Advertisement

General Thoracic and Cardiovascular Surgery

, Volume 67, Issue 1, pp 180–186 | Cite as

Differential selective hypothermic intercostal artery perfusion: a new method to probe spinal cord perfusion during thoracoabdominal aortic aneurysm repair

  • Yoshikatsu SaikiEmail author
  • Koyu Watanabe
  • Koki Ito
  • Keisuke Kanda
  • Goro Takahashi
  • Yukihiro Hayatsu
  • Ichiro Yoshioka
  • Naotaka Motoyoshi
  • Satoshi Kawatsu
  • Osamu Adachi
  • Masatoshi Akiyama
  • Kiichiro Kumagai
  • Shunsuke Kawamoto
SPECIAL EDITION Controversies in Surgery for Thoracic Aorta
  • 143 Downloads

Abstract

Objective

To prevent paraplegia in patients undergoing thoracoabdominal aortic aneurysm repair, the importance of preoperative identification of the Adamkiewicz artery and reconstruction of critical intercostal artery have been advocated. Conversely, significance of collateral network for spinal cord perfusion has been recognized. We invented a new system consisting of a direct monitoring of cerebrospinal fluid temperature (CSFT) and differential selective hypothermic intercostal artery perfusion (D-HIAP).

Methods

After exposing a critical intercostal artery, a 10-mm prosthetic graft was anastomosed in an end to side fashion. A balloon-tipped catheter was inserted into the graft to perfuse with 15 °C blood. Neighboring intercostal arteries were also perfused in the same fashion. Serial monitoring of CSFT was performed. Between January 2011 and January 2015, D-HIAP was employed in 50 patients with Adamkiewicz artery that located within a reconstructed area.

Results

Significant CSFT drop was recorded after initiation of D-HIAP in 42 (84%) patients. Of those, 34 (68%) patients showed significantly lowered CSFT with D-HIAP into a single critical intercostal artery. Perfusion into plural intercostal arteries was necessary for CSFT drop in 2 cases (4%), and plural intercostal artery perfusion further enhanced CSFT drop that had been modestly achieved by single intercostal artery perfusion in 6 cases (12%). Eight (16%) patients did not exhibit a significant drop in CSFT even when D-HIAP was employed for the critical and neighboring intercostal arteries.

Conclusions

The detection of a disparity in temperature between the intrathecal space and blood generated by D-HIAP revealed individual variability in CSFT changes, which may imply a complexity in spinal cord perfusion. Intraoperative D-HIAP may help to identify a major blood supply for spinal cord perfusion and underlying collateral network.

Keywords

Thoracoabdominal aortic aneurysm Spinal cord injury Hypothermic perfusion 

Notes

Acknowledgements

The authors appreciate Dr. Konosuke Sasaki for his excellent assistance in statistical analyses.

Supplementary material

11748_2018_1005_MOESM1_ESM.docx (15 kb)
Supplementary material 1 (DOCX 15 KB)

References

  1. 1.
    Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg. 1993;17:357–70.CrossRefGoogle Scholar
  2. 2.
    Strauss DJ, Devivo MJ, Paculdo DR, Shavelle RM. Trends in life expectancy after spinal cord injury. Arch Phys Med Rehabil. 2006;87:1079–85.CrossRefGoogle Scholar
  3. 3.
    Middleton JW, Dayton A, Walsh J, Rutkowski SB, Leong G, Duong S. Life expectancy after spinal cord injury: a 50-year study. Spinal Cord. 2012;50:803–11.CrossRefGoogle Scholar
  4. 4.
    Estrera AL, Rubenstein FS, Miller CC, Huynh TT, Letsou GV, Safi HJ. Descending thoracic aortic aneurysm: surgical approach and treatment using the adjuncts cerebrospinal fluid drainage and distal aortic perfusion. Ann Thorac Surg. 2001;72:481–6.CrossRefGoogle Scholar
  5. 5.
    Cambria RP, Clouse WD, Davison JK, Dunn PF, Corey M, Dorer D. Thoracoabdominal aneurysm repair: results with 337 operations performed over a 15-year interval. Ann Surg. 2002;236:471–9.CrossRefGoogle Scholar
  6. 6.
    Coselli JS, LeMaire SA, Koksoy C, Schmittling ZC, Curling PE. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. J Vasc Surg. 2002;35:631–9.CrossRefGoogle Scholar
  7. 7.
    Conrad MF, Crawford RS, Davison JK, Cambria RP. Thoracoabdominal aneurysm repair: a 20-year perspective. Ann Thorac Surg. 2007;83:856-61.CrossRefGoogle Scholar
  8. 8.
    Ogino H, Sasaki H, Minatoya K, Matsuda H, Yamada N, Kitamura S. Combined use of Adamkiewicz artery demonstration and motor-evoked potentials in descending and thoracoabdominal aortic repair. Ann Thorac Surg. 2006;82:592–6.CrossRefGoogle Scholar
  9. 9.
    Strauch JT, Spielvogel D, Lauten A, Zhang N, Shiang H, Weisz D, et al. Importance of extrasegmental vessels for spinal cord blood supply in a chronic porcine model. Eur J Cardiothorac Surg. 2003;24:817–24.CrossRefGoogle Scholar
  10. 10.
    Griepp RB, Griepp EB. Spinal cord perfusion and protection during descending thoracic and thoracoabdominal aortic surgery: the collateral network concept. Ann Thorac Surg. 2007;83:865-92.Google Scholar
  11. 11.
    Lancaster RT, Conrad MF, Patel VI, Cambria MR, Ergul EA, Cambria RP. Further experience with distal aortic perfusion and motor-evoked potential monitoring in the management of extent I–III thoracoabdominal aortic anuerysms. J Vasc Surg. 2013;58:283–90.CrossRefGoogle Scholar
  12. 12.
    Min HK, Sung K, Yang JH, Kim WS, Jun TG, Lee YT, et al. Can intraoperative motor-evoked potentials predict all the spinal cord ischemia during moderate hypothermic beating heart descending thoracic or thoraco-abdominal aortic surgery? J Cardiac Surgy. 2010;25:542–7.CrossRefGoogle Scholar
  13. 13.
    Tabayashi K, Saiki Y, Kokubo H, Takahashi G, Akasaka J, Yoshida S, et al. Protection from postischemic spinal cord injury by perfusion cooling of the epidural space during most or all of a descending thoracic or thoracoabdominal aneurysm repair. Gen Thorac Cardiovasc Surg. 2010;58:228–34.CrossRefGoogle Scholar
  14. 14.
    Takase K, Sawamura Y, Igarashi K, Chiba Y, Haga K, Saito H, et al. Demonstration of the artery of Adamkiewicz at multi-detector row helical CT1. Radiology. 2002;223:39–45.CrossRefGoogle Scholar
  15. 15.
    Takagi H, Ota H, Natsuaki Y, Komori Y, Ito K, Saiki Y, et al. Identifying the Adamkiewicz artery using 3-T time-resolved magnetic resonance angiography: its role in addition to multidetector computed tomography angiography. Jpn J Radiol. 2015;33:749–56.CrossRefGoogle Scholar
  16. 16.
    Bischoff MS, Scheumann J, Brenner RM, Ladage D, Bodian CA, Kleinman G, et al. Staged approach prevents spinal cord injury in hybrid surgical-endovascular thoracoabdominal aortic aneurysm repair: an experimental model. Ann Thorac Surg. 2011;92:138–46.CrossRefGoogle Scholar
  17. 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;91:71–8.Google Scholar
  18. 18.
    Shiiya N, Wakasa S, Matsui K, Sugiki T, Shingu Y, Yamakawa T, Matsui Y. Anatomical pattern of feeding artery and mechanism of intraoperative spinal cord ischemia. Ann Thorac Surg. 2009;88:768 – 72.CrossRefGoogle Scholar

Copyright information

© The Japanese Association for Thoracic Surgery 2018

Authors and Affiliations

  • Yoshikatsu Saiki
    • 1
    Email author
  • Koyu Watanabe
    • 1
  • Koki Ito
    • 1
  • Keisuke Kanda
    • 1
  • Goro Takahashi
    • 1
  • Yukihiro Hayatsu
    • 1
  • Ichiro Yoshioka
    • 1
  • Naotaka Motoyoshi
    • 1
  • Satoshi Kawatsu
    • 1
  • Osamu Adachi
    • 1
  • Masatoshi Akiyama
    • 1
  • Kiichiro Kumagai
    • 1
  • Shunsuke Kawamoto
    • 1
  1. 1.Division of Cardiovascular SurgeryTohoku University Graduate School of MedicineSendaiJapan

Personalised recommendations