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

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Aspects of the spinal cord circulation as assessed by intrathecal oxygen tension monitoring during various arterial interruptions in the pig Lennart Christiansson, MD, PhDa, A.Tulga Ulus, MDa, Anders Hellberg, MD, PhDb, David Bergqvist, MD, PhDb, Lars Wiklund, MD, PhDa, Sadettin Karacagil, MD, PhDb The Journal of Thoracic and Cardiovascular Surgery Volume 121, Issue 4, Pages 762-772 (April 2001) DOI: 10.1067/mtc.2001.112466 Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 1 Clamping techniques. Schematic shows what combinations of numbered clamping locations were used in the various experimental groups. For orientation, larger arteries and important vertebral bodies are delineated. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 762-772DOI: (10.1067/mtc.2001.112466) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 2 Paratrend 7 recordings and trend printouts (examples from groups P, D, and DS). Single arrows indicate the start of clamping (1 kPa = 7.5 mm Hg). Trend registrations of 30 minutes show changes in intrathecal pH, PCO2, and PO2 in response to aortic crossclamping and other manipulations of the spinal cord circulation. a shows an example from group P in which the proximal aorta was crossclamped for 30 minutes. Within minutes, PO2 fell to undetectable levels, and the changes in the metabolic variables pH and PCO2 were pronounced. The reverse blood flow in segmental arteries with unimpeded runoff to the distal aorta explains why ischemia develops in the spinal cord. The result of double-aortic crossclamping (group D) is seen in b. PO2 was reduced to an intermediate level, and the changes in pH and PCO2 developed slowly and never reached convincingly dysoxic levels. The explanation for this is that steal circulation is prevented in the excluded thoracoabdominal aortic segment, which makes the proximal collateral circulation more effective. The importance of the distal clamp location is demonstrated from a separate experiment in c. Double arrows indicate that the distal second clamp (with a time interval of 5 minutes) was placed 2 segments above the celiac trunk. This increases PO2 to some extent, but when the clamp is moved close to the celiac trunk 5 minutes later (triple arrow) , PO2 improves further as a result of prevention of steal in important segmental arteries (Adamkiewicz artery). d shows the effect of combined clamping (double aortic and both subclavian arteries, group DS). Although aortic steal was partly prevented, this combination of aortic clamping and interruption of both the subclavian-intercostal and vertebral collateral circulation creates ischemia comparable with that of the group with only proximal aortic crossclamping. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 762-772DOI: (10.1067/mtc.2001.112466) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 3 Two-dimensional image and Doppler ultrasonography. Arrows indicate aortic lumen and the proximal part of the largest segmental artery close to the celiac trunk. The direction of intercostal blood flow is shown in relation to proximal aortic crossclamping. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 762-772DOI: (10.1067/mtc.2001.112466) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 4 Paratrend 7 recordings and trend printouts (examples from groups I and IS). Arrows indicate the start of clamping (1 kPa = 7.5 mm Hg). Trend registrations of 30 minutes (2 hours in d ) show changes in intrathecal pH, PCO2, and PO2 in response to interruption of segmental arteries and other manipulations of the spinal cord circulation. On clamping or ligation of all segmental arteries below T5 (group I), we could not demonstrate any significant changes in the intrathecal variables, as shown in a. Maintained proximal pressure assures adequate collateral circulation through the subclavian-intercostal and vertebral pathways. b shows an example from group IS (IS:1), in which adding selective proximal intercostal clamping creates ischemia as a result of insufficient vertebral feeding of the longitudinal spinal arteries. In c another example of the same group (IS:4) shows only a 50% reduction in PO2, with no change in the metabolic parameters. The interpretation of this is that the remaining collateral circulation is sufficient to prevent ischemia in this case. This is confirmed in the same experiment, as shown by the 2-hour trend in d. After the 90-minute experiment, the selective clamps on the supreme intercostal arteries were moved to the subclavian arteries (double arrow) , whereby the interruption of the remaining collateral circulation resulted in ischemia. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 762-772DOI: (10.1067/mtc.2001.112466) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 5 Topographic anatomy of supreme intercostal arteries. The Journal of Thoracic and Cardiovascular Surgery 2001 121, 762-772DOI: (10.1067/mtc.2001.112466) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions