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Kozlov BN, Panfilov DS, Ponomarenko IV, Miroshnichenko AG, Nenakhova AA, Maksimov AI, Shipulin VM. The risk of spinal cord injury during the frozen elephant trunk procedure in acute aortic dissection. Interact Cardiovasc Thorac Surg 2018; 26:972-976. [DOI: 10.1093/icvts/ivx432] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 09/13/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Boris N Kozlov
- Cardiovascular Surgery Department, Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
| | - Dmitri S Panfilov
- Cardiovascular Surgery Department, Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
| | - Igor V Ponomarenko
- Cardiovascular Surgery Department, Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
| | - Andrey G Miroshnichenko
- Cardiovascular Surgery Department, Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
| | - Aleksandra A Nenakhova
- Cardiovascular Surgery Department, Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
| | - Alexander I Maksimov
- Cardiovascular Surgery Department, Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
| | - Vladimir M Shipulin
- Cardiovascular Surgery Department, Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
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Awad H, Ramadan ME, El Sayed HF, Tolpin DA, Tili E, Collard CD. Spinal cord injury after thoracic endovascular aortic aneurysm repair. Can J Anaesth 2017; 64:1218-1235. [PMID: 29019146 DOI: 10.1007/s12630-017-0974-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 08/04/2017] [Accepted: 09/13/2017] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Thoracic endovascular aortic aneurysm repair (TEVAR) has become a mainstay of therapy for aneurysms and other disorders of the thoracic aorta. The purpose of this narrative review article is to summarize the current literature on the risk factors for and pathophysiology of spinal cord injury (SCI) following TEVAR, and to discuss various intraoperative monitoring and treatment strategies. SOURCE The articles considered in this review were identified through PubMed using the following search terms: thoracic aortic aneurysm, TEVAR, paralysis+TEVAR, risk factors+TEVAR, spinal cord ischemia+TEVAR, neuromonitoring+thoracic aortic aneurysm, spinal drain, cerebrospinal fluid drainage, treatment of spinal cord ischemia. PRINCIPAL FINDINGS Spinal cord injury continues to be a challenging complication after TEVAR. Its incidence after TEVAR is not significantly reduced when compared with open thoracoabdominal aortic aneurysm repair. Nevertheless, compared with open procedures, delayed paralysis/paresis is the predominant presentation of SCI after TEVAR. The pathophysiology of SCI is complex and not fully understood, though the evolving concept of the importance of the spinal cord's collateral blood supply network and its imbalance after TEVAR is emerging as a leading factor in the development of SCI. Cerebrospinal fluid drainage, optimal blood pressure management, and newer surgical techniques are important components of the most up-to-date strategies for spinal cord protection. CONCLUSION Further experimental and clinical research is needed to aid in the discovery of novel neuroprotective strategies for the protection and treatment of SCI following TEVAR.
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Affiliation(s)
- Hamdy Awad
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Doan Hall 534, 410 West 10th Avenue, Columbus, OH, 43210, USA.
| | - Mohamed Ehab Ramadan
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Doan Hall 534, 410 West 10th Avenue, Columbus, OH, 43210, USA.,Department of Anesthesiology, Theodor Bilharz Research Institute, Giza, Egypt
| | - Hosam F El Sayed
- Division of Vascular Diseases & Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Daniel A Tolpin
- Division of Cardiovascular Anesthesiology, The Texas Heart Institute, Baylor St. Luke's Medical Center, Houston, TX, USA
| | - Esmerina Tili
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Doan Hall 534, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Charles D Collard
- Division of Cardiovascular Anesthesiology, The Texas Heart Institute, Baylor St. Luke's Medical Center, Houston, TX, USA
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Fort AC, Rubin LA, Meltzer AJ, Schneider DB, Lichtman AD. Perioperative Management of Endovascular Thoracoabdominal Aortic Aneurysm Repair. J Cardiothorac Vasc Anesth 2017; 31:1440-1459. [DOI: 10.1053/j.jvca.2017.03.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Indexed: 01/16/2023]
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Soliman R, Zohry G. The myocardial protective effect of dexmedetomidine in high-risk patients undergoing aortic vascular surgery. Ann Card Anaesth 2017; 19:606-613. [PMID: 27716690 PMCID: PMC5070319 DOI: 10.4103/0971-9784.191570] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective: The aim of the study was to assess the effect of dexmedetomidine in high-risk patients undergoing aortic vascular surgery. Design: A randomized prospective study. Setting: Cairo University, Egypt. Materials and Methods: The study included 150 patients undergoing aortic vascular surgery. Intervention: The patients were classified into two groups (n = 75). Group D: The patients received a loading dose of 1 μg/kg dexmedetomidine over 15 min before induction and maintained as an infusion of 0.3 μg/kg/h to the end of the procedure. Group C: The patients received an equal volume of normal saline. The medication was prepared by the nursing staff and given to anesthetist blindly. Measurements: The monitors included the heart rate, mean arterial blood pressure, central venous pressure, electrocardiogram (ECG), serum troponin I level, end-tidal sevoflurane, and total dose of morphine in addition transthoracic echocardiography to the postoperative in cases with elevated serum troponin I level. Main Results: The dexmedetomidine decreased heart rate and minimized the changes in blood pressure compared to control group (P < 0.05). Furthermore, it decreased the incidence of myocardial ischemia reflected by troponin I level, ECG changes, and the development of new regional wall motion abnormalities (P < 0.05). Dexmedetomidine decreased the requirement for nitroglycerin and norepinephrine compared to control group (P < 0.05). The incidence of hypotension and bradycardia was significantly higher with dexmedetomidine (P < 0.05). Conclusion: The dexmedetomidine is safe and effective in patients undergoing aortic vascular surgery. It decreases the changes in heart rate and blood pressure during the procedures. It provides cardiac protection in high-risk patients reflected by decreasing the incidence of myocardial ischemia and serum level of troponin. The main side effects of dexmedetomidine were hypotension and bradycardia.
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Affiliation(s)
- Rabie Soliman
- Department of Anesthesia, Cairo University, Cairo, Egypt
| | - Gomaa Zohry
- Department of Anesthesia, Cairo University, Cairo, Egypt
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Zhang J, Wang H, Liu H, Wang G. Subacute post-traumatic ascending myelopathy after T12 burst fracture in a 32-year-old male: case report and surgical result of cervical durotomy. Spinal Cord Ser Cases 2017; 2:16004. [PMID: 28053748 DOI: 10.1038/scsandc.2016.4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 02/10/2016] [Accepted: 02/13/2016] [Indexed: 11/09/2022] Open
Abstract
To draw attention to a rare neurological deterioration after spinal cord injury (SCI) and to discuss evidence supporting an increase in cerebrospinal fluid pressure (CSFP), we present an extremely rare case of subacute post-traumatic ascending myelopathy (SPAM) in which the patient sustained a T12 fracture initially resulting in paraplegia and after undergoing posterior fixation and anterior decompression. The patient was a 32-year-old healthy man who sustained a T12 burst fracture with complete paraplegia after a fall injury. The patient underwent a posterior reduction and short-segment fixation 8 h after the injury and an anterior thoracoscopic-assisted decompression on post-traumatic day 8. On post-traumatic day 21, he had a progressive neurological deterioration with dyspnoea and decreased muscle strength of both upper extremities that could not be relieved by conservative intervention. After undergoing a cervical posterior laminectomy and durotomy, the patient exhibited the clinical manifestation of brain herniation. There was no recovery of autonomous respiration, and the patient entered a coma. The patient died on post-traumatic day 25 because of cardiac and respiratory arrest. SPAM is a rare, potentially fatal neurological deterioration after SCI; however, a prompt diagnosis can be made by magnetic resonance imaging. Our observations suggest that an increase in CSFP may be the main cause of SPAM. The paraplegic level should be recorded daily so that neurological deterioration can be recognised as soon as possible.
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Affiliation(s)
- Jian Zhang
- Number 1 Department of Orthopedic Surgery, Baodi Hospital , Tianjin, China
| | - Huili Wang
- Number 1 Department of Orthopedic Surgery, Baodi Hospital , Tianjin, China
| | - Haiying Liu
- Department of Spinal Surgery, Peking University People's Hospital , Beijing, China
| | - Guangshun Wang
- Department of Thoracic Surgery, Baodi Hospital , Tianjin, China
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Riambau V, Böckler D, Brunkwall J, Cao P, Chiesa R, Coppi G, Czerny M, Fraedrich G, Haulon S, Jacobs M, Lachat M, Moll F, Setacci C, Taylor P, Thompson M, Trimarchi S, Verhagen H, Verhoeven E, ESVS Guidelines Committee, Kolh P, de Borst G, Chakfé N, Debus E, Hinchliffe R, Kakkos S, Koncar I, Lindholt J, Vega de Ceniga M, Vermassen F, Verzini F, Document Reviewers, Kolh P, Black J, Busund R, Björck M, Dake M, Dick F, Eggebrecht H, Evangelista A, Grabenwöger M, Milner R, Naylor A, Ricco JB, Rousseau H, Schmidli J. Editor's Choice – Management of Descending Thoracic Aorta Diseases. Eur J Vasc Endovasc Surg 2017; 53:4-52. [DOI: 10.1016/j.ejvs.2016.06.005] [Citation(s) in RCA: 598] [Impact Index Per Article: 85.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Zhang J, Wang G. Subacute posttraumatic ascending myelopathy: a literature review. Spinal Cord 2016; 55:644-650. [PMID: 27995944 PMCID: PMC5504449 DOI: 10.1038/sc.2016.175] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 10/19/2016] [Accepted: 10/29/2016] [Indexed: 11/20/2022]
Abstract
Study design: A literature review. Objectives: Our aim was to summarise the history, epidemiology, aetiological mechanism, pathological study, clinical and radiological evaluation, treatment and prognosis of subacute posttraumatic ascending myelopathy (SPAM). Methods: Medical literature on SPAM were searched in the PubMed, Medline, Ovid and Embase databases. The cases of SPAM reported in literature were analysed, and the history, epidemiology, aetiological mechanism, pathological study, clinical and radiological evaluation, treatment and prognosis of SPAM were summarised. Results: SPAM remains a relatively rare disorder occurring within the first few weeks after spinal cord injury (SCI). The incidence rate ranges from 0.42% to 1% among all SCI. SPAM is likely to occur in young and middle-aged male patients. Risk factors of SPAM include complete injury, low blood pressure, early postoperative mobilisation and nonsurgical treatment. Conclusions: SPAM is well recognised according to typical clinical manifestation and magnetic resonance imaging characteristics. There is no effective therapy for this neurological deterioration. The prognosis of SPAM is poor. There is usually a slight improvement of one or more level(s) below the maximal level of deterioration. The mortality rate is approximately 10%.
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Affiliation(s)
- J Zhang
- Department of Orthopedic Surgery, Tianjin Baodi Hospital, Tianjin, China
| | - G Wang
- Department of Thoracic Surgery, Tianjin Baodi Hospital, Tianjin, China
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He L, Xu JM, Li H, Zhong F, Liu Z, Li CQ, Dai RP. Moderate hypothermia increased the incidence of delayed paralysis through activation of the spinal microglia in an aortic cross-clamping rat model. Int J Cardiol 2016; 220:454-61. [PMID: 27390969 DOI: 10.1016/j.ijcard.2016.06.169] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/24/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Hypothermia reduces immediate paralysis during surgical repair of aortic aneurysms. However, it is unknown what the impact of hypothermia is on delayed paralysis, a serious complication of this type of surgery. METHODS Sprague-Dawley rats were subjected to occlusion of the descending aorta at different duration under normothermia (38.0±0.5) or hypothermia (33.0±0.5°). Neurologic function was assessed. Motor neuron number, glial activation, and cytokine expression in the spinal cord were examined. Minocycline was administered perioperatively by intraperitoneal injection in the rats subjected to the aorta occlusion. RESULTS In contrast to normothermia conditions at which immediate paralysis occurred when the duration of aorta occlusion exceeded 11.5min, hypothermia did not induce immediate paralysis if the duration of aorta occlusion was less than 41min. However, delayed paralysis was developed when the duration of aorta occlusion exceeded 18min, and reached peak level when the duration of aorta occlusion was 40min at hypothermia condition. The number of motoneurons was significantly decreased (P<0.05) at 30h postoperation. In addition, microglia was activated, and interleukin-1β and interleukin-6 levels were upregulated, both of which were co-localized in microglia at 24h postoperation in the hypothermia group. Minocycline treatment attenuated the incidence and degree of paralysis but did not decrease the mortality. CONCLUSIONS Hypothermia, a neuroprotective strategy in cardiothoracic surgery, increased the incidence of delayed paralysis through activation of spinal microglia and cytokines. Blocking the activated microglia may be a potential intervention to prevent the incidence of delayed paralysis.
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Affiliation(s)
- Liang He
- Department of Anesthesia, The Second Xiangya Hospital of Central South University, Ren-Min Road 139#, Changsha 410011, China.; Department of Anesthesiology, The Affiliated Hospital of Guilin Medical University, Lequn Road 15#, Guilin 54100, China
| | - Jun-Mei Xu
- Department of Anesthesia, The Second Xiangya Hospital of Central South University, Ren-Min Road 139#, Changsha 410011, China
| | - Hui Li
- Department of Anesthesia, The Second Xiangya Hospital of Central South University, Ren-Min Road 139#, Changsha 410011, China
| | - Feng Zhong
- Department of Anesthesia, The Second Xiangya Hospital of Central South University, Ren-Min Road 139#, Changsha 410011, China
| | - Zhi Liu
- Department of Anesthesia, The Second Xiangya Hospital of Central South University, Ren-Min Road 139#, Changsha 410011, China
| | - Chang-Qi Li
- Department of Anatomy and Neurobiology, Xiangya School of Medicine, Central South University, Changsha 410000, China
| | - Ru-Ping Dai
- Department of Anesthesia, The Second Xiangya Hospital of Central South University, Ren-Min Road 139#, Changsha 410011, China..
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Dias-Neto M, Reis PV, Rolim D, Ramos JF, Teixeira JF, Sampaio S. Strategies to prevent TEVAR-related spinal cord ischemia. Vascular 2016; 25:307-315. [DOI: 10.1177/1708538116671235] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Spinal cord ischemia remains the Achilles’ heel of thoracic and thoracoabdominal diseases management. Great improvements in morbidity and mortality have been obtained with the endovascular approach TEVAR (Thoracic Endovascular Aortic Repair) but this devastating complication continues to severely affect the quality of life, even if the primary success of the procedure – dissection/aneurysm exclusion – has been achieved. Several strategies to deal with this complication have been published in the literature over the time. Knowledge and technology have been evolving from identification of the risk factors associated with spinal cord ischemia, including lessons learned from open surgery, and from developments in the collateral network concept for spinal cord perfusion. In this comprehensive review, the authors cover several topics from the traditional measures comprising haemodynamic control, cerebrospinal drainage and neuroprotective drugs, to the staged-procedures approach, the emerging MISACE (minimally invasive selective segmental artery coil-embolization) and innovative neurologic monitoring such as NIRS (near-infrared spectroscopy) of the collateral network.
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Affiliation(s)
- Marina Dias-Neto
- Department of Angiology and Vascular Surgery, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal
- Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Alameda Professor Hernani Monteiro, Portugal
| | - Pedro Videira Reis
- Department of Anaesthesiology, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal
| | - Dalila Rolim
- Department of Angiology and Vascular Surgery, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal
| | - José Fernando Ramos
- Department of Angiology and Vascular Surgery, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal
| | - José Fernando Teixeira
- Department of Angiology and Vascular Surgery, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal
| | - Sérgio Sampaio
- Department of Angiology and Vascular Surgery, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal
- Faculty of Medicine, Department of Information and Decision Sciences in Health (CIDES), Research Center in Health Technologies and Information systems (CINTESIS), University of Porto, Alameda Professor Hernani Monteiro, Portugal
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Martínez-Saniger A, López-Herrera-Rodríguez D, Guerrero-Domínguez R, Sánchez-Carrillo F. Spinal cord ischaemia after endovascular thoracic aneurysm repair. NEUROLOGÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.nrleng.2014.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Lindsay H, Srinivas C, Djaiani G. Neuroprotection during aortic surgery. Best Pract Res Clin Anaesthesiol 2016; 30:283-303. [DOI: 10.1016/j.bpa.2016.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 04/21/2016] [Accepted: 05/09/2016] [Indexed: 01/16/2023]
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Henderson R, Chow R, Morales R, Taylor B, Mazzeffi MA. Removal of an Entrapped Lumbar Drain After Thoracic Endovascular Aortic Repair. ACTA ACUST UNITED AC 2016; 7:93-5. [DOI: 10.1213/xaa.0000000000000351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gerstein NS, Panikkath PV, Carlson AP, Pollock DM, Tayler E, Augoustides JG. CASE 4—2016. J Cardiothorac Vasc Anesth 2016; 30:548-54. [DOI: 10.1053/j.jvca.2015.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Indexed: 01/16/2023]
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Zhang J, Wang H, Zhang C, Li W. Intrathecal decompression versus epidural decompression in the treatment of severe spinal cord injury in rat model: a randomized, controlled preclinical research. J Orthop Surg Res 2016; 11:34. [PMID: 27006005 PMCID: PMC4802628 DOI: 10.1186/s13018-016-0369-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 03/15/2016] [Indexed: 11/30/2022] Open
Abstract
Background In the setting of severe spinal cord injury (SCI), there is no markedly efficacious clinical therapeutic regimen to improve neurological function. After epidural decompression, as is shown in animal models, the swollen cord against non-elastic dura and elevation of intrathecal pressure may be the main causes of aggravated neurologic function. We performed an intrathecal decompression by longitudinal durotomy to evaluate the neuroprotective effect after severe SCI by comparing with epidural decompression. Methods Eighty-four adult male Sprague-Dawley rats were assigned to three groups: sham group (group S), epidural decompression (group C), and intrathecal decompression group (group D). A weight-drop model was performed at T9. The Basso-Beattie-Bresnahan (BBB) score was used to evaluate neurological function. Animals were sacrificed at corresponding time points, and we performed pathohistological examinations including HE staining and immunohistochemical staining (IHC) of glial fibrillary acidic protein (GFAP), neurocan, and ED1 at the epicenter of injured cords. Finally, the lesions were quantitatively analyzed by SPSS 22.0. Results The mortality rates were, respectively, 5.55 % (2/36) and 13.9 % (5/36) in groups C and D, and there was no significant difference between groups C and D (P = 0.214). Compared with epidural decompression, intrathecal decompression could obviously improve BBB scores after SCI. HE staining indicated that more white matter was spared, and fewer vacuoles and less axon degradation were observed. The expression peak of GFAP, neurocan, and ED1 occurred at an earlier time and was down-regulated in group D compared to group C. Conclusions Our findings based on rat SCI model suggest that intrathecal decompression by longitudinal durotomy can prompt recovery of neurological function, and this neuroprotective mechanism may be related to the down-regulation of GFAP, neurocan, and ED1.
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Affiliation(s)
- Jian Zhang
- No.1 Department of Orthopedic Surgery, Tianjin Baodi Hospital, No.8, Guangchuan Road, Baodi District, Tianjin, 301800, China.
| | - Huili Wang
- No.1 Department of Orthopedic Surgery, Tianjin Baodi Hospital, No.8, Guangchuan Road, Baodi District, Tianjin, 301800, China
| | - Chenggang Zhang
- Institute of Radiation and Radiation Medicine, Academy of Military Medical Sciences, No.27, Taiping Road, Haidian District, Beijing, 100850, China
| | - Weiguang Li
- Institute of Radiation and Radiation Medicine, Academy of Military Medical Sciences, No.27, Taiping Road, Haidian District, Beijing, 100850, China
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See RB, Awosika OO, Cambria RP, Conrad MF, Lancaster RT, Patel VI, Chitilian HV, Kumar S, Simon MV. Extended Motor Evoked Potentials Monitoring Helps Prevent Delayed Paraplegia After Aortic Surgery. Ann Neurol 2016; 79:636-45. [PMID: 26841128 DOI: 10.1002/ana.24610] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 02/01/2016] [Accepted: 02/01/2016] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Motor evoked potentials (MEPs) monitoring can promptly detect spinal cord ischemia (SCI) from aortic clamping during open thoracoabdominal aneurysm repair (OTAAR) with distal aortic perfusion (DAP) and thus help decrease the risk of immediate postoperative SCI (IP-SCI). However, neither stable MEPs during aortic clamp interval (ACI) nor absence of IP-SCI eliminate the possibility of delayed postoperative SCI (DP-SCI). We hypothesized that extension of MEPs monitoring beyond ACI can also help decrease the risk of DP-SCI. METHODS We identified 150 consecutive patients at our institution between April 2005 and October 2014 who underwent OTAAR with DAP and MEPs monitoring and had no IP-SCI. Using logistic regression analysis, we studied the independent effect of extended MEPs monitoring on the risk of developing DP-SCI. We used a propensity score analysis to adjust for potential confounders, such as poorly controlled hypertension, previous aneurysm surgery, splenectomy, acute aortic dissection, aneurysm type, older age, and history of diabetes and smoking. RESULTS From the 150 patients, 129 (86%) remained neurologically intact whereas 21 (14%) developed DP-SCI. Nineteen of these twenty-one patients (90%) had no extended monitoring. Fifty-seven of fifty-nine (97%) patients who benefited from extended monitoring had no DP-SCI (p = 0.003). Extended MEPs monitoring was independently associated with decreased risk of DP-SCI (odds ratio = 0.14; 95% confidence interval: 0.03, 0.65; p = 0.01). INTERPRETATION MEPs detect the lowest systemic blood pressure that ensures appropriate spinal cord perfusion in the postoperative period. Thus, they inform the hemodynamic management of patients post-OTAAR, particularly in the absence of a reliable neurological exam.
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Affiliation(s)
- Reiner B See
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Oluwole O Awosika
- Department of Neurology, Massachusetts General Hospital, Boston, MA.,National Institute of Neurological Disorders and Stroke/National Institutes of Health, Bethesda, MD
| | - Richard P Cambria
- Department of Vascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Mark F Conrad
- Department of Vascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Robert T Lancaster
- Department of Vascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Virendra I Patel
- Department of Vascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Hovig V Chitilian
- Department of Anesthesia, Massachusetts General Hospital, Boston, MA
| | - Sandeep Kumar
- Department of Neurology, Beth Israel Deaconess Center, Boston, MA
| | - Mirela V Simon
- Department of Neurology, Massachusetts General Hospital, Boston, MA
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Lockit Plus Catheter Securement Device for Lumbar Subarachnoid Drains. J Neurosurg Anesthesiol 2015; 28:277. [PMID: 26447498 DOI: 10.1097/ana.0000000000000237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Schaffer JM, Lingala B, Fischbein MP, Dake MD, Woo YJ, Mitchell RS, Miller DC. Midterm Outcomes of Open Descending Thoracic Aortic Repair in More Than 5,000 Medicare Patients. Ann Thorac Surg 2015; 100:2087-94; discussion 2094. [PMID: 26431919 DOI: 10.1016/j.athoracsur.2015.06.068] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 06/08/2015] [Accepted: 06/22/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Diseases involving the descending thoracic aorta (DTA) represent a heterogeneous substrate with a variety of therapeutic options. Although thoracic endovascular aortic repair has been increasingly applied to DTA disease, open surgical repair is ostensibly more durable. METHODS A total of 5,578 patients who underwent open DTA repair (Current Procedural Terminology code 33875) from 1999 to 2010 were identified from the Medicare database; 5,489 patients had complete data. Survival was assessed with Kaplan-Meier analysis. Cox regression determined predictors of death. Hospital and surgeon volume and variability were modeled, and their association with survival assessed. RESULTS Median survival after open DTA repair was only 4.3 years (95% confidence interval: 4.0 to 4.6). The likelihood of death varied significantly by certain aortic diseases: aortic rupture and acute aortic dissection patients had the highest early mortality. Survival beyond 180 days was best for patients with acute aortic dissection and isolated thoracic aortic aneurysm, and lowest for patients with thoracoabdominal aneurysm and aortic rupture. Hospital and surgeon volume, as well as interhospital and intersurgeon variability, had associations with overall survival. CONCLUSIONS Open DTA repair has treated a spectrum of aortic diseases in Medicare beneficiaries. Overall mortality was high, predominately confined to the initial postoperative hazard phase. Independent hospital and surgeon effects, hospital and surgeon volume, and a more recent date of surgery correlated with improved survival, while increased operative urgency and complexity correlated with worse outcomes. These observations argue for regionalization of DTA treatment for Medicare patients in specialized centers to concentrate expertise, which should translate into better outcomes.
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Affiliation(s)
- Justin M Schaffer
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Bharathi Lingala
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Michael D Dake
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - R Scott Mitchell
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - D Craig Miller
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California.
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Isaak RS, Furman W. Con: Patients at Risk for Spinal Cord Ischemia After Thoracic Endovascular Aortic Repairs Should Not Receive Prophylactic Cerebrospinal Fluid Drainage. J Cardiothorac Vasc Anesth 2015; 29:1381-3. [DOI: 10.1053/j.jvca.2015.05.191] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Indexed: 11/11/2022]
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Rotational Thromboelastometry-Guided Hemostatic Therapy for Management of Cerebrospinal Fluid Catheter in Patients Undergoing Endovascular Aortic Repair. Reg Anesth Pain Med 2015. [PMID: 26204388 DOI: 10.1097/aap.0000000000000285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Central neuraxial techniques are typically avoided in patients with underlying coagulopathy or abnormal coagulation tests. Vertebral canal hematoma is a rare but devastating complication of those procedures. Although the sensitivity and specificity of standard laboratory tests