A new intercostal artery management strategy for thoracoabdominal aortic aneurysm repair.
ABSTRACT The purpose of this study is to describe a new approach for addressing the intraoperative management of intercostal arteries during thoracoabdominal aortic aneurysm (TAAA) repair, using preoperative spinal MRA for detection of intercostal arteries supplying the anterior spinal artery.
Patients undergoing TAAA repair from August 2005 to September 2007 were included. Spinal artery MRA was performed to identify the anterior spinal artery, the artery of Adamkiewicz, and its major intercostal source artery (SA-AAK). Intraoperative spinal cord protection was carried out using standard techniques. Important intercostal arteries were either preserved or reimplanted as a button patch after removing aortic clamps. Demographic and perioperative data were collected for review. Analysis was performed with Fisher's exact test or Student's t-test, where applicable, using SAS ver. 8.0 (Cary, NC).
Spinal artery MRA was performed in 27 patients. The SA-AAK was identified in 85% of preoperative studies. Open or endovascular repair was performed in 74% and 26% of patients, respectively. The SA-AAK was preserved or reimplanted in 13 (65%) of patients who underwent open repair. A mean of 1.67 (range 1-3) intercostal arteries were reimplanted. All patients undergoing endovascular repair necessitated coverage of the SA-AAK. No patient developed immediate or delayed paraplegia. Longer mean operative times in the reimplanted cohort were not statistically significant (330 versus 245 min, P = 0.1).
The SA-AAK identified by MRA can be preserved or safely reimplanted after TAAA repair. Further study is warranted to determine if selective intercostal reimplantation can reduce the risk of immediate or delayed paraplegia.
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ABSTRACT: Thoracoabdominal aneurysms account for roughly 3% of identified aneurysms annually in the United States. Advancements in endovascular techniques and devices have broadened their application to these complex surgical problems. This paper will focus on the current state of endovascular thoracoabdominal aneurysm repair, including specific considerations in patient selection, operative planning, and perioperative complications. Both total endovascular and hybrid options will be considered.Vascular Health and Risk Management 01/2014; 10:493-505. DOI:10.2147/VHRM.S46452
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ABSTRACT: OBJECTIVE: Paraparesis and paraplegia after thoracic endovascular aneurysm repair (TEVAR) is a greatly feared complication. Multiple case series report this risk up to 13% with no, or inconsistent, application of interventions to enhance and protect spinal cord perfusion. In this study, we report our single-institution experience of TEVAR, using the same proactive spinal cord ischemia protection protocol we use for open repair. METHODS: Endovascular thoracic aortic interventions were performed for both on-label (aneurysm) and off-label (trauma, other) indications. Aortic area covered was recorded as a fraction from the subclavian to celiac origins and reported as a percentage. If debranching was required, measurements were taken from the most distal arch vessel left intact. Intraoperative imaging and postoperative computed tomographic angiogram were used in calculating aortic percent coverage. Outcomes were recorded in a clinical database and analyzed retrospectively. The spinal cord ischemia protection included routine spinal drainage (spinal fluid pressure <10 mm Hg), endorphin receptor blockade (naloxone infusion), moderate intraoperative hypothermia (<35°C), hypotension avoidance (mean arterial pressure >90 mm Hg), and optimizing cardiac function. RESULTS: From 2005 to 2012, 94 consecutive TEVARs were studied. Indications were thoracic aneurysm (n = 48), plaque rupture with or without dissection (n = 23), trauma (n = 15), and other (n = 8). Forty-nine percent were acute, average age was 68.5 years, 60% (n = 56) were male, and the mean follow-up was 12 months. Mean length of aortic coverage was 161 cm, correlating to 59.4% aortic coverage. One patient had delayed paralysis (1.1%; observed/expected ratio, 0.12) and recovered enough to ambulate easily without assistance. Other complications included wound (7.5%), stroke (4.3%), myocardial infarct (4.3%), and renal failure (1.1%). CONCLUSIONS: Proactive spinal cord protective protocols appear to reduce the incidence of spinal ischemia after TEVAR compared with historical series. This study would suggest that active, as opposed to reactive, approaches to spinal ischemia portend a better long-term outcome. Multimodal protection is essential, especially if long segment coverage is planned.Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 03/2013; 57(6). DOI:10.1016/j.jvs.2012.12.032 · 2.98 Impact Factor
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ABSTRACT: Despite much advancement in preoperative evaluation and perioperative care of patients with thoracoabdominal aortic aneurysms (TAAA), open surgical repair of TAAAs remains a formidable challenge for the vascular surgeon. It requires extensive dissection and mobilization of the aorta and its branches, as well as cross-clamping of the aorta above intercostal and visceral arteries. Over the past decade, the mortality and morbidity associated with open TAAA repair have improved significantly. However, it remains one of the most complex, extensive surgical procedures performed in the field of vascular surgery. Recently, there has been much attention directed at less invasive methods such as the so-called "hybrid" or "debranching" procedure, or complete endovascular repair with fenestrated and branched endografts for repairing TAAAs. However, the gold standard for repair of TAAA remains open surgery, and this article summarizes the clinical outcomes of open surgical repair of TAAAs during the past decade (2000-2010) to provide a benchmark for comparison with results from previous decades and also with which to compare the results of modern-day hybrid and/or complete endovascular techniques.Annals of Vascular Surgery 12/2011; 26(4):600-5. DOI:10.1016/j.avsg.2011.11.002 · 1.03 Impact Factor