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DOI: 10.1055/s-2008-1038704
© Georg Thieme Verlag KG Stuttgart · New York
Rate of Paraplegia and Mortality in Elective Descending and Thoracoabdominal Aortic Repair in the Modern Surgical Era
Publication History
received February 1, 2008
Publication Date:
14 August 2008 (online)
![](https://www.thieme-connect.de/media/thoracic/200806/lookinside/thumbnails/10.1055-s-2008-1038704-1.jpg)
Abstract
Background: The risk of paraplegia and hospital death is the major concern in the surgical repair of descending and thoracoabdominal aortic pathologies. For specific indications, the evolving technology of endovascular stent grafting is becoming increasingly popular. We reviewed our results for elective surgical repair of various aortic pathologies with respect to this innovative therapeutic background. Methods: From July 1993 to April 2006, 56 patients (mean age 55 ± 16 years, range 25 to 80 years, 62.5 % males) underwent elective surgical repair of the descending (n = 37, 66.1 %) and thoracoabdominal aorta (n = 19, 33.9 %), including seven reoperations and five cases of previous endovascular stent grafting. The underlying pathologies were: degenerative aneurysm (n = 21), type B aortic dissection (n = 24), and Marfan's syndrome with a chronic type B dissection and an increase in the diameter of the descending aorta (n = 11), respectively. Most patients were operated using deep hypothermic circulatory arrest. Results: Thirty-day mortality was 5.4 % (n = 3). Two patients died of myocardial infarction, one after coronary stent occlusion. Another patient died due to ventricular disruption at the side of the left ventricular apical vent. The rate of paraplegia was 3.6 % (n = 2) with one case of complete and one of incomplete paraplegia. Survival at five years was 78 %. Conclusions: If modern surgical principles are used in elective descending and thoracoabdominal aortic repair, surgery can be performed with a low postoperative risk for hospital death or paraplegia. These results should be taken into account when evaluating alternative therapeutic strategies in patients with similar pathologies.
Key words
aortic disease - cardiovascular surgery - surgery - aorta - spinal cord
References
- 1 Crawford E S, Coselli J S, Safi H J. Partial cardiopulmonary bypass, hypothermic circulatory arrest, and posterolateral exposure for thoracic aortic aneurysm operation. J Thorac Cardiovasc Surg. 1987; 94 824-827
- 2 Cooley D A, Baldwin R T. Technique of open distal anastomosis for repair of descending thoracic aortic aneurysms. Ann Thorac Surg. 1992; 54 932-936
- 3 Borst H G, Jurmann M, Buehner B, Laas J. Risk of replacement of descending aorta with a standardized left heart bypass technique. J Thorac Cardiovasc Surg. 1994; 107 126-133
- 4 Kouchoukos N T, Daily B B, Rokkas C K. et al . Hypothermic bypass and circulatory arrest for operations of the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg. 1995; 60 67-76
- 5 Lansman S L, Hagl C, Finjk D. et al . Acute type B aortic dissection: surgical therapy. Ann Thorac Surg. 2002; 74 S1833-S1835
- 6 Girardi L N, Krieger K H, Altorki N K, Mack C A, Lee L Y, Isom W. Ruptured descending and thoracoabdominal aortic aneurysms. Ann Thorac Surg. 2002; 74 S1066-S1070
- 7 Crawford E S, Crawford J L, Safi H J. 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
- 8 Patel H J, Shillingford M S, Mihalik S, Proctor M C, Deep G M. Resection of the descending thoracic aorta: outcomes after use of hypothermic circulatory arrest. Ann Thorac Surg. 2006; 82 90-96
- 9 Shiiya N, Kunihara T, Matsuzaki K, Yasuda K. Evolving strategy and results of spinal cord protection in type I and II thoracoabdominal aortic aneurysm repair. Ann Thorac Surg. 2005; 11 178-185
- 10 Coselli J S, Bozinovski J, LeMaire S A. Open surgical repair of 2286 thoracoabdominal aortic aneurysms. Ann Thorac Surg. 2007; 83 S862-S864
- 11 Orend K H, Scharrer-Pamler R, Kapfer X. et al . Endovascular treatment in diseases of the descending thoracic aorta: 6-year results of a single center. J Vasc Surg. 2003; 37 91-99
- 12 Marcheix B, Dambrin C, Bolduc J-P. et al . Midterm results of endovascular treatment of atherosclerotic aneurysms of the descending thoracic aorta. J Thorac Cardiovasc Surg. 2006; 132 1030-1036
- 13 Khoynezhad A, Donayre C E, Bui H, Kopchok G E, Walot I, White R A. Risk factors of neurologic deficit after thoracic aortic endografting. Ann Thorac Surg. 2007; 83 S882-S889
- 14 Cheung A T, Pochettino A, McGarvey M L. et al . Strategies to manage paraplegia risk after endovascular stent repair of descending thoracic aortic aneurysms. Ann Thorac Surg. 2005; 80 1280-1289
- 15 Makaroun M S, Dillavou E D, Kee S T. et al . Endovascular treatment of thoracic aortic aneurysms: results of the phase II multicenter trial of the GORE TAG thoracic endoprosthesis. J Vasc Surg. 2005; 41 1-9
- 16 Czerny M, Grimm M, Zimpfer D. et al . Results after endovascular stent graft placement in atherosclerotic aneurysms involving the descending aorta. Ann Thorac Surg. 2007; 83 450-455
- 17 Bortone A S, De Cillis E, D'Agostino D. et al . Endovascular treatment of thoracic aortic disease: four years of experience. Circulation. 2004; 119 (Suppl) II262-II267
- 18 Dapunt O E, Galla J D, Sadeghi A M. et al . The natural history of thoracic aortic aneurysms. J Thorac Cardiovasc Surg. 1994; 107 1323-1333
- 19 Mauney M C, Blackbourne L H, Langenburg S E, Buchanan S A, Kron I L, Tribble C G. Prevention of spinal cord injury after repair of the thoracic or thoracoabdominal aorta. Ann Thorac Surg. 1995; 59 245-252
- 20 Kouchoukos N T, Wareing T H, Izumoto H. et al . Elective hypothermic cardiopulmonary bypass and circulatory arrest for spinal cord protection during operations on the thoracoabdominal aorta. J Thorac Cardiovasc Surg. 1990; 99 659-664
- 21 DeBakey M E, McCollum C H, Graham J M. Surgical treatment of aneurysms of the descending thoracic aorta. J Thorac Cardiovasc Surg (Torino). 1978; 19 571-576
- 22 Kouchoukos N T, Rokkas C K. Hypothermic cardiopulmonary bypass for spinal cord protection: rationale and clinical results. Ann Thorac Surg. 1999; 67 1940-1942
- 23 Salzano R P, Ellison L H, Altonji P F. et al . Regional deep hypothermia of the spinal cord protects against ischemic injury during thoracic aortic cross-clamping. Ann Thorac Surg. 1994; 57 65-67
- 24 Coles J G, Wilson G J, Sima A F. et al . Intraoperative management of thoracic aortic aneurysms. Experimental evaluation of perfusion cooling of the spinal cord. J Thorac Cardiovasc Surg. 1983; 85 292-299
- 25 Rokkas C K, Sundaresan S, Shuman T A. et al . Profound systemic hypothermia protects the spinal cord during periods of ischemia. J Thorac Cardiovasc Surg. 1993; 106 1024-1035
- 26 Robertson C S, Foltz R, Grossman R G. et al . Protection against experimental ischemic spinal cord injury. J Neurosurg. 1986; 64 633-642
- 27 Ross S D, Kron I L, Parrino P E, Shockey K S, Kern J A, Tribble C G. Preservation of intercostal arteries during thoracoabdominal aortic aneurysm surgery: a retrospective study. J Thorac Cardiovasc Surg. 1999; 118 17-25
- 28 Svensson L G, Hess K R, Coselli J S, Safi H J. Influence of segmental arteries, extent, and arteriofemoral bypass on postoperative paraplegia after thoracoabdominal aortic operations. J Vasc Surg. 1994; 20 255-262
- 29 Minatoya K, Karck M, Hagl C. et al . The impact of spinal angiography on the neurological outcome after surgery on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg. 2002; 74 S1870-S1872
- 30 Blaisdell F W, Cooley D A. The mechanism of paraplegia after temporary thoracic aortic occlusion and its relationship to spinal fluid pressure. Surgery. 1962; 51 351-355
- 31 Archer C W, Wynn M M, Hoch J R, Popic P M, Turnipseed W D. Combined use of cerebral spinal fluid drainage and naloxone reduces the risk of paraplegia in thoracoabdominal aneurysm repair. J Vasc Surg. 1994; 19 236-246
- 32 McCullough J L, Hollier L H, Nugent M. Paraplegia after thoracic aortic occlusion: influence of cerebrospinal fluid drainage. J Vasc Surg. 1988; 7 153-160
- 33 Dardik A, Perler B A, Roseborough G S, Williams G M. Subdural hematoma after thoracoabdominal aortic aneurysm repair: an underreported complication of spinal fluid drainage?. J Vasc Surg. 2002; 36 47-50
- 34 Miyamoto K, Ueno A, Wada T. A new and simple method of preventing spinal cord damage following temporary occlusion of thoracic aorta by draining cerebrospinal fluid. J Cardiovasc Surg. 1960; 1 188-197
- 35 Crawford E S, Svensson L G, Hess K R. et al . A prospective randomized study of cerebrospinal fluid drainage to prevent paraplegia after high-risk surgery on the thoracoabdominal aorta. J Vasc Surg. 1991; 13 36-46
- 36 Svensson L G, Khitin L, Nadolny E M, Kimmel W A. Systemic temperature and paralysis after thoracoabdominal and descending aortic operations. Arch Surg. 2003; 138 175-179
- 37 Griepp R B, Ergin M A, Galla J D. 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 1202-1213
- 38 Estrera A L, Miller 3rd C C. Descending thoracic aortic aneurysm repair. 12-year experience using distal aortic perfusion and cerebrospinal fluid drainage. Ann Thorac Surg. 2005; 80 1290-1296
- 39 Bavaria J E, Appoo J J, Makaroun M S. et al . Endovascular stent grafting versus open surgical repair of descending thoracic aneurysms in low-risk patients: a multicenter comparative trial. J Thorac Cardiovasc Surg. 2007; 133 369-377
- 40 Glade G J, Vahl A C, Wisselink W, Linsen M AM, Balm R. Mid-term survival and costs of treatment of patients with descending thoracic aortic aneurysms; endovascular vs. open repair: a case-control study. Eur J Vasc Endovasc Surg. 2005; 29 28-34
- 41 Ricco J B, Cau J, Marchand C. et al . Stent-graft repair for thoracic aortic disease: results of an independent nationwide study in France from 1999 to 2001. J Thorac Cardiovasc Surg. 2006; 131 131-137
- 42 Ehrlich M, Grabenwoger M, Cartes-Zumelzu F. et al . Endovascular stent graft repair for aneurysms on the descending thoracic aorta. Ann Thorac Surg. 1998; 66 19-25
- 43 Nienaber C A, Fattori R, Lund G. et al . Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med. 1999; 340 1539-1545
- 44 Fattori R, Nienaber C A, Rousseau H. et al . Results of endovascular repair of the thoracic aorta with the Talent Thoracic stent graft: The Talent Thoracic Retrospective Registry. J Thorac Cardiovasc Surg. 2006; 132 332-339
Dr. MD, PhD Martin Misfeld
University of Luebeck
Department of Cardiac and Thoracic Vascular Surgery
Ratzeburger Allee 160
23538 Luebeck
Germany
Phone: + 49 (0) 45 15 00 21 08
Fax: + 49 (0) 45 15 00 20 51
Email: martinmisfeld@yahoo.com