Perioperative Paraplegia Research Articles

Treatment of perioperative paraplegia in acute aortic dissection

Treatment of perioperative paraplegia in acute aortic dissection

TAA 6. Staging Procedures, Cerebrospinal Fluid Drainage, Selective Neuromonitoring, and Use of Conduits During Complex Endovascular Aortic Repair in Patients With High Risk of Spinal Cord Injury

Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) and thoracoabdominal aortic aneurysm (TAAA) repair is a devastating complication. Outcomes improved significantly after 2015, when we revised our spinal cord protection strategy. This study describes a single experience of SCI prevention in patients who have had endovascular repair. A prospectively maintained database of patients having repair using standard, branched/fenestrated stent grafts at a single university center was reviewed. We optimized the implantation procedure, including the early restoration of pelvic and lower limb perfusion by precannulated devices and temporal conduits. The left subclavian artery was routinely revascularized before coverage. Procedures for extent thoracic and II and III TAAAs were staged. The aim was also to maintain controlled perfusion to the sac before complete exclusion. In cases of TEVAR, the first step was subclavian revascularization, then endograft deployment, and the next step was proximal occlusion of the left subclavian artery with a plug. For the TAAA, strategies used for staging included placement of the thoracic component; branch/fenestration device deployment, maintaining perfusion to the sac by delayed completion of either one of the stent graft side branches, perfusion branches, or contralateral iliac limb extension; and complete exclusion after side branch occlusion test and motor and somatosensory evoked potential monitoring (Fig). The current policy was to place a spinal drain; the mean arterial pressure is raised to >90 to 100 mm Hg, and the hemoglobin level is maintained at 10 g/dL. Twenty-nine patients (median age, 73 years; 24 male patients; 20 TEVARs and 9 branched/fenestrated endovascular aneurysm repairs) underwent endovascular repair. No death or neurologic symptoms or signs related to SCI were registered at 30 days. Temporary iliofemoral conduits were used in 16 limbs in 14 patients. One patient had a ≥75% decrease in motor and somatosensory evoked potential amplitude, and the complete exclusion of the sac was delayed for 2 more weeks. No patients developed late SCI or mortality. This series illustrates the importance of a dedicated institutional protocol aimed at ensuring the intraoperative maneuvers to avoid perioperative paraplegia. This study aimed to demonstrate the possible protective effects of ischemic preconditioning on the preservation of spinal cord function after segmental and sequential artery occlusion.

Acute Subdural Hematoma Following Thoracoabdominal Aortic Repair in a Patient with Marfan Syndrome: A Rare Complication of Cerebrospinal Fluid Drainage

Cerebrospinal fluid (CSF) drainage is a routinely used adjunct in operation of thoracoabdominal aortic aneurysm (TAAA), which may reduce the incidence of perioperative paraplegia by improving spinal cord perfusion. Neurological complications of CSF drainage have been reported, possibly due to excessive CSF drainage, and acute subdural hematoma (SDH) in particular may lead to catastrophic complications. We present a rare case of acute SDH due to CSF drainage that was not excessive, after TAAA repair in a patient with Marfan syndrome, who recovered without invasive treatment.

Advances in Imaging of the Spinal Cord Vascular Supply and its Relationship with Paraplegia after Aortic Interventions. A Review

Introduction: Preoperative knowledge of the spinal cord (SC) vasculature could be useful for stratifying and decreasing the risk of perioperative paraplegia after thoracic and thoraco-abdominal aortic surgery. Recent advances in magnetic resonance (MR) and computed tomography (CT) angiography and post-processing techniques have improved this knowledge. Methods: A search of MEDLINE/Pubmed and SCOPUS databases identified 1414 pertinent abstracts; 123 full-length manuscripts were screened to identify relevant studies with acceptable design and patient numbers. Forty-three were selected. Results: SC circulation was studied in 1196 patients to detect the great radicular artery: 522 by MR-angiography and 674 by CT angiography. Detection rates were 67–100% (mean 80.8%) with MR-angiography being 18–100% (mean 72%) with CT angiography. The side and level of the great radicular artery were consistent between the methods. Several authors tried to use the imaging results to guide clinical management. Conclusions: Non-invasive imaging of the SC blood supply allows preoperative definition of the vasculature in many, but not all, cases. The impact of these findings on clinical management is potentially beneficial but still uncertain. Further improvements in image acquisition and post-processing techniques are needed. Future studies need to be large enough to compensate for inter-individual variability in SC vasculature in health and disease; however, even a partial reduction of paraplegia rate offers a formidable motivation for further research in this area.

