Advertisement

General Thoracic and Cardiovascular Surgery

, Volume 67, Issue 1, pp 187–191 | Cite as

Japanese perspective in surgery for thoracoabdominal aortic aneurysms

  • Norihiko ShiiyaEmail author
  • Naoki Washiyama
  • Kazumasa Tsuda
  • Ken Yamanaka
  • Daisuke Takahashi
  • Katsushi Yamashita
  • Kayoko Natsume
  • Yuki Takeuchi
  • Suguru Kubota
  • Yoshiro Matsui
SPECIAL EDITION Controversies in Surgery for Thoracic Aorta

Abstract

Objective

Operative mortality and morbidity after thoracoabdominal aortic surgery remain high. We report our strategy and outcomes, especially those of spinal cord protection.

Methods

Outcomes of 178 patients (age: 26–88 years) who underwent thoracoabdominal aortic replacement were retrospectively analyzed. 65 had aortic dissection, 14 had infected aneurysms, and 22 presented with rupture. Operations were non-elective in 24 and redo through re-thoracotomy in 21. Extent of replacement was Crawford-I in 39, II in 26, III in 78, and IV in 35. Staged repair was recently preferred, which resulted in decrease in extent II repair and increase in redo since 2009. Operations were performed under distal aortic perfusion and multi-segmental sequential repair to maximize collateral blood flow, and deep hypothermic circulatory arrest was preserved for those requiring open aortic anastomosis (n = 20). A total of 166 separate grafts were used for intercostal reconstruction in 88 patients, which was guided by preoperative feeding artery localization. Their patency was studied by postoperative MD-CT in 74 patients for 145 grafts.

Results

There were 3.9% hospital mortality and 5.1% spinal cord injury. Preoperative feeding artery localization resulted in reduced number of reconstruction and improved patency, and grafts connecting to the feeding artery were patent in 92%. Results of redo operations were not different (no mortality and spinal cord injury) from the de novo operations.

Conclusions

Our concept of spinal cord protection, which was based on selective intercostal reconstruction while maximizing spinal cord collateral blood flow, seems justified.

Keywords

Thoracoabdominal aortic aneurysm Spinal cord protection Open surgical repair 

Notes

Compliance with ethical standards

Conflict of interest

The authors have declared that no conflict of interest exists.

References

  1. 1.
    Coselli JS, LeMaire SA, Preventza O, de la Cruz KI, Cooley DA, Price MD, et al. Outcomes of 3309 thoracoabdominal aortic aneurysm repairs. J Thorac Cardiovasc Surg. 2016;151:1323–37.CrossRefGoogle Scholar
  2. 2.
    Committee for Scientific Affairs JATS, Masuda M, Okumura M, Doki Y, Endo S, Hirata Y et al. Thoracic and cardiovascular surgery in Japan during 2014: annual report by the Japanese Association for Thoracic Surgery. Gen Thorac Cardiovasc Surg. 2016;64:665–97.CrossRefGoogle Scholar
  3. 3.
    Inoue Y, Minatoya K, Oda T, Seike Y, Tanaka H, Sasaki H. Novel surgical incision for treatment of extensive aortic aneurysm: a case of straight incision with rib-cross (SIRC) approach. Gen Thorac Cardiovasc Surg. 2016;64:55–7.CrossRefGoogle Scholar
  4. 4.
    Yoshioka K, Tanaka R, Kamada T, Abiko A. Three-dimensional demonstration of the collateral circulation to the artery of Adamkiewicz via the thoracodorsal artery with multi-slice computed tomography angiography. Eur J Cardiothorac Surg. 2010;37:1234.CrossRefGoogle Scholar
  5. 5.
    Shiiya N, Matsuzaki K, Kunihara T, Yasuda K. Use of a soft reservoir bag in a fully heparin-coated closed-loop cardiopulmonary bypass system for distal aortic perfusion during aortic surgery. J Artif Org. 2005;8:85–90.CrossRefGoogle Scholar
  6. 6.
    Shiiya N, Matsuzaki K, Kunihara T, Sugiki H. Heparin reduction with the use of cardiotomy suction is associated with hyperfibrinolysis during distal aortic perfusion with a heparin-coated semi-closed cardiopulmonary bypass system. J Artif Org. 2006;9:214–9.CrossRefGoogle Scholar
  7. 7.
    Shiiya N, Yasuda K, Matsui Y, Sakuma M, Sasaki S. Spinal cord protection during thoracoabdominal aortic aneurysm repair: results of selective reconstruction of the critical segmental arteries guided by evoked spinal cord potential monitoring. J Vasc Surg. 1995;21:970–5.CrossRefGoogle Scholar
  8. 8.
    Maruyama R, Kamishima T, Shiiya N, Asano T, Matsuzaki K, Miyasaka K, et al. MDCT scan visualizes the Adamkiewicz artery. Ann Thorac Surg. 2003;76:1308.CrossRefGoogle Scholar
  9. 9.
    Shiiya N, Wakasa S, Matsui K, Sugiki T, Shingu Y, Yamakawa T, et al. Anatomical pattern of feeding artery and mechanism of intraoperative spinal cord ischemia. Ann Thorac Surg. 2009;88:768–71. (discussion 72).CrossRefGoogle Scholar
  10. 10.
    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 Cardiovasc Surg. 2005;11:178–85.Google Scholar
  11. 11.
    Etz CD, Zoli S, Mueller CS, Bodian CA, Di Luozzo G, Lazala R, et al. Staged repair significantly reduces paraplegia rate after extensive thoracoabdominal aortic aneurysm repair. J Thorac Cardiovasc Surg. 2010;139:1464–72.CrossRefGoogle Scholar
  12. 12.
    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–S869. (discussion S90–2).CrossRefGoogle Scholar
  13. 13.
    Acher CW, Wynn MM. Thoracoabdominal aortic aneurysm. How we do it. Cardiovasc Surg. 1999;7:593–6.CrossRefGoogle Scholar
  14. 14.
    Etz CD, Di Luozzo G, Zoli S, Lazala R, Plestis KA, Bodian CA, et al. Direct spinal cord perfusion pressure monitoring in extensive distal aortic aneurysm repair. Ann Thorac Surg. 2009;87:1764–73. (discussion 73–4).CrossRefGoogle Scholar
  15. 15.
    Etz CD, Luehr M, Kari FA, Bodian CA, Smego D, Plestis KA, et al. Paraplegia after extensive thoracic and thoracoabdominal aortic aneurysm repair: does critical spinal cord ischemia occur postoperatively? J Thorac Cardiovasc Surg. 2008;135:324–30.CrossRefGoogle Scholar
  16. 16.
    Etz CD, Homann TM, Luehr M, Kari FA, Weisz DJ, Kleinman G, et al. Spinal cord blood flow and ischemic injury after experimental sacrifice of thoracic and abdominal segmental arteries. Eur J Cardiothorac Surg. 2008;33:1030–8.CrossRefGoogle Scholar
  17. 17.
    Dommisse GF. The arteries, arterioles, and capillaries of the spinal cord. Surgical guidelines in the prevention of postoperative paraplegia. Ann R Coll Surg Engl. 1980;62:369–76.Google Scholar
  18. 18.
    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;91:71–8.Google Scholar
  19. 19.
    Shiiya N, Matsui Y, Murashita T, Sasaki S, Sakuma M, Yasuda K. Effects of multiple small segmental resection and hypothermia with regard to causes of spinal cord injury and selection of reconstruction methods in thoracoabdominal aortic aneurysms. Jpn J Vasc Surg. 1997;6:531–36. (article in Japanese).Google Scholar

Copyright information

© The Japanese Association for Thoracic Surgery 2017

Authors and Affiliations

  • Norihiko Shiiya
    • 1
    Email author
  • Naoki Washiyama
    • 1
  • Kazumasa Tsuda
    • 1
  • Ken Yamanaka
    • 1
  • Daisuke Takahashi
    • 1
  • Katsushi Yamashita
    • 1
  • Kayoko Natsume
    • 1
  • Yuki Takeuchi
    • 1
  • Suguru Kubota
    • 2
  • Yoshiro Matsui
    • 2
  1. 1.First Department of SurgeryHamamatsu University School of MedicineHamamatsuJapan
  2. 2.Department of Cardiovascular and Thoracic SurgeryHokkaido University Graduate School of MedicineSapporoJapan

Personalised recommendations