Thoracoabdominal Aortic Surgery Research Articles

Cool-shot Technique to Protect Spinal Cord During Thoracoabdominal Aortic Replacement.

Deep hypothermia helps protect the spinal cord, but is invasive. Here, we present a method to avoid reperfusion injury by selectively circulating cold blood under high pressure to the intercostal artery during reperfusion after intercostal artery reconstruction. Of the 23 patients who underwent thoracoabdominal aortic aneurysm open repair, one died. The motor evoked potential disappeared during aortic clamping in nine patients. Six patients recovered completely from aortic clamping release, two showed recovery >50% and one achieved full recovery three months later. Permanent motor impairment did not occur. This method could prevent reperfusion injury and paraplegia following thoracoabdominal aortic aneurysm surgery.

Intercostal Artery Re-Implantation in Thoraco-Abdominal Aortic Aneurysm Surgery

Intercostal Artery Re-Implantation in Thoraco-Abdominal Aortic Aneurysm Surgery

Simultaneous upper and lower body perfusion using hypothermia during thoracoabdominal aortic surgery

BackgroundIn open thoracoabdominal aortic aneurysm (TAAA) repair, we have been performing vascular reconstruction under moderate to deep hypothermia and assisted circulation using simultaneous upper and lower body perfusion. This method is effective for protecting the spinal cord and the brain, heart, and abdominal organs and for avoiding lung damage.MethodsTAAA repair was performed under hypothermia at 20–28 °C in 18 cases (Crawford type I in 0 cases, type II in 5, type III in 3, type IV in 4, and Safi V in 6) between October 2014 and January 2023. Cardiopulmonary bypass was conducted by combined upper and lower body perfusion, with perfusion both via the femoral artery and either transapically or via the descending aorta or the left brachial artery.ResultsThe ischemic time for the artery of Adamkiewicz and the main segmental arteries was 40–124 min (75 ± 33 min). No spinal cord ischemic injury or brain or heart complications occurred. One patient with postoperative right renal artery occlusion and one with an infected aneurysm required tracheostomy, but the intubation time for the other 16 was 32 ± 33 h. The duration of postoperative intensive care unit stay was 6.5 ± 6.2 days, the length of hospital stay was 29 ± 15 days, and no in-hospital deaths occurred.ConclusionsSimultaneous upper and lower body perfusion under moderate to deep hypothermia during thoracoabdominal aortic surgery may avoid not only spinal cord injury, but also cardiac and brain complications.

The impact of postoperative cerebrospinal fluid drainage on neurological improvement following thoracic aortic and thoracoabdominal aortic surgery.

Various preventive measures and treatment methods exist to prevent paraplegia during thoracic aortic surgery. Postoperative cerebrospinal fluid drainage (CSFD) is one of the treatment options when paraplegia occurs. This study aimed to evaluate the neurological efficacy of postoperative CSFD in patients undergoing thoracic aortic and thoracoabdominal aortic surgery. We analyzed perioperative data from 85 patients who underwent perioperative CSFD for thoracic and thoracoabdominal aortic surgery between January 2006 and December 2022, focusing on neurological changes. A total of 61 patients (72%) received preoperative CSFD, and 24 patients (28%) received postoperative CSFD. Perioperative neurological data were analyzed with a focus on perioperative changes. In the postoperative CSFD group, the manual muscle test (MMT) score before CSFD was 0.8, that just after CSFD was 2.4, and that at discharge was 3.0. Therefore, postoperative CSFD improved MMT scores compared with preoperative CSFD. The mean time between surgery completion and postoperative CSFD implantation was 9.8 hours. However, 6 (25%) of the patients who developed postoperative paraplegia and underwent early postoperative CSFD remained paraplegic without any improvement. In the preoperative CSFD group, there was only one case (2%) of postoperative paraplegia. Postoperative CSFD improved the neurological prognosis of individuals undergoing thoracic aortic and thoracoabdominal aortic surgery. However, 25% of the patients remained paraplegic despite postoperative CSFD.

Safety of cerebrospinal fluid drainage in descending and thoracoabdominal aortic replacement surgery.

Spinal cord injury (SCI) remains a significant morbidity of surgical repair of descending thoracic aortic aneurysms (DTAA) and thoracoabdominal aortic aneurysms (TAAA). We present our 17-year experience with cerebrospinal fluid drainage (CSFD) as a protective strategy during open surgical repair of descending and thoracoabdominal aortic disease. We conducted a retrospective chart review of 132 patients who underwent open surgical repair of DTAA and TAAA and dissections with concurrent use of CSFD for spinal cord protection. Information regarding survival, postoperative course, and complications related to CSFD use were extracted from electronic health records (EHR) and analyzed. Mean patient age was 65.4±13.0 years, and 82 (62.1%) were male. A CSFD was successfully inserted in all patients. The mean hospital length of stay after surgery was 12.2±11.2 days, and in-hospital mortality was 7.6%. Postoperative transient paresis was observed in 5 patients (3.8%), and permanent paraplegia was seen in 4 (3.0%). CSFD related complications were reported in 25 patients (19%). Complications included persistent cerebrospinal fluid (CSF) leakage, blood-tinged CSF (with subdural hematoma reported in 3 patients) and spinal cutaneous fistula in 9 (7%), 14 (11%), and 1 (1%), respectively. Long term survival was 50.9% at 15 years. CSFD is associated with minor complications, without major sequalae. It is a safe practice and likely contributes innocuously to decreased SCI in patients undergoing open repair of DTAA and TAAA.

IFABP levels predict visceral malperfusion in the first hours after open thoracoabdominal aortic repair.

Intestinal ischemia after open thoracoabdominal aortic repairs, is a rare but devastating complication, associated with high mortality. Notoriously challenging to diagnose, visceral malperfusion necessitates immediate surgical attention. Intestinal fatty acid-binding protein (IFABP) has been proposed as a biomarker for the diagnosis of intestinal wall damage. In this prospectively conducted, observational study we evaluated the diagnostic capacity of IFABP levels in patients' serum and their correlation with visceral malperfusion. 23 patients undergoing open thoracoabdominal aortic repairs were included in this study and 8 of them were diagnosed postoperatively with visceral malperfusion-defined as a partial or complete thrombotic occlusion of the superior mesenteric artery and/or the coeliac trunk. IFABP levels and laboratory parameters often associated with intestinal ischemia (leucocytes, CRP, PCT and lactate) were measured at baseline, directly postoperatively, and at 12, 24 and 48 h after surgery. Postoperative visceral malperfusion-as revealed in CT angiography-was assessed and the predictive ability of IFABP levels to detect visceral malperfusion was evaluated with receiver-operator curve analysis. Patients with visceral malperfusion had a relevant risk for a fatal outcome (p = .001). IFABP levels were significantly elevated directly postoperatively and at 12 h after surgery in cases of visceral malperfusion. High IFABP concentrations in serum detected visceral malperfusion accurately during the first 12 h after surgery, with the maximum diagnostic ability achieved immediately after surgery (AUC 1, Sensitivity 100%, Specificity 100%, p < .001). We conclude, that IFABP measurements during the first postoperative hours after open thoracoabdominal aortic surgery can be a valuable tool for reliable and timely detection of visceral malperfusion.

Necrostatin-1 Attenuates Delayed Paraplegia after Transient Spinal Cord Ischemia in Rabbits by Inhibiting the Upregulation of Receptor-Interacting Protein Kinase 1 and 3

Delayed-onset paraplegia is a disastrous complication after thoracoabdominal aortic open surgery and thoracic endovascular aortic repair. Studies have revealed that transient spinal cord ischemia caused by temporary occlusion of the aorta induces delayed motor neuron death owing to apoptosis and necroptosis. Recently, necrostatin-1 (Nec-1), a necroptosis inhibitor, has been reported to reduce cerebral and myocardial infarction in rats or pigs. In this study, we investigated the efficacy of Nec-1 in delayed paraplegia after transient spinal cord ischemia in rabbits and assessed the expression of necroptosis- and apoptosis-related proteins in motor neurons. This study used rabbit transient spinal cord ischemia models using a balloon catheter. They were divided into a vehicle-treated group (n=24), Nec-1-treated group (n=24), and sham-controls (n=6). In the Nec-1-treated group, 1mg/kg of Nec-1 was intravascularly administered immediately before ischemia induction. Neurological function was assessed using the modified Tarlov score, and the spinal cord was removed 8hr and 1, 2, and 7days after reperfusion. Morphological changes were examined using hematoxylin and eosin staining. The expression levels of necroptosis-related proteins (receptor-interacting protein kinase [RIP] 1 and 3) and apoptosis-related proteins (Bax and caspase-8) were assessed using western blotting and histochemical analysis. We also performed double-fluorescence immunohistochemical studies of RIP1, RIP3, Bax, and caspase-8. Neurological function significantly improved in the Nec-1-treated group compared with that in the vehicle-treated group 7days after reperfusion (median 3 and 0, P=0.025). Motor neurons observed 7days after reperfusion were significantly decreased in both groups compared with the sham group (vehicle-treated, P<0.001; Nec-1-treated, P<0.001). However, significantly more motor neurons survived in the Nec-1-treated group than in the vehicle-treated group (P<0.001). Western blot analysis revealed RIP1, RIP3, Bax, and caspase-8 upregulation 8hr after reperfusion in the vehicle-treated group (RIP1, P=0.001; RIP3, P=0.045; Bax, P=0.042; caspase-8, P=0.047). In the Nec-1-treated group, the upregulation of RIP1 and RIP3 was not observed at any time point, whereas that of Bax and caspase-8 was observed 8hr after reperfusion (Bax, P=0.029; caspase-8, P=0.021). Immunohistochemical study revealed the immunoreactivity of these proteins in motor neurons. Double-fluorescence immunohistochemistry revealed the induction of RIP1 and RIP3, and that of Bax and caspase-8, in the same motor neurons. These data suggest that Nec-1 reduces delayed motor neuron death and attenuates delayed paraplegia after transient spinal cord ischemia in rabbits by selectively inhibiting necroptosis of motor neurons with minimal effect on their apoptosis.

Mechanism of Increased Spinal Cord Blood Flow due to Noradrenaline Administration Using Vascular Resistance: An Experimental Study Using a Canine Model

During thoracoabdominal aortic surgery, the spinal cord is placed under ischemic conditions. Elevation of systemic blood pressure is thus recommended as a method of increasing the blood supply from collateral networks. This study examined the mechanisms by which noradrenaline administration increases spinal cord blood flow (SCBF) by elevating systemic blood pressure. In beagles (n = 7), the thoracoabdominal aorta and L2-L7 spinal cord segmental arteries (SAs) were exposed and a distal perfusion bypass was created to simulate clinical practice. SCBF was measured by laser flowmetry at the L5 dura mater and spinal cord perfusion pressure (SCPP) was measured inside the clamped aorta. The six pairs of SAs from L2 to L7 were clamped, and mean systemic blood pressure (mSBP), SCBF, and SCPP were measured before and after clamping and after starting continuous infusion of noradrenaline at 0.5 µg/kg/min. Rates of change in systemic vascular resistance (SVR) and spinal cord vascular resistance (SCVR) were calculated from the measured values. With no SA clamping (control), the rate of increase in SCVR was 0.74 times the rate of increase in SVR (y = 0.2 + 0.74x, r = 0.889, r2 = 0.789; P < 0.01). When all six pairs of SAs were clamped, a weak correlation was evident between rate of change in SCVR and rate of change in SVR, and the rate of increase in SCVR was lower than the rate of increase in SVR (y = 0.39 + 0.07x, r = 0.209, r2 = 0.039; P < 0.01). When all six pairs of SAs were clamped in the absence of distal perfusion, a weak correlation was also evident between rate of change in SCVR and rate of change in SVR, and the rate of increase in SCVR was lower than the rate of increase in SVR (y = 0.19 + 0.08x, r = 0.379, r2 = 0.144; P < 0.01). The rate of increase in SCVR induced by noradrenaline administration was lower than the rate of increase in SVR in the control group with no spinal cord SA clamping and in both experimental groups with clamped SAs (with and without distal perfusion), creating an environment conducive to spinal cord flow distribution.

Intranasal administration of polysulfide prevents neurodegeneration in spinal cord and rescues mice from delayed paraplegia after spinal cord ischemia

BackgroundDelayed paraplegia is a devastating complication of thoracoabdominal aortic surgery. Hydrogen sulfide (H2S) was reported to be protective in a mouse model of spinal cord ischemia and the beneficial effect of H2S has been attributed to polysulfides. The objective of this study was to investigate the effects of polysulfides on delayed paraplegia after spinal cord ischemia. Methods and resultsSpinal cord ischemia was induced in male and female C57BL/6J mice by clamping the aortic arch and the left subclavian artery. Glutathione trisulfide (GSSSG), glutathione (GSH), glutathione disulfide (GSSG), or vehicle alone was administered intranasally at 0, 8, 23, and 32 h after surgery. All mice treated with vehicle alone developed paraplegia within 48 h after surgery. GSSSG, but not GSH or GSSG, prevented paraplegia in 8 of 11 male mice (73%) and 6 of 8 female mice (75%). Intranasal administration of 34S-labeled GSSSG rapidly increased 34S-labeled sulfane sulfur species in the lumbar spinal cord. In mice treated with intranasal GSSSG, there were increased sulfane sulfur levels, and decreased neurodegeneration, microglia activation, and caspase-3 activation in the lumbar spinal cord. In vitro studies using murine primary cortical neurons showed that GSSSG increased intracellular levels of sulfane sulfur. GSSSG, but not GSH or GSSG, dose-dependently improved cell viability after oxygen and glucose deprivation/reoxygenation (OGD/R). Pantethine trisulfide (PTN-SSS) also increased intracellular sulfane sulfur and improved cell viability after OGD/R. Intranasal administration of PTN-SSS, but not pantethine, prevented paraplegia in 6 of 9 male mice (66%). ConclusionsIntranasal administration of polysulfides rescued mice from delayed paraplegia after transient spinal cord ischemia. The neuroprotective effects of GSSSG were associated with increased levels of polysulfides and sulfane sulfur in the lumbar spinal cord. Targeted delivery of sulfane sulfur by polysulfides may prove to be a novel approach to the treatment of neurodegenerative diseases.

In Memoriam: Randall B. Griepp (1940-2022): Master Surgeon, Innovator, Scientist, Teacher, and Sailor

Dr Randall B.Griepp's career spanned the founding age of cardiovascular and thoracic aortic surgery, the era he called "the golden age of cardiac surgery." He made groundbreaking contributions in cardiac transplantation while at Stanford and in the surgical technique and the methods of cerebral and spinal cord protection for thoracic and thoracoabdominal aortic surgery throughout his years as chairman of cardiothoracic surgery at The Mount Sinai Medical Center in New York. His commitment to honesty and his personal ethic and stature served as a role model for a generation of trainees, many of whom went on to leadership roles in cardiovascular surgery.

The Neuroprotective Effects of Ginsenoside Rd Pretreatment in a Rat Model of Spinal Cord Ischemia-Reperfusion Injury.

Paraplegia may develop as a result of spinal cord ischemia-reperfusion injury in patients who underwent thoracoabdominal aortic surgery. The objective of this research is to determine the neuroprotective effects of ginsenoside Rd pretreatment in a rat model of spinal cord ischemia-reperfusion injury. Sprague-Dawley rats (n=36) were randomly assigned to three groups. The sham (n=12) and control (n=12) groups received normal saline orally. The Rd group (n=12) received ginsenoside Rd (100 mg/kg) orally 48 hours before the induction of spinal cord ischemia. Spinal cord ischemia was induced by aortic occlusion using a Fogarty balloon catheter in the Rd and control groups. A neurological assessment according to the motor deficit index and a histological evaluation of the spinal cord were performed. To evaluate the antioxidant activity of ginsenoside Rd, malondialdehyde levels and superoxide dismutase activity were determined. Further, the tissue levels of tumor necrosis factor-alpha and interleukin-1 beta were measured. The Rd group showed significantly lower motor deficit index scores than did the control group throughout the entire experimental period (P<0.001). The Rd group demonstrated significantly greater numbers of normal motor neurons than did the control group (P=0.039). The Rd group exhibited decreased malondialdehyde levels (P<0.001) and increased superoxide dismutase activity (P=0.029) compared to the control group. Tumor necrosis factor-alpha and interleukin-1 beta tissue levels were significantly decreased in the Rd group (P<0.001). Ginsenoside Rd pretreatment may be a promising treatment to prevent ischemia-reperfusion injury in patients who undergo thoracoabdominal aortic surgery.

Anesthesia and surgery-induced elevation of CSF sTREM2 is associated with early cognitive dysfunction after thoracoabdominal aortic dissection surgery

PurposeSoluble triggering receptor expressed on myeloid cells 2 (sTREM2) concentration is increased in cerebrospinal fluid (CSF) in early symptomatic phase of Alzheimer’s disease (AD). This study investigated whether CSF sTREM2 has a relationship with early cognitive dysfunction following surgery in cardiac surgery patients.MethodsA total of 82 patients undergoing thoracoabdominal aortic replacement were recruited in this study. Neuropsychological testing battery was conducted before and after surgery. Postoperative cognitive dysfunction (POCD) was defined as a Z-score > 1.96 on at least 2 different tests or Telephone Interviews for Cognitive Status-Modified (TICS-M) score < 27. The CSF and serum sTREM2, Aβ42, T-tau and P-tau were collected and measured by ELISA on day before surgery and postoperative day 3.ResultsPatients were classified into POCD (n = 34) and non-POCD (n = 48) groups according to Z-score. Compared to non-POCD group, the levels of CSF sTREM2 (p < 0.001) and serum sTREM2 (p = 0.001) were significantly higher in POCD group on postoperative day 3. The levels of Aβ42 (p = 0.005) and Aβ42/T-tau ratio (p = 0.036) were significantly lower in POCD group on postoperative day 3. Multivariate logistic regression analysis revealed that higher value of postoperative CSF sTREM2 (odds ratio: 1.06, 95% confidence interval: 1.02–1.11, p = 0.009), age (OR: 1.15, 95%CI: 1.03–1.28, p = 0.014) and POD duration (OR: 2.47, 95%CI: 1.15–5.29, p = 0.02) were the risk factors of POCD.ConclusionThis study indicates that anesthesia and surgery-induced elevation of CSF sTREM2 is associated with an increased risk of early cognitive dysfunction following surgery.

Pain and functioning of patients after endovascular treatment of thoracoabdominal aortic aneurysms during the first five days after the procedure

Abstract Aim. The study assessed the pain and functioning of patients after thoracoabdominal aortic aneurysms surgery. Material and methods. The study involved 35 patients after the thoracoabdominal aortic aneurysm surgery. The study used the method of a diagnostic survey, and the research tool was a proprietary questionnaire, using a numerical and descriptive pain scale and the Laitinen Scale. The results were analyzed in the program SPSS Statistics 21.0. Results. When it comes to 54.3% of the respondents, they experienced the strongest pain on the first day after the procedure, 45.7% experienced the pain periodically and it was felt the most in the evening (48%). More than half of the respondents indicated that the experienced pain completely affected the movement/walking and it was the strongest then, and it was the same while getting up. Pain intensity and the presence of functional limitations did not have a statistically significant correlation with the analyzed socio-medical variables (p&gt;0.05). Conclusions. Patients experienced the pain after thoracoabdominal aortic aneurysm surgery and it limited their functioning, therefore they needed help in performing basic life activities.

Near-infrared spectroscopy to monitor spinal cord oxygenation in οpen thoraco-abdominal aortic surgery. A case series

Objectives. We adopted the near-infrared spectroscopy (NIRS) technology to monitor the spinal oxygen supply through the paraspinous muscles oxygenation in agreement with the concept of “collateral network” circulation. We retrospectively investigated our database of subjects who underwent thoraco-abdominal aorta open repair assessing for the reliability of this monitoring to predict spinal cord injury. Methods. Consecutive patients who underwent elective thoraco-abdominal aorta open repair between March 2019 and September 2021. In addition to standard monitoring, patients received the monitoring of the paraspinous muscles oxygenation by NIRS. Results. In one patient a significant drop of the mean arterial pressure (49 mmHg) and the spinal-cord perfusion pressure (31 mmHg) occurred after the aortic clamping, with a contemporary lowering of the left-side oxygenation of paraspinous muscles (&lt;40%). Both the blood pressure and the spinal cord perfusion pressure were restored within 10 minutes, but the oxygenation remained at an unsafe level (&lt;55%) until the end of the surgery. This same patient experienced a lower-limb paralysis post-operatively. It did not happen in the other 11 cases of the sample. Conclusions. The main finding of our retrospective analysis indicates reliability of this technology to monitor the spinal cord oxygenation during open thoraco-abdominal aortic surgery and possibly predict spinal cord injury. Still, several questions need to be addressed about the suitability of this technology to the anatomic and pathophysiology of the spinal cord circulation

Onset of Adverse Abdominal Events Due to Intestinal Ischemia-Reperfusion Injury after Aortic Cross-Clamping Is Associated with Elevated HSP70 Serum Levels in the Early Postoperative Phase

Tissue injury of the viscera during open thoracoabdominal aortic (TAA) reconstructions has been reported as the aftermath of the ischemia-reperfusion mechanism following supracoeliac aortic cross-clamping. Abdominal complications after open aortic reconstructions, although rare through the intraoperative implementation of selective visceral artery blood perfusion, are associated with high rates of reinterventions and a poor prognosis. Recent animal experiments demonstrated that provoking mesenteric ischemia in rats induces the leukocyte-mediated transcription of heat-shock protein 70 (HSP70), a chaperone belonging to the danger-associated molecular pattern proteins (DAMPs). Translating these findings clinically, we investigated the serum levels of HSP70 in patients undergoing open aortic reconstructions with supracoeliac clamping. We postoperatively observed a relevant induction of HSP70, which remained significantly elevated in cases of postoperative abdominal complications (paralytic ileus, abdominal compartment syndrome, and visceral malperfusion). The receiver-operator curve analysis revealed the reliable prognostic accuracy of HSP70 as a biomarker for these complications as soon as 12 h post-operation (AUC 0.908, sensitivity 88.9%, specificity 83.3%). In conclusion, measuring HSP70 serum levels in the early postoperative phase may serve as a further adjutant in the diagnostic decision making for both the vascular surgeon and intensivist for the timely detection and management of abdominal complications following open TAA surgery.

Thoracoabdominal aortic aneurysm repair: A Single center experience

Aim: The gold standard repair of thoracoabdominal aortic aneurysm (TAAA) is still open surgery. However, few cardiovascular centers are experienced in TAAA repair. The aim of this study was to examine the methods and four-year outcomes of the open TAAA repair program initiated by a single surgical team. Material and Methods: In this retrospective cohort, patients who were operated for TAAA between August 2018 and March 2022 were collected. Patients treated with the endovascular approach were excluded. After exclusion, 19 patients were included in our analysis. As postoperative outcomes, in-hospital mortality, spinal cord deficit, major neurologic complications, need for dialysis, and visceral ischemia were collected. Results: Crawford extent II TAAA repair was performed in 10 (52.6%) patients, Crawford extent III in 5 (26.3%) patients, and Crawford extent IV in 4 (21.1%) patients. In hospital mortality occurred in 6 (31.6%) patients. The causes of mortality were perioperative myocardial infarction in 2 (10.5%) patients, visceral ischemia in 1 (5.3%) patient, multisystem organ failure in 3 (15.8%) patients. The highest mortality rate (50.0%) occurred in Crawford extent II repair. Spinal cord deficit developed in 2 (10.5%) patients. Conclusion: Thoracoabdominal aortic aneurysm surgery is associated with high mortality rates. Open thoracoabdominal aortic aneurysm repair programs in tertiary vascular centers should be supported, to improve the surgical results of thoracoabdominal aortic aneurysm repair.

Abstract 13235: Ischemic Preconditioning and Lazaroid (u-74389g) Administration Similarly Attenuate Ischemia-Reperfusion-Induced Spinal Cord Inflammatory and Apoptotic Responses by Targeting the S100-Receptor for Advanced Glycation End Product Pathway

Introduction: Spinal cord injury and subsequent paraplegia represents a devastating complication of thoracoabdominal aortic surgery. Pro-inflammatory cytokine expression and spinal cord neuronal apoptosis have been implicated in inflammation and neurodegeneration respectively after ischemia. Hypothesis: We investigated the neuroprotective effects of the steroid antioxidant Lazaroid U-74389G versus conventional ischemic preconditioning (IPC) in a pig model of spinal cord ischemia-reperfusion injury by examining the expression of pro-inflammatory and pro-apoptotic S100 members and the receptor for advanced glycation end products (RAGE). Methods: Spinal cord ischemia was induced by thoracoabdominal aortic occlusion (TAO). A total of 27 pigs were randomized in four groups. Group I (n=5) sham operation, group II (n=7) TAO for 45min and received placebo, group III (n=8) received 3 doses of Lazaroid (3 mg/kg) 60min and 30min before and at 30min during TAO (duration 45min), and group IV (n=6) TAO for 20min followed by additional TAO for 45min and 80 minutes later. Neurologic evaluation was performed according to Tarlov score (0-4, 4=normal). The lumbar spinal cords were harvested at 7th postoperative day for the expression of inflammatory and apoptotic markers by real-time RT-PCR. Results: Group III and IV had better neurologic outcome postoperatively compared to group II where all animals developed paraplegia (Tarlov scores: 3.5 versus 3.6 versus 0.33, respectively, P&lt;0.001). Group II showed marked pro-inflammatory responses as quantified by 2-4-fold increases in the mRNA of pro-inflammatory S100A6, S100A8 and high-mobility group box 1, and RAGE, compared to group I. Additionally, group II, exhibited apoptosis as quantified by a 40-60% decrease in the mRNA of anti-apoptotic BCL2 and BIRC2, and 2-3-fold increases in pro-apoptotic BAX mRNA and caspase 3 activity. Compared to group II, inflammatory and apoptotic responses were highly attenuated albeit to a similar degree in groups III and IV. Conclusions: In a large animal model very close to the clinical setting, we demonstrated that in addition to IPC, Lazaroid represents an alternative yet effective pharmacologic intervention in reducing spinal cord ischemia-reperfusion injury following TAO.

Derivation and Validation of Clinical Phenotypes of the Cardiopulmonary Bypass-Induced Inflammatory Response.

Precision medicine aims to change treatment from a "one-size-fits-all" approach to customized therapies based on the individual patient. Applying a precision medicine approach to a heterogeneous condition, such as the cardiopulmonary bypass (CPB)-induced inflammatory response, first requires identification of homogeneous subgroups that correlate with biological markers and postoperative outcomes. As a first step, we derived clinical phenotypes of the CPB-induced inflammatory response by identifying patterns in perioperative clinical variables using machine learning and simulation tools. We then evaluated whether these phenotypes were associated with biological response variables and clinical outcomes. This single-center, retrospective cohort study used Cleveland Clinic registry data from patients undergoing cardiac surgery with CPB from January 2010 to March 2020. Biomarker data from a subgroup of patients enrolled in a clinical trial were also included. Patients undergoing emergent surgery, off-pump surgery, transplantation, descending thoracoabdominal aortic surgery, and planned ventricular assist device placement were excluded. Preoperative and intraoperative variables of patient baseline characteristics (demographics, comorbidities, and laboratory data) and perioperative data (procedural data, CPB duration, and hemodynamics) were analyzed to derive clinical phenotypes using K-means-based consensus clustering analysis. Proportion of ambiguously clustered was used to assess cluster size and optimal cluster numbers. After clusters were formed, we summarized perioperative profiles, inflammatory biomarkers (eg, interleukin [IL]-6 and IL-8), kidney biomarkers (eg, urine neutrophil gelatinase-associated lipocalin [NGAL] and IL-18), and clinical outcomes (eg, mortality and hospital length of stay). Pairwise standardized difference was reported for all summarized variables. Of 36,865 eligible cardiac surgery cases, 25,613 met inclusion criteria. Cluster analysis derived 3 clinical phenotypes: α, β, and γ. Phenotype α (n = 6157 [24%]) included older patients with more comorbidities, including heart and kidney failure. Phenotype β (n = 10,572 [41%]) patients were younger and mostly male. Phenotype γ (n = 8884 [35%]) patients were 58% female and had lower body mass index (BMI). Phenotype α patients had worse outcomes, including longer hospital length of stay (mean = 9 days for α versus 6 for both β [absolute standardized difference {ASD} = 1.15] and γ [ASD = 1.08]), more kidney failure, and higher mortality. Inflammatory biomarkers (IL-6 and IL-8) and kidney injury biomarkers (urine NGAL and IL-18) were higher with the α phenotype compared to β and γ immediately after surgery. Deriving clinical phenotypes that correlate with response biomarkers and outcomes represents an initial step toward a precision medicine approach for the management of CPB-induced inflammatory response and lays the groundwork for future investigation, including an evaluation of the heterogeneity of treatment effect.

The fate of the downstream aorta after total arch replacement.

The goal of this study was to evaluate the fate of the downstream aorta following total arch replacement. Between October 1999 and March 2018, a total of 740 patients underwent total arch replacement. After excluding connective tissue disease, previous descending or thoracoabdominal aortic surgery, patients without adequate preoperative images or operative mortality, late outcomes consisting of additional surgery for distal dilation and distal aortic events were evaluated in 623 survivors (240 aortic dissections, including 139 patients with acute dissection and 383 with a non-dissection aneurysm). The mean follow-up was 5.0 ± 4.0 years. The mean preoperative maximum diameter of the descending aorta was 36.9 ± 8.0 mm. An elephant trunk was inserted in 232 patients, including 183 patients with aortic dissection. Freedom from additional surgery for distal dilation was 88.5% at 5 years and 80.2% at 10 years. Freedom from distal aortic events was 81.9% at 5 years and 70.5% at 10 years. Multivariable regression analysis demonstrated that the preoperative diameter of the descending aorta was a significant risk factor for unfavourable distal aortic events. Computed tomography evaluation demonstrated a significant increase in the descending aortic diameter over time (P &lt; 0.001). Positive aortic remodelling was observed in the proximal descending (P &lt; 0.001) to mid-descending (P &lt; 0.001) aorta exclusively in patients with acute aortic dissection. The diameter of the descending aorta increased significantly after total arch replacement, particularly in the distal descending aorta. The preoperative descending aortic diameter portended a significant risk for unfavourable distal aortic events.

Surgical treatment of thoracoabdominal aortic pathology - retrospective study of 300 patients.

Thoracoabdominal aortic surgery is a technically demanding and extensive treatment that has its place in the era of endovascular techniques. To ensure the best possible outcomes, it requires a well-coordinated team of surgeons, anaesthetists, intensive care physicians and other medical staff. The authors present a series of 300 patients operated on between 1 January 2003 and 15 March 2022. Although the group included sporadic cases of severe obliterating involvement of the visceral aorta, patients with thoracoabdominal aortic aneurysms (TAAA) constituted the vast majority. All known organ preservation procedures were used during the operations. The thoraco-phreno-retroperitoneal approach was chosen in almost all TAAA cases; the thoraco-phreno-transperitoneal approach was used only in two reoperations. In this cohort, type II thoracoabdominal aneurysm according to Crawford classification was most common (33%). This was followed by type IV (32%), type III (15.3%), type I (8.7%), type V (6.7%) and other thoracoabdominal aortic procedures (4.3%). Thirty-day mortality rate was 9.6% (2019 - 6%, 2020 - 9.5%, 2021 - 3.8%) in this group; surgical postoperative complications occurred in 36 patients (12%). Neurological complications were reported in 16 cases (5.3%), of which postoperative paraplegia was noted 6 times (2%). Temporary postoperative dialysis due to renal insufficiency was performed in 19 patients (6.3%) and 4 patients (1.3%) have entered the chronic dialysis programme. In 67 patients (23.3%), temporary tracheostomy was done postoperatively due to prolonged withdrawal from the lung ventilator. Surgical treatment of the thoracoabdominal aorta is one of the most extensive procedures in vascular surgery and the mortality and morbidity rates still remain relatively high. A multidisciplinary approach, sufficient experience and a dedicated team are essential for a successful outcome of these highly specialised operations.