Direct Spinal Cord Perfusion Pressure Monitoring in Extensive Distal Aortic Aneurysm Repair

Abstract

Although maintenance of adequate spinal cord perfusion pressure (SCPP) by the paraspinal collateral network is critical to the success of surgical and endovascular repair of descending thoracic and thoracoabdominal aortic aneurysms, direct monitoring of SCPP has not previously been described. A catheter was inserted into the distal end of a ligated thoracic segmental artery (SA) (T6 to L1) in 13 patients, 7 of whom underwent descending thoracic and thoracoabdominal aortic aneurysm repair using deep hypothermic circulatory arrest. Spinal cord perfusion pressure was recorded from this catheter before, during, and after serial SA sacrifice, in pairs, from T3 through L4, at 32 degrees C. Somatosensory and motor evoked potentials were also monitored during SA sacrifice and until 1 hour after cardiopulmonary bypass. Target mean arterial pressure was 90 mm Hg during SA sacrifice and after nonpulsatile cardiopulmonary bypass, and 60 mm Hg during cardiopulmonary bypass. A mean of 9.8 +/- 2.6 SAs were sacrificed without somatosensory and motor evoked potential loss. Spinal cord perfusion pressure fell from 62 +/- 12 mm Hg (76% +/- 11% of mean arterial pressure) before SA sacrifice to 53 +/- 13 mm Hg (58% +/- 15% of mean arterial pressure) after SA clamping. The most significant drop occurred with initiation of nonpulsatile cardiopulmonary bypass, reaching 29 +/- 11 mm Hg (46% +/- 18% of mean arterial pressure) before deep hypothermic circulatory arrest. Spinal cord perfusion pressure recovered during rewarming to 40 +/- 14 mm Hg (51% +/- 20% of mean arterial pressure), and further within the first hour of reestablished pulsatile flow. Somatosensory and motor evoked potentials returned in all patients intraoperatively. Recovery of SCPP began intraoperatively, and in 5 patients with prolonged monitoring, continued during the first 24 hours postoperatively. All but 1 patient, who had remarkably low postoperative SCPPs and experienced paraparesis, regained normal spinal cord function. This study supports experimental data showing that SCPP drops markedly but then recovers gradually during the first several hours after extensive SA sacrifice. Direct monitoring may help prevent a fall of SCPP below levels critical for spinal cord recovery after surgery and endovascular repair of descending thoracic and thoracoabdominal aortic aneurysms.