Advances in Imaging of the Spinal Cord Vascular Supply and its Relationship with Paraplegia after Aortic Interventions. A Review

Preoperative knowledge of the spinal cord (SC) vasculature could be useful for stratifying and decreasing the risk of perioperative paraplegia after thoracic and thoraco-abdominal aortic surgery. Recent advances in magnetic resonance (MR) and computed tomography (CT) angiography and post-processing techniques have improved this knowledge. A search of MEDLINE/Pubmed and SCOPUS databases identified 1414 pertinent abstracts; 123 full-length manuscripts were screened to identify relevant studies with acceptable design and patient numbers. Forty-three were selected. SC circulation was studied in 1196 patients to detect the great radicular artery: 522 by MR-angiography and 674 by CT angiography. Detection rates were 67-100% (mean 80.8%) with MR-angiography being 18-100% (mean 72%) with CT angiography. The side and level of the great radicular artery were consistent between the methods. Several authors tried to use the imaging results to guide clinical management. Non-invasive imaging of the SC blood supply allows preoperative definition of the vasculature in many, but not all, cases. The impact of these findings on clinical management is potentially beneficial but still uncertain. Further improvements in image acquisition and post-processing techniques are needed. Future studies need to be large enough to compensate for inter-individual variability in SC vasculature in health and disease; however, even a partial reduction of paraplegia rate offers a formidable motivation for further research in this area.

Stent graft repair of descending aortic dissection in patients with Marfan syndrome: An effective alternative to open reoperation?

Aneurysms or dissections can involve multiple aortic segments in patients with Marfan syndrome, requiring staged replacement of the entire aorta. The optimal treatment of descending aortic dissection in these patients is a major challenge. We investigated the feasibility and outcomes of endovascular repair of the descending aorta in patients already submitted to open aortic root/arch surgery. From March 1998 to July 2008, 12 patients (10 male and 2 female patients; mean age, 37.8 +/- 11.6 years) affected by Marfan syndrome underwent endovascular treatment for dissection of the descending aorta after previous open aortic root/arch surgery. Stent graft procedures were performed urgently in 5 patients and electively in 7 patients. Neither in-hospital deaths nor perioperative paraplegia or stroke occurred. Follow-up (median, 31 months; range, 3-57 months) was 100% complete. One patient needed surgical conversion for persistent type I endoleak, leading to false lumen expansion 3 months after endovascular repair. Extension of the dissection occurred in 2 patients 1 month and 2 years after the procedure, respectively. No late death or aortic rupture was observed. Endovascular repair of the dissected descending thoracic aorta can be performed in patients with Marfan syndrome with a low risk of death or major complications. In case of staged procedures, stent graft treatment can be considered a possible alternative to open reoperation. Long-term durability remains to be determined.

Neurologic complications associated with endovascular repair of thoracic aortic pathology: Incidence and risk factors. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) Registry

Endovascular treatment of thoracic aortic disease may be associated with severe neurologic complications. The current study used the data of a multicenter registry to assess of the incidence and the risk factors for paraplegia or paraparesis and intracranial stroke. The European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) database prospectively enrolled 606 patients. Thoracic pathologies with urgent or elective presentation, which included degenerative aneurysm in 291, aortic dissection in 215, traumatic rupture in 67, anastomotic false aneurysm in 24, and infectious or nonspecified disorders in 9. Study end points included evidence of perioperative spinal cord ischemia (SCI) or stroke. Univariate analysis and multivariate regression models were used to assess the significance of clinical factors that potentially influenced the occurrence of neurological sequelae. Paraplegia or paraparesis developed in 15 patients (2.5%) and stroke in 19 (3.1%); two patients had both complications. At multivariate regression analysis, independent correlation with SCI was observed for four factors: (1) left subclavian artery covering without revascularization (odds ratio [OR], 3.9; P = .027), (2) renal failure (OR, 3.6; P = .02), (3) concomitant open abdominal aorta surgery (OR, 5.5; P = .037) and (4) three or more stent grafts used (OR, 3.5; P = .043). In patients with perioperative stroke, two correlating factors were identified: (1) duration of the intervention (OR, 6.4; P = .0045) and (2) female sex (OR, 3.3; P = .023). A neurologic complication (paraplegia or stroke) developed in 8.4% of the patients in whom left subclavian covering was required compared with 0% of patients with prophylactic revascularization (P = .049). Perioperative paraplegia or paraparesis was significantly associated with blockage of the left subclavian artery without revascularization. The clinical significance of this source of collateral perfusion of the spinal cord had not been confirmed previously. Intracranial stroke was associated with lengthy manipulation of wires, catheters, and introducer sheaths within the aortic arch, reflected by a longer duration of the procedure.

Reversal of Renal Failure and Paraplegia After Thoracoabdominal Aneurysm Repair

Re pair of ruptured thoracoabdominal aortic aneurysms is complicated by high rates of perioperative paraplegia, renal insufficiency, and mortality. This report describes a patient with a ruptured thoracoabdominal aortic aneurysm in whom preoperative acute renal failure was reversed with hemodialysis, aortic replacement, and renal revascularization. Prompt cerebrospinal fluid drainage reversed delayed-onset postoperative paraplegia and led to immediate, complete neurologic recovery.

