Journal of Vascular Surgery
Volume 49, Issue 5 , Pages 1117-1124 , May 2009

A modern theory of paraplegia in the treatment of aneurysms of the thoracoabdominal aorta: An analysis of technique specific observed/expected ratios for paralysis

  • Charles W. Acher, MD

      Affiliations

    • Corresponding Author InformationReprint requests: Charles W. Acher, MD, University of Wisconsin, University of Wisconsin Hospital, 600 Highland Ave, Room G4-317, Madison, WI 53792-7375
    • ,
  • Martha Wynn, MD

Received 11 September 2008 ,Accepted 30 October 2008.

References 

  1. Adams HD, van Geertruyden HH. Neurologic complications of aortic surgery. Ann Surg. 1956;144:574–610
  2. Griepp RB, Griepp EB. Spinal cord perfusion and protection during descending thoracic and thoracoabdominal aortic surgery: the collateral network concept. Ann Thorac Surg. 2007;83:S865–S869discussion S890-2.
  3. Acher CW, Wynn MM, Hoch JR, Popic P, Archibald J, Turnipseed WD. Combined use of cerebral spinal fluid drainage and naloxone reduces the risk of paraplegia in thoracoabdominal aneurysm repair. J Vasc Surg. 1994;19:236–246discussion 247-8.
  4. Acher CW, Wynn MM, Mell MW, Tefera G, Hoch JR. A quantitative assessment of the impact of intercostal artery reimplantation on paralysis risk in thoracoabdominal aortic aneurysm repair. Ann Surg. 2008;248:529–540
  5. Acher CW, Wynn MM, Hoch JR, Kranner PW. Cardiac function is a risk factor for paralysis in thoracoabdominal aortic replacement. J Vasc Surg. 1998;27:821–828discussion 829-30.
  6. Coselli JS, LeMaire SA, Schmittling ZC, Köksoy C. Cerebrospinal fluid drainage in thoracoabdominal aortic surgery. Semin Vasc Surg. 2000;13:308–314
  7. Etz CD, Halstead JC, Spielvogel D, Shahani R, Lazala R, Homann TM, et al. Thoracic and thoracoabdominal aneurysm repair: is reimplantation of spinal cord arteries a waste of time?. Ann Thorac Surg. 2006;82:1670–1677
  8. Nylander WA, Plunkett RJ, Hammon JW, Oldfield EH, Meacham WF. Thiopental modification of ischemic spinal cord injury in the dog. Ann Thorac Surg. 1982;33:64–68
  9. Michenfelder JD, Milde JH. The relationship among canine brain temperature, metabolism, and function during hypothermia. Anesthesiology. 1991;75:130–136
  10. Laschinger JC, Cunningham JN, Cooper MM, Krieger K, Nathan IM, Spencer FC. Prevention of ischemic spinal cord injury following aortic cross-clamping: use of corticosteroids. Ann Thorac Surg. 1984;38:500–507
  11. Rokkas CK, Cronin CS, Nitta T, Helfrich LR, Lobner DC, Choi DW, et al. Profound systemic hypothermia inhibits the release of neurotransmitter amino acids in spinal cord ischemia. J Thorac Cardiovasc Surg. 1995;110:27–35
  12. Kunihara T, Matsuzaki K, Shiiya N, Saijo Y, Yasuda K. Naloxone lowers cerebrospinal fluid levels of excitatory amino acids after thoracoabdominal aortic surgery. J Vasc Surg. 2004;40:681–690
  13. Wu GJ, Chen WF, Sung CS, Jean YH, Shih CM, Shyu CY, et al. Preventive effects of intrathecal methylprednisolone administration on spinal cord ischemia in rats: the role of excitatory amino acid metabolizing systems. Neuroscience. 2007;147:294–303
  14. Allen BT, Davis CG, Osborne D, Karl I. Spinal cord ischemia and reperfusion metabolism: the effect of hypothermia. J Vasc Surg. 1994;19:332–339discussion 339-40.
  15. Lim KH, Connolly M, Rose D, Siegman F, Jacobowitz I, Acinapura A, et al. Prevention of reperfusion injury of the ischemic spinal cord: use of recombinant superoxide dismutase. Ann Thorac Surg. 1986;42:282–286
  16. Griepp RB, Ergin MA, Galla JD, Lansman S, Khan N, Quintana C, et al. Looking for the artery of Adamkiewicz: a quest to minimize paraplegia after operations for aneurysms of the descending thoracic and thoracoabdominal aorta. J Thorac Cardiovasc Surg. 1996;112:1202–1213discussion 1213-5.
  17. Svensson LG, Rickards E, Coull A, Rogers G, Fimmel CJ, Hinder RA. Relationship of spinal cord blood flow to vascular anatomy during thoracic aortic cross-clamping and shunting. J Thorac Cardiovasc Surg. 1986;91:71–78
  18. Katz NM, Blackstone EH, Kirklin JW, Karp RB. Incremental risk factors for spinal cord injury following operations for acute aortic traumatic transection. J Thorac Cardiovasc Surg. 1981;81:669–674
  19. Blaisdell FW, Cooley DA. The mechanism of paraplegia after temporary thoracic aortic occlusion and its relationship to spinal fluid pressure. Surgery. 1962;51:351–355
  20. Marini CP, Levison J, Caliendo F, Nathan IM, Cohen JR. Control of proximal hypertension during aortic cross-clamping: its effect on cerebrospinal fluid dynamics and spinal cord perfusion. Semin Thorac Cardiovasc Surg. 1998;10:51–56
  21. Toung TJ, Chang Y, Williams M, Crain BJ, Traystman RJ, Bhardwaj A. Experimental spinal cord ischemia: model characterization and improved outcome with arterial hypertension. Crit Care Med. 2004;32:1346–1351
  22. Jacobs MJ, Mess W, Mochtar B, Nijenhuis RJ, Statius van Eps RG, Schurink GW. The value of motor evoked potentials in reducing paraplegia during thoracoabdominal aneurysm repair. J Vasc Surg. 2006;43:239–246
  23. Marsala M, Vanicky I, Yaksh TL. Effect of graded hypothermia (27° to 34°C) on behavioral function, histopathology, and spinal blood flow after spinal ischemia in rat. Stroke. 1994;25:2038–2046
  24. Strauch JT, Lauten A, Spielvogel D, Rinke S, Zhang N, Weisz D, et al. Mild hypothermia protects the spinal cord from ischemic injury in a chronic porcine model. Eur J Cardiothorac Surg. 2004;25:708–715
  25. Faden AT, Jacobs TP, Mougey E, Holaday JW. Endorphins in experimental spinal injury: therapeutic effect of naloxone. Ann Neurol. 1981;10:326–332
  26. Williams GM, Roseborough GS, Webb TH, Perler BA, Krosnick T. Preoperative selective intercostal angiography in patients undergoing thoracoabdominal aneurysm repair. J Vasc Surg. 2004;39:314–321
  27. Cunningham JN, Laschinger JC, Spencer FC. Monitoring of somatosensory evoked potentials during surgical procedures on the thoracoabdominal aorta. J Thorac Cardiovasc Surg. 1987;94:275–285
  28. Crawford ES, Crawford JL, Safi HJ, Coselli JS, Hess KR, Brooks B, et al. Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients. J Vasc Surg. 1986;3:389–404
  29. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg. 1993;17:357–368discussion 368-70.
  30. Uezu T, Koja K, Kuniyoshi Y, Miyagi K, Shimoji M, Arakaki K, et al. Blood distribution to the anterior spinal artery from each segment of intercostal and lumbar arteries. J Cardiovasc Surg (Torino). 2003;44:637–645
  31. Backes WH, Niejenhuis RJ, Mess WH, Wilmink FA, Schurink GW, Jacobs MJ. Magnetic resonance angiography of collateral blood supply to spinal cord in thoracic and thoracoabdominal aortic aneurysm patients. J Vasc Surg. 2008;48:261–271
  32. Maharajh GS, Pascoe EA, Halliday WC, Grocott HP, Thiessen DB, Girling LG, et al. Neurological outcome in a porcine model of descending thoracic aortic surgery. Stroke. 1996;27:2095–2100discussion 2101.
  33. Svensson LG, Von Ritter CM, Groeneveld HT, Rickards ES, Hunter SJ, Robinson MF, et al. Cross-clamping of the thoracic aorta (Influence of aortic shunts, laminectomy, papaverine, calcium channel blocker, allopurinol, and superoxide dismutase on spinal cord blood flow and paraplegia in baboons). Ann Surg. 1986;204:38–47
  34. Meylaerts SA, De Haan P, Kalkman CJ, Jaspers J, Vanicky I, Jacobs MJ. Prevention of paraplegia in pigs by selective segmental artery perfusion during aortic cross-clamping. J Vasc Surg. 2000;32:160–170
  35. Resch TA, Greenberg RK, Lyden SP, Clair DG, Krajewski L, Kashyap VS, et al. Combined staged procedures for the treatment of thoracoabdominal aneurysms. J Endovasc Ther. 2006;13:481–489
  36. Böckler D, Kotelis D, Geisbüsch P, Hyhlik-Dürr A, Klemm K, von Tengg-Kobligk H, et al. Hybrid procedures for thoracoabdominal aortic aneurysms and chronic aortic dissections - a single center experience in 28 patients. J Vasc Surg. 2008;47:724–732
  37. Roselli EE, Greenberg RK, Pfaff K, Francis C, Svensson L, Lytle BW. Endovascular treatment of thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg. 2007;133:1474–1482
  38. Chuter TA, Rapp JH, Hiramoto JS, Schneider DB, Howell B, Reilly LM. Endovascular treatment of thoracoabdominal aortic aneurysms. J Vasc Surg. 2008;47:6–16
  39. Greenberg RK, Lu Q, Roselli EE, Svensson LG, Moon MC, Hernandez AV, et al. Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques. Circulation. 2008;118:808–817
  40. Lepore V, Lönn L, Delle M, Bugge M, Jeppsson A, Kjellman U, et al. Endograft therapy for diseases of the descending thoracic aorta: results in 43 high-risk patients. J Endovasc Ther. 2002;9:829–837
  41. Rodriguez JA, Olsen DM, Shtutman A, Lucas LA, Wheatley G, Alpern J, et al. Application of endograft to treat thoracic aortic pathologies: a single center experience. J Vasc Surg. 2007;46:413–420
  42. Thompson M, Ivaz S, Cheshire N, Fattori R, Rousseau H, Heijmen R, et al. Early results of endovascular treatment of the thoracic aorta using the Valiant endograft. Cardiovasc Intervent Radiol. 2007;30:1130–1138
  43. Toumpoulis IK, Anagnostopoulos CE, Drossos GE, Malamou-Mitsi VD, Pappa LS, Katritsis DG. Early ischemic preconditioning without hypotension prevents spinal cord injury caused by descending thoracic aortic occlusion. J Thorac Cardiovasc Surg. 2003;125:1030–1036

 Competition of interest: none.

PII: S0741-5214(08)02000-4

doi: 10.1016/j.jvs.2008.10.074

Journal of Vascular Surgery
Volume 49, Issue 5 , Pages 1117-1124 , May 2009

Article Tools

* Image Usage & Resolution