Artery Of Adamkiewicz Research Articles

Surgical Management of Descending Thoracic Aortic Disease: Open and Endovascular Approaches

Recent years have witnessed the emergence of novel technologies that enable less invasive endovascular treatment of descending thoracic aortic disease (TAD). This has occurred against a backdrop of improved identification of various disease processes and better results with open surgical repair. The natural history of the specific acute aortic syndromes that affect the descending thoracic aorta has also been described with more clarity and has become more commonly recognized. This is in part secondary to the widespread availability and application of advanced imaging technologies that permit precise diagnoses. As data are accumulating, these pathological processes involving the descending thoracic aorta are no longer thought of as simply variants of one another but as distinct entities with well-defined clinical behavior. As the technology for endovascular repair continues to mature and its utilization increases, there is a need for a careful assessment of the current state of medical management, traditional open therapy, and evolving endovascular treatment of distinct thoracic aortic pathologies. The purpose of this scientific statement is to present a contemporary review of the various pathological processes that affect the descending thoracic aorta: Aneurysms, dissections, intramural hematomas (IMHs), penetrating atherosclerotic ulcers (PAUs), and aortic transections. These disorders will be considered in detail, with an exploration of the natural history, available treatment options, and controversies regarding management. Current intervention criteria will be reviewed with respect to both open surgical repair and endovascular treatment. Our goal is to provide the healthcare professional with a better understanding of the pathophysiology of the various disease processes that involve the descending thoracic aorta and to review current outcomes and technical pitfalls associated with these therapies to facilitate strong, evidence-based decision making in the care of these patients. Treatment of descending TAD involves complex, exigent decision making in an era of evolving technology. Survival data for nonoperative …

Presurgical Localization of the Artery of Adamkiewicz with Time-resolved 3.0-T MR Angiography

To evaluate the use of time-resolved magnetic resonance (MR) angiography in the presurgical localization of the artery of Adamkiewicz prior to reimplantation of the feeding intercostal artery, lumbar artery, or both during aortic aneurysm repair. This institutional review board-approved retrospective study included 68 patients (36 men, 32 women) who underwent time-resolved spinal MR angiography (0.2 mmol per kilogram of body weight gadobenate dimeglumine administered at a rate of 2.0 mL per second) performed with a 3.0-T imager with a dedicated eight-element spine coil. Images were reviewed at a three-dimensional workstation by two experienced radiologists in consensus. The artery of Adamkiewicz was identified, and the location of the feeding intercostal and/or lumbar artery was ascertained by using a five-point confidence index (scores ranged from 1 to 5). The phases in which the artery of Adamkiewicz, aorta, and great anterior radiculomedullary vein (GARV) demonstrated peak enhancement were also recorded. The artery of Adamkiewicz and the location of the feeding intercostal and/or lumbar artery were identified with high confidence in 60 (88%) of the 68 patients. Origins of the artery of Adamkiewicz were on the left side of the body in 65% of patients and on the right side in 35%. The level of origin ranged from the T6 neuroforamina to the L1 neuroforamina. The arrival of contrast material was highly variable in this patient population, which had substantial aortic disease. The highest signal intensity in the aorta, artery of Adamkiewicz, and GARV occurred a mean of 55 seconds (range, 27-99 seconds; 95% confidence interval [CI] 51, 58), 72 seconds (range, 38-110 seconds; 95% CI: 68, 76), and 95 seconds (range, 46-156 seconds; 95% CI: 89, 101) after contrast material administration, respectively. The artery of Adamkiewicz and the anterior spinal artery can be identified and differentiated from the GARV even in patients with substantially altered hemodynamics by using time-resolved 3.0-T MR angiography.

Spinal cord protection with selective spinal perfusion during descending thoracic and thoracoabdominal aortic surgery☆

Open repair of aortic aneurysm causes spinal cord perfusion pressure to decrease due to the steal phenomenon from the bleeding of intercostal arteries and cross-clamping of the aorta. We attempted to perfuse the intercostal arteries for preoperative detection of the artery of Adamkiewicz using newly developed catheters. Fifteen patients underwent selective spinal perfusion with our original catheter as spinal protection during the procedure of distal descending thoracic aneurysm (DTA) or thoracoabdominal aortic aneurysm (TAAA) repair. Seven patients had distal DTA and eight had TAAA. Monitoring of motor evoked potential (MEP) was performed in all patients throughout the operation. The perfusion flow was 30-40 ml/min for each intercostal artery and was adjusted to keep the proximal circuit pressure at 150-200 mmHg. The average number of perfused intercostal arteries was 2.3 per patient and the number of intercostal arteries reimplanted per patient was 2.5. Intercostal arteries were reimplanted using an interpositional graft. MEPs were still observable after graft replacement in all patients and there were no cases of paraparesis/paraplegia. All patients were discharged ambulatory. Selective spinal perfusion maintains the quantity of total blood flow in the spinal cord and is very useful for reducing the incidence of ischemic injury of the spinal cord during operation.

