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: 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.European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery 09/2009; 38(5):567-77. DOI:10.1016/j.ejvs.2009.07.011 · 3.07 Impact Factor
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ABSTRACT: 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.Radiology 06/2010; 255(3):873-81. DOI:10.1148/radiol.10091304 · 6.21 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