Perioperative paraplegia and multiorgan failure from heparin-induced thrombocytopenia

Heparin-induced thrombocytopenia and thrombosis syndrome is a rare but devastating completion. We report a patient with heparin-induced thrombocytopenia in whom heparin-induced thrombocytopenia and thrombosis syndrome developed after a cardiac operation, complicated by acute thrombosis of the aorta followed by renal failure, paralysis, and ischemic necrosis of the lower extremities. The literature suggests aspirin, dipyridamoie, and iloprost as effective prophylactic agents for perioperative heparin-induced thrombocytopenia and thrombosis syndrome. This unfortunate complication underscores the importance of close platelet count monitoring in all preoperative patients undergoing prolonged heparin therapy.

Mechanism of increased cerebrospinal fluid pressure with thoracic aortic occlusion

Recent clinical reports have suggested that drainage of cerebrospinal fluid lowers the incidence of perioperative paraplegia in patients with thoracoabdominal aneurysms. Unfortunately, the precise mechanisms for both the neurologic deficits and the beneficial effects of cerebrospinal fluid drainage remain unclear. To better understand the relationship between cerebrospinal fluid pressure, central venous pressure, and the compliance of the cerebrospinal fluid compartment, we studied 12 anesthetized dogs subjected to thoracic aortic occlusion. Pericardia were opened in six (group I), and left intact in six (group II). Systemic hemodynamics and cerebrospinal fluid pressure (mm Hg) were measured before and after thoracic aortic occlusion. In group II, intravenous volume loading (15 ml/kg) was superimposed on aortic occlusion. Compliance of the cerebrospinal fluid space (ml/mm Hg) was measured at each interval by use of sequential injection and withdrawal of small aliquots of fluid. Results are expressed as mean ± SE; ∗p < 0.05. Thoracic aortic occlusion resulted in predictable changes in mean arterial pressure (group I 95.8 ± 7.1 to 123.3 ± 7.1∗, group II 82.5 ± 6.9 to 98.3 ± 9.5∗) and central venous pressure (1.9 ± 0.7 to 3.8 ± 0.6∗, 3.0 ± 0.8 to 4.0 ± 0.9∗). Although cerebrospinal fluid pressure was increased by thoracic aortic occlusion in both groups (8.0 ± 1.2 to 12.6 ± 1.9∗; 5.8 ± 0.9 to 8.5 ± 1.1∗), compliance of the dural space was not changed (0.61 ± 0.19 to 0.60 ± 0.18; 0.54 ± 0.14 to 0.62 ± 0.09). In group II animals cerebrospinal fluid pressure was further increased with volume loading (8.0 ± 1.5 to 13.3 ± 1.5∗) and changes in cerebrospinal fluid pressure and central venous pressure were correlated (r = 0.54). The increase in cerebrospinal fluid pressure with volume loading and thoracic aortic occlusion was significantly greater than the increase in cerebrospinal fluid pressure and thoracic aortic occlusion alone (5.3 ± 0.4 vs 2.8 ± 0.6∗). Increased cerebrospinal fluid pressure with thoracic aortic occlusion is due to volume changes in venous capacitance beds within the dural space. This change in pressure is not associated with any decrease in compliance; hence, there is no rationale for direct compression of the cord (spinal cord compartment syndrome). Based on anatomic considerations, it appears that any benefits of cerebrospinal fluid drainage reflect enhanced patency of thin-walled intradural veins, which are prone to collapse (Starling resistor concept). Further definition of the complex relationship between central and local venous volumes and pressures may allow a unified explanation for immediate and delayed neurologic deficits.

Use of the TDMAC heparin shunt for operations on the descending thoracic aorta (author's transl)

This report summarizes our experience with the TDMAC heparin shunt for aortic bypass in descending thoracic aortic surgery. Between 1977 and 1981 twenty-four operations were performed with this shunt (19 men, 4 women, mean age 42 age). Indications for surgery were acute traumatic aortic rupture (6 patients), chronic aortic rupture (6 patients), acute aortic dissection (1 patient), chronic aortic dissection (4 patients), atherosclerotic aneurysms (3 patients), aortic aneurysms combined with PDA (1 patient), aortic aneurysm secondary to coarctation repair (1 patient), and infection of a vascular prosthesis (1 patient). Four patients died (hospital mortality 16.7%). One patient suffered perioperative paraplegia. In this patient the small size (7 mm) shunt hat been used. Therefore we suggest the large bore (9 mm) shunt be applied whenever possible, since even this larger size device displays a significant pressure gradient. When insertion of the shunt into the left subclavian artery is difficult, the ascending aorta or the apex of the left ventricle may be cannulated instead. In our cases we did not encounter any complications arising from shunt cannulation. The advantages of the TDMAC heparin shunt focus on the reduction of bleeding complications more common under systemic heparinization, and on less pronounced hemodynamic and metabolic sequelae following aortic clamping and declamping. With this shunt nearly all possible ischemic organ damage can be avoided.