Occlusion of the Artery of Adamkiewicz After Hip and Knee Arthroplasty

The artery of Adamkiewicz is the most significant tributary of the anterior spinal artery in the midthoracic region; the occlusion of this artery results in a well-described phenomenon consisting of paraplegia with loss of the sensation of pain, temperature, and touch as well as loss of sphincter control. Proprioception and vibration sense are typically preserved. Although this phenomenon has been associated with several surgeries as well as preexisting aortic abnormalities, the literature thus far has not reported this as a complication of hip or knee arthroplasty. Two case histories are presented.

Three-dimensional demonstration of the collateral circulation to the artery of Adamkiewicz via the thoracodorsal and inferior phrenic arteries

Fig. 1. Preoperative evaluation of the thoracic aortic aneurysm and the artery of Adamkiewicz using a 64-slice computed tomography. The anterior view of volume-rendered image with semitransparent aorta and skeletal system shows the artery of Adamkiewicz (arrow) originating from the left 9th intercostal artery (ICA 9). The heart and ascending aorta are electronically removed to show the artery of Adamkiewicz.

Root Cause Analysis of Paraplegia Following Transforaminal Epidural Steroid Injections: The ‘Unsafe’ Triangle

The utilization rate of transforaminal epidural steroid injections (TFESIs), an elective diagnostic and therapeutic spinal procedure, has risen dramatically over the past decade. In 2006 alone, greater than 300,000 thoracolumbar TFESIs were performed on Medicare beneficiaries. Despite the purported superiority of the transforaminal route, compared to other modes of epidural injection, TFESIs are associated with potential hazards. The artery of Adamkiewicz (ARM) might enter any mid thoracic, lower thoracic, or lumbar foramen; the exact level, in a specific patient, will be unknown to the proceduralist· The authors propose that the “safe triangle” approach to transforaminal epidural injections is not safe (TFESIs). Injury to the ARM can lead to paraplegia, independent of operator skill or adjuvant safety initiatives (digital subtraction angiography, local anesthetic test dose). Injury to the ARM is a “black swan” event. The authors believe that catastrophic injury may be averted when performing TFESIs by avoiding the “un-safe,” superoanterior triangle in the foramen and that transforaminal injections should be performed at the inferior aspect of the foramen, known as Kambin’s triangle. Key words: transforaminal, spinal cord, artery of Adamkiewicz, paraplegia, foramen, radiculomedullary, root cause analysis, patient safety, medico-legal, black swan

Magnetic resonance imaging and motor-evoked potentials in spinal cord infarction: report of two cases

Because in the early phases of spinal cord ischemia magnetic resonance imaging (MRI) can be normal, its clinical diagnosis is often difficult. We aimed to explore if motor-evoked potentials (MEPs) recordings may contribute to earlier diagnosis of spinal cord stroke. The clinical, MRI, and MEP findings in one case each of cervical and lumbar spinal cord infarction were reported. Spinal MRI at admission was unremarkable in both patients. At this time, MEPs were abnormal in both patients, to the upper and lower limbs in the first patient, exclusively to the lower limbs in the second. Follow-up MRI examinations documented an infarction in the territory of the anterior spinal artery and of the Adamkiewicz artery, respectively. MEP study can be useful in demonstrating spinal cord involvement also when radiological evidence for spinal cord damage is absent or equivocal. Early diagnosis may allow earlier intervention and contribute to improved patient management.

Is hypothermia a reliable adjunct for spinal cord protection in descending and thoracoabdominal aortic repair with regional or systemic cooling?

1multidisciplinary approaches have been directed toward minimizing spinal cord ischemic injury during surgery of the descending thoracic and thoracoabdominal aorta. The principal modality has been distal aortic perfusion during the aortic crossclamping, which was passive in the past with a temporary shunt tube or bypass and that currently has been active with a left heart bypass or a cardiopulmonary bypass (CPB). Other approaches include the following: intraoperative monitoring of spinal cord ischemia with somatosensory evoked potentials and transcranial motor evoked potentials; reattaching the responsible intercostal artery; increasing collateral fl ow by controlling the back-bleeding of the patent intercostal arteries with high cardiac output and arterial pressures with cerebrospinal fl uid (CSF) drainage; increasing ischemic tolerance with pharmacological adjuncts including naloxane, steroid, barbiturates, and with hypothermia; reducing excitotocixity from neuronal ischemia with hypothermia, naloxane, and steroid; and attenuating reperfusion injury with steroid, hypothermia, and free radical scavengers. Particularly, in Japan, with recent great advances in diagnostic imaging modalities, preoperative demonstration of the arteria radicularis magna (Adamkiewicz artery) by magnetic resonance imaging (MRI) or computed tomography (CT) scans has been highlighted as a reliable guide for reattachment or preservation of the responsible intercostal arteries including the collaterals. Since the 1950s hypothermia has been proven effective for protecting organs, including the central nervous system, in the cardiovascular surgical fi eld. 2–5 When focusing on milestones of aortic surgery, systemic profound hypothermia at 12°–15°C was applied to aortic arch surgery for brain protection in 1975. 6

A Little Talk on Adamkiewicz's Artery. Some Practical Considerations on the Pre-Operative Identification of This Artery Starting from a Single Team Experience in Pre-Surgical Selective Embolization of Vascularized Spinal Lesions

The major radicular artery eponymically named "Adamkiewicz's artery" (AKA) is an important vessel supplying the spinal cord, especially the lumbar enlargement. This report emphasizes the importance of anatomical knowledge of this artery and highlights the concept of the potential risk of neurological complications during different procedures: spine orthopedic/neurosurgery, aortic repair (vascular surgery) and endovascular selective embolizations performed by interventional neuro/radiologists. Anatomical considerations are made on the spinal cord arterial circulation with a special focus on the AKA. Our review of the literature considered this anatomical element essential to compare the potential risk of spinal cord ischemic damage during orthopedic/neurosurgical spine procedures, aortic vascular surgery repair procedures and endovascular selective arterial embolizations. Evaluation of the endovascular selective arterial spine embolization risk was based on our series of 410 embolization procedures. Spinal cord infarction and transient or permanent paraplegia may result from inadvertent interruption of the AKA. The presence of intersegmental collaterals may decrease the risk of spinal cord ischemia: this is an important element to bear in mind that may help in spine surgery or aortic repair procedures performed by vascular surgeons. Nevertheless, during aortic repair (open surgery or stent-graft procedures) interruption of bilateral segmental arteries at multiple consecutive levels including that of the AKA may occur thereby increasing the ischemic spinal cord risk, annulling the benefit of intersegmental collaterals. Accidental embolizations of the AKA during endovascular spine procedures (i.e. selective arterial embolizations) performed by interventional neuro/radiologists will cause an almost certain spinal cord infarction due to the consequent embolizations of the anterior spinal artery (ASA).

Angio-CT Imaging of the Spinal Cord Vascularisation: A Pictorial Essay

Knowledge of the spinal cord (SC) vascular supply is important in patients undergoing procedures that involve the thoracic and thoraco-abdominal aorta; the SC vasculature, however, has a complex and highly variable anatomy. Recent breakthroughs in imaging methods have expanded the non-invasive diagnostic ability to determine a patient's spinal cord vascular pattern, particularly in detecting the presence and location of the artery of Adamkiewicz. CT is the imaging modality of choice for most patients with thoracic and thoraco-abdominal aortic disease for pre-operative planning of endovascular treatment: thus the data set required for our analysis of spinal cord vascular anatomy is already available. This paper provides examples of the SC vasculature imaging that can be obtained with 64 row scanners and appropriate postprocessing.

３Ｔ ＭＲＩにおける造影 Ａｄａｍｋｉｅｗｉｃｚ Ａｒｔｅｒｙ撮像法の検討

Contrast enhanced magnetic resonance angiography (CE-MRA) is a common method for imaging the Adamkiewicz Artery (AKA). Test-bolus imaging methods have long been the mainstream, and recently, a time resolved technique (4D-MRA) is also reported. However, the current rates of detection for both are mixed, and the best method has not been established yet. For AKA, the present rate is 72% left, Th8～L1 91% that exists between, with a vessel diameter of 0.5 to 1.5 mm. Additionally, the AKA branch is known to have large individual differences, and thus, a wide range of high spatial resolution imaging. At our institution from January 2009, a 3 T system is installed, and 4D-MRA (time-resolved angiography with interleaved stochastic trajectories: TWIST) imaging became possible. TWIST is a sequence to balance the temporal resolution and spatial resolution, and is considered optimal for the imaging of AKA. In accordance with this idea, the first group of seven patients was imaged by TWIST, but in all cases, the results were not depicting AKA. In subsequent cases, the technique was changed to a 3D-gradient echo sequence with a Bolus-tracking method (Care bolus), and good results were obtained. In conclusion, AKA TWIST was not thought to depict the relationship between specific parameters. When using TWIST for imaging AKA, we will need to find out why it was not visualized, by examining AKA with simulated vessel phantoms, TWIST and Care Bolus. Furthermore, we report on our visual evaluation of the Retrospective clinical pictures.

New intraspinal cause of physiological FDG uptake

We present a paediatric case of Papillary Ca thyroid under evaluation for elevated Thyroglobulin (Tg) level with negative 131I wholebody scintigraphy. Differentiated thyroid cancer (DTC) arises from follicular epithelium and retains basic biological features like expression of sodium iodide symporter (NIS), which is the cellular basis of radio iodine (131I) concentration during thyroid ablation. Once dedifferentiation of thyroid cells occurs, cells fail to concentrate 131I, posing both diagnostic and therapeutic problems in DTC and one may have to resort to other imaging techniques for disease localization. As DTC progression is slow, patients have a relatively good prognosis. However children with thyroid malignancies need aggressive management, as initial presentation itself maybe with nodal metastases. It is well known that FDG PET CT apart from its oncological applications, is also used in the evaluation of vascular inflammation especially Takayasu’s arteritis. It is also reported in literature, that 18F-FDG uptake can be seen relatively frequently in the arterial tree of cancer patients. Dunphy et al reported the association of vascular FDG uptake in inflammation as well as in normal arteries. This study typically describes FDG uptake in a patchwork of normal vessel, focal inflammation and or calcification of vessels. The other plausible reasons for significant vascular 18F-FDG uptake are drugs such as potent non steroidal anti-inflammatory agents, dexamethasone, prednisone and tacrolimus. Our patient showed false positive 18F Fluorodeoxyglucose (FDG) uptake in spinal cord at D11/12 and D12/L1 vertebral levels in FDG PET CT imaging performed as part of raised Thyroglobulin workup. This intra spinal FDG uptake is attributed to physiological uptake and inadequate FDG clearance from artery of Adamkiewicz, which can be added as a new physiological cause of FDG uptake unreported in literature as yet.

MRI and MRA of Aortic Disease

Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) play a critical role in diagnosing aortic disease such as aortic dissection and aneurysm. Additionally, the advent of contrast-enhanced MRA has allowed MRA to advance markedly and several new imaging techniques to emerge as well. While computed tomography (CT) angiography using multidetector-row CT is a significant innovation, MRA may generate more useful diagnostic information, such as on the artery of Adamkiewicz.

Three-dimensional demonstration of the collateral circulation to the artery of Adamkiewicz via the thoracodorsal artery with multi-slice computed tomography angiography

Three-dimensional demonstration of the collateral circulation to the artery of Adamkiewicz via the thoracodorsal artery with multi-slice computed tomography angiography

A novel approach to prevent spinal cord ischemia: Inoue stent graft with a side branch of small caliber for the reconstruction of the artery of Adamkiewicz

Paraplegia remains a serious complication after endovascular repair of thoracic aortic aneurysms, and it has been reported that paraplegia might be due to ischemia of the artery of Adamkiewicz. This study investigates the feasibility of an Inoue stent graft with a side branch of a small caliber for the reconstruction of the intercostal artery branching the artery of Adamkiewicz. Branched Inoue stent grafts were implanted into the thoracic aorta and 11th intercostal artery of 5 mongrel dogs. The side branch measured 3 x 5 mm and contained a bare-metal coronary stent for fixing to the intercostal arterial wall. Aortography and selective angiography of the 11th intercostal artery were performed before and immediately after implantation and after 1, 4, 8, and 12 weeks. The luminal diameter of the intercostal artery before implantation was 2.4 +/- 0.3 mm. All stent grafts were successfully deployed. The main body of the graft did not develop endoleak or migrate, and the side branch remained patent for 12 weeks. Angiography performed 1 week postoperatively revealed smooth flow with slight stenosis (4.2% +/- 1.7%) along the side branches and the intercostal arteries in all dogs. Four weeks postoperatively, however, mild concentric stenosis (38% +/- 16%) along the side branch was observed in 4 of the 5 dogs. The percent stenosis at 8 and 12 weeks was 38% +/- 15% and 33% +/- 11%, respectively; these values were not significantly different from the value at 4 postoperative weeks. A novel Inoue stent graft with a side branch of small caliber was successfully deployed into the canine thoracic aorta and intercostal artery; the side branch remained patent for 12 weeks. This novel technique may enable endovascular reconstruction of the Adamkiewicz artery.

Spinal Cord Injury is Not Negligible after TEVAR for Lower Descending Aorta

Objectives To clarify the incidence of spinal cord injury (SCI) after thoracic endovascular aneurysm repair (TEVAR), we investigate the intercostal/lumbar arteries that supply the Adamkiewicz artery (ICA-AKA). Patients Among 81 patients subjected to TEVAR, we retrospectively reviewed the clinical records of 50 patients (range: 57–86 (median age: 77) years, 41 males) who underwent TEVAR for part of or the whole distal descending aorta (T7 to L2) after identification of ICA-AKA by magnetic resonance angiography (MRA) or computed tomography angiography (CTA). Results The 50 patients were classified into group A: 17 patients whose patent ICA-AKA was not covered, group B: 24 patients whose ICA-AKA was covered and group C: nine patients in whom no patent ICA-AKA was identified. Only three patients in group B suffered paraplegia and of them two recovered full ambulation. The estimated incidence of permanent and transient paraplegia was 3.7% in all TEVAR patients, 6.0% when part of or the entire distal aorta was covered and 12.5% when the patent ICA-AKA was covered. The length of aortic coverage in patients with paraplegia was >300 mm. Conclusions Paraplegia after TEVAR occurred in one of eight patients in whom the stent graft covered ICA-AKA. Long coverage of the aorta including the ICA-AKA was critical. To prevent this serious complication, identification of the ICA-AKA is crucial.

Paraplegia Following Image-Guided Transforaminal Lumbar Spine Epidural Steroid Injection: Two Case Reports

To present two case reports of a rare but devastating injury after image-guided, lumbar transforaminal injection of steroids, and to explore features in common with previously reported cases. Image (fluoroscopic and computed tomography [CT])-guided, lumbar transforaminal injections of corticosteroids have been adopted as a treatment for radicular pain. Complications associated with these procedures are rare, but can be severe. An 83-year-old woman underwent a fluoroscopically guided, left L3-L4, transforaminal injection of betamethasone (Celestone Soluspan). A 79-year-old man underwent a CT-guided, right L3-L4, transforaminal injection of methylprednisolone (DepoMedrol). Both patients developed bilateral lower extremity paralysis, with neurogenic bowel and bladder, immediately after the procedures. Magnetic resonance imaging scans were consistent with spinal cord infarction. There was no evidence of intraspinal mass or hematoma. These cases consolidate a pattern emerging in the literature. Distal cord and conus injury can occur following transforaminal injections at lumbar levels, whether injection is on the left or right. This conforms with the probability of radicular-medullary arteries forming an arteria radicularis magna at lumbar levels. All cases used particulate corticosteroids, which promotes embolization in a radicular artery as the likely mechanism of injury. The risk of this complication can be reduced, and potentially eliminated, by the utilization of particulate free steroids, testing for intra-arterial injection with digital subtraction angiography, and a preliminary injection of local anesthetic.

A New Intercostal Artery Management Strategy for Thoracoabdominal Aortic Aneurysm Repair

Conclusion: Identification of the anterior spinal artery, artery of Adamkiewicz with magnetic resonance angiography (MRA), and subsequent selective reimplantation of intercostal arteries during open thoracoabdominal aneurysm (TAA) repair may serve as an effective additional adjunct in reducing immediate or delayed paraplegia after repair of TAAs. Summary: Spinal cord ischemia (SCI) before the use of perioperative protective measures occurred in 16% to 31% of patients undergoing TAA repair. Advances in surgical technique, postoperative care, and anesthetic management have been introduced to address the rate of SCI after TAA repair. Intraoperative techniques have contributed to a reduction in the occurrence of SCI with TAA repair. Some have used spinal angiography to identify critical intercostal arteries; however, the technique has proved difficult to use and is associated with some risk. Current advances in computed tomography angiography (CTA) and MRA have made it possible to noninvasively identify important intersegmental arteries in patients undergoing TAA repair. In this article the authors introduce a new adjunct for TAA repair that involves the perioperative identification and selective implantation of critical intercostal arteries based on preoperative MRA imaging. Included in this study were patients undergoing TAA repair from August 2005 to September 2007 at the University of Wisconsin. Spinal artery MRA was used to identify the anterior spinal artery and its major intercostal source preoperatively. Patients received intraoperative spinal cord protection using standard adjuncts. Intercostal arteries felt to be important were preserved or reimplanted as a button after removal of aortic clamps. Perioperative and demographic data were retrospectively collected. MRA of the spinal artery was performed in 27 patients with identification of the anterior spinal artery in 85% of the studies. Open repair was performed in 74% and endovascular repair in 26%. The major intercostal source artery for the anterior spinal artery was preserved or reimplanted in 13 patients (65%) who underwent open repair. In seven patients (35%), there was no attempt to preserve or reimplant any intercostal arteries because the major source artery for the anterior spinal artery was not identified, was diminutive (<1.5 mm in diameter), not accessible, or was associated with significant calcification. In the patients undergoing reimplantation, a mean of 1.67 intercostal arteries were reimplanted (range, 1-3). Of the patients undergoing endovascular repair, the major source intercostal artery for the anterior spinal artery was covered in all cases. No immediate or delayed paraplegia developed in any patient in either group. Comment: The new adjunct here is essentially selective reimplantation of intercostal arteries based on preoperative MRA imaging. It is impossible to know whether this strategy will provide any additional benefit in reducing SCI. In many patients in the open cohort, “important” intercostal arteries were not reimplanted for technical reasons, and all of the patients who underwent endovascular repair and in whom “important” intercostal arteries were identified preoperatively, those arteries were covered during the course of the endovascular repair. No cases of paraplegia were documented in the reimplanted or non-reimplanted patients treated with open repair, or in any of those treated with endovascular repair. The potential utility of this approach is that if you are a selective “reimplanter” of intercostal arteries during TAA repair it is possible, perhaps, with preoperative MRA of the spinal cord circulation, to identify precisely which intercostal arteries to reimplant. Whether this strategy will ultimately result in decreased rates of paraplegia will require a relatively large, multicenter randomized trial and is very unlikely ever to be performed.

Extra-Anatomical Revascularization of the Adamkiewicz Artery Using the Internal Mammary Artery: Preliminary Anatomical Study

Ischemic spinal cord injury remains a major complication of both open and endovascular repairs of extensive lesions of the thoracic or thoracoabdominal aorta. Patients undergoing endovascular treatment cannot benefit from direct revascularization of the Adamkiewicz artery (AA). Primary revascularization of the intercostal artery (ICA) giving rise to the AA using the internal mammary artery (IMA) could ensure uninterrupted flow in the AA even if the origin of the feeding ICA was obstructed. The purpose of this study was to assess the anatomical feasibility of revascularization of the ICA giving rise to the AA using the IMA. Twenty-four dissections were carried out on 12 cadavers (eight men, four women) with a mean age of 76 at the time of death. Preparation consisted of intra-arterial injection of polymethylsiloxane (Rhodorsil, Rhodia, France). For each IMA, the following parameters were determined: diameter in relation to the ICA in the paravertebral region before division, length, and level of the intercostal space in which direct anastomosis was possible. Dissection showed that the mean diameter at the end of the IMA was 1.8mm (range 1.2-2.4). The mean diameter of the ICA in the paravertebral region was compatible with that of the IMA, i.e., 1.6mm (range 0.9-2.5). The mean length of the IMA was 185 mm (range 165-230). The lowest intercostal space available in the paravertebral region for direct anastomosis between the IMA and ICA was the seventh space in one case, the eighth in 12, the ninth in eight, and the tenth in three. The findings of this preliminary study document the feasibility of using the IMA to revascularize the ICA in the paravertebral region. This technique could provide a means of preserving spinal cord vascularization during endovascular treatment of thoracic or thoracoabdominal aortic lesions.

Neurological Symptoms After a Provocative Dive: Spinal DCS or Anterior Spinal Artery Syndrome?

Reported here is a 37-yr-old professional diving instructor who had developed complaints of back pain and weakness in the lower extremities after diving. He was eventually diagnosed as having spinal cord decompression sickness along with a likely diagnosis of anterior spinal artery (artery of Adamkiewicz) syndrome. Additionally, since the transthoracic echocardiography revealed patent foramen ovale, we hypothesized that it might have been a potential route for gas bubbles to occlude the anterior spinal artery in this diver.