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

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Operative Strategy for Descending and Thoracoabdominal Aneurysm Repair With Preoperative Demonstration of the Adamkiewicz Artery Kojiro Furukawa, MD, Keiji Kamohara, MD, Junichi Nojiri, MD, Yoshiaki Egashira, MD, Yukio Okazaki, MD, Sho Kudo, MD, Shigeki Morita, MD The Annals of Thoracic Surgery Volume 90, Issue 6, Pages 1840-1846 (December 2010) DOI: 10.1016/j.athoracsur.2010.07.056 Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Two cases of intraarterial computed tomographic angiography are shown. (A) Shows that the right sixth intercostal artery is connected directly to the Adamkiewicz artery in a chronic, dissecting thoracoabdominal aortic aneurysm (Crawford type III). (B) Shows two Adamkiewicz arteries from the tenth intercostal and the fourth lumbar arteries in a chronic, dissecting descending aortic aneurysm (arrows). The Annals of Thoracic Surgery 2010 90, 1840-1846DOI: (10.1016/j.athoracsur.2010.07.056) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 In an atherosclerotic thoracoabdominal aortic aneurysm (Crawford type 4), the Adamkiewicz artery originates from the ninth interthoracic vertebral level (white arrow); however, the innate origin of the aorta is severely stenotic. As a result, the Adamkiewicz artery is visualized from the eleventh intercostal artery (black arrow) through collateral circulation. The Annals of Thoracic Surgery 2010 90, 1840-1846DOI: (10.1016/j.athoracsur.2010.07.056) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 The aortic origin of the segmental artery to the Adamkiewicz artery was confirmed intraoperatively at the level of its intercostal space, as well as its relation with the aneurysm, and its relation with the celiac, superior mesenteric, and renal arteries. (A) The black arrow indicates the aortic origin of the segmental artery (right ninth intercostal artery [rt. 9th]) to the Adamkiewicz artery. (B) The long white arrow indicates the aortic origin of the segmental artery (left eleventh intercostal artery [lt. 11th ICA]) to the Adamkiewicz artery and the short arrow shows the celiac artery. The Annals of Thoracic Surgery 2010 90, 1840-1846DOI: (10.1016/j.athoracsur.2010.07.056) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Distal perfusion cannula 2.0 mm in diameter (white arrow) is inserted into the segmental artery and a 4-0 polypropylene suture is placed to tourniquet catheter (black arrow). The Annals of Thoracic Surgery 2010 90, 1840-1846DOI: (10.1016/j.athoracsur.2010.07.056) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Localization of the segmental artery-Adamkiewicz artery. (T = thoracic; L = lumbar.) The Annals of Thoracic Surgery 2010 90, 1840-1846DOI: (10.1016/j.athoracsur.2010.07.056) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 The patency of the reconstructed segmental artery (SA) that connected with the Adamkiewicz artery (AKA) evaluated with postoperative intraarterial computed tomographic angiography or multidetector computed tomography. Forty-four percent of the segmental arteries were occluded. In one paraparesis patient, the reconstructed graft was patent. (SCI = spinal cord injury.) The Annals of Thoracic Surgery 2010 90, 1840-1846DOI: (10.1016/j.athoracsur.2010.07.056) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 Mechanism and prevention of spinal cord injury. (CSF = cerebral spinal fluid; SA = segmental artery; AKA = Adamkiewicz artery.) The Annals of Thoracic Surgery 2010 90, 1840-1846DOI: (10.1016/j.athoracsur.2010.07.056) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions