melville Williams, MD, Bruce A. Perler, MD, James F. Burdick, MD, Floyd A. Osterman, MD, Sally Mitchell, MD, Dimitri Merine, MD, Benjamin Drenger, MD, Stephen D. Parker, MD, Charles Beattie, MD, Bruce A. Reitz, MD Journal of Vascular Surgery Volume 13, Issue 1, Pages 23-35 (January 1991) DOI: 10.1016/0741-5214(91)90009-J Copyright © 1991 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 1 The characteristic appearance on digital subtraction angiography of the GRA (large arrow) joining the anterior spinal artery (small arrow) in the area of lumbar enlargement of this artery. Note the presence of numerous collateral vessels and the indistinct origin of the GRA (open arrow) from small tortuous vessels. Journal of Vascular Surgery 1991 13, 23-35DOI: (10.1016/0741-5214(91)90009-J) Copyright © 1991 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 2 A flush injection of the midthoracic aorta in an 81-year-old man. A, The main aneurysm originates at T-10 (open arrow), but a second bulge in the wall of the vessels appears at T-7 (dark arrow). A number of intercostal arteries were identified in the critical zone (small arrows). The one labeled (a) was found to supply the anterior spinal artery. B, This intercostal vessel could have been included in the proximal anastomosis if it were necessary to repair the bleb. Notice the origin is from small vessels, and that collateral vessels are abundant. Journal of Vascular Surgery 1991 13, 23-35DOI: (10.1016/0741-5214(91)90009-J) Copyright © 1991 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 3 Demonstration of a successful second attempt. A, Engagement of an intercostal artery at T-10 was possible after graft replacement of the entire abdominal and distal descending thoracic aorta. The numbered grid aids localization on spot films. Note the selective injection of the left T-10 (small arrow) fills T-9 (large arrow) and the anterior spinal artery (open arrow). B, Delayed digital subtraction angiography image of the same catheter injection shows a large posterior collateral (open arrow) and a smaller one (small arrow) join T-10 to T-9. The GRA (dark arrow) arises from T-9 to join the anterior spinal artery (small arrow). Journal of Vascular Surgery 1991 13, 23-35DOI: (10.1016/0741-5214(91)90009-J) Copyright © 1991 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 4 Small branch origin of the GRA. A, The GRA (large arrow) originates from at least two small arteries (open arrow). B, Subsequent exposures demonstrate caudal flow in the anterior spinal artery (arrow). We never observed bidirectional flow at the junction of the GRA with the anterior spinal artery. Journal of Vascular Surgery 1991 13, 23-35DOI: (10.1016/0741-5214(91)90009-J) Copyright © 1991 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 5 The best demonstration of an important GRA (small arrow) originating directly from the intercostal artery (large arrow). This patient was treated with spinal fluid drainage, intrathecal papaverine, and atriofemoral bypass. Intercostal ischemic time was 12 minutes. Yet she awoke with paralysis at the T-11 level. Journal of Vascular Surgery 1991 13, 23-35DOI: (10.1016/0741-5214(91)90009-J) Copyright © 1991 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 6 Demonstration of the posterior aortic flush technique currently used. When direct injection is not technically possible, the catheter tip is positioned posteriorly and a hand injection of 20 ml of contrast made. Note filling of two pairs of intercostal arteries and the GRA (arrow). Journal of Vascular Surgery 1991 13, 23-35DOI: (10.1016/0741-5214(91)90009-J) Copyright © 1991 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 7 Schematic representation of the arterial supply to the spinal cord. The anterior and posterior spinal arteries originate from branches of the vertebral arteries and have contributions from the thyrocervical and costocervical trunks. The thoracic radicular artery is one of the more constant radicular branches contributing to the anterior spinal artery, particularly when the GRA originates from L-1 or L-2. We have drawn the origin of the GRA or artery of Adamkiewicz originating from a nest of collateral vessels from several intercostal arteries as this has been our observation in patients with aneurysms. The terminal portion of the spinal cord receives input from small branches of the internal iliac and/or middle sacral artery. The anterior and posterior spinal arteries are connected at this point by a circular artery, but are likewise fairly independent. Journal of Vascular Surgery 1991 13, 23-35DOI: (10.1016/0741-5214(91)90009-J) Copyright © 1991 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 8 Schematic representation of the risk of spinal cord injury associated with the repair of various segments of the descending thoracic and abdominal aorta. The risk of paraplegia from clinical reports is associated with the length of the aortic segment requiring repair and the risk of injury to the GRA. Journal of Vascular Surgery 1991 13, 23-35DOI: (10.1016/0741-5214(91)90009-J) Copyright © 1991 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions