Intercostal Artery Reconstruction: The Simple and Effective Technique on Spinal Cord Protection during Thoracoabdominal Aortic Replacement

Abstract

To retrospectively analyze the role of intercostal artery reconstruction in the spinal cord protection for patients undergoing extensive thoracoabdominal aortic aneurysm repair. From August 2007 to 2014, thoracoabdominal aortas (Crawford II) of 81 consecutive patients with mean age 39.4 ± 10.32years were repaired. Seventy-three of these patients (90.12%) were diagnosed with aortic dissection in our group, 25 (30.86%) with Stanford type A dissection and 48 (59.26%) with Stanford B aortic dissection. All 25 patients with type A dissection have previously undergone surgical procedures which include Bentall's procedures in 11 cases, ascending aortic replacement in 6 cases, and total aortic arch replacement in 8 cases. All procedures were performed under profound hypothermia with interval cardiac arrest after making a thoracoabdominal incision. Extracorporeal circulation was instituted with 2 arterial cannulae and a single venous cannula in the right atrium. T6-T12 intercostal arteries and L1 and L2 lumbar arteries were formed to a neo-intercostal artery in place and were connected to an 8mm branch for maintaining spinal cord blood perfusion. Visceral arteries were joined into a patch and anastomosed to the end of the main graft. The left renal artery was anastomosed to an 8mm branch or joined to the patch. The other 10mm branches were anastomosed to iliac arteries. With 100% follow-up, early mortality was 7.4%. Six deaths were recorded; 1 patient died of cerebral hemorrhage, 3 of renal failure, 1 of heart failure because of myocardial infarction, and the last one died from the rupture of celiac artery dissection. The rate of postoperative spinal cord deficits was 3.7%, 2 patients with paraplegia and 1 patient with paraparesis. None had bladder or rectum dysfunction. Neo-intercostal arteries were clogged in 12 patients within follow-up period and formed pseudoaneurysm in 2 patients with Marfan syndrome. The mean survival time in this group was 54.22 ± 3.03months (95% confidence interval 44.37-59.90months) with survival rate of 92.37% after 1year, 89.02% after 2years, and 85.54% after 5years. All patients were free from spinal cord deficits. Intercostal artery reconstruction is an effective technique for spinal cord protection in patients with the thoracoabdominal aortic repair. It can achieve favorable results and avoid spinal cord deficits with long-term follow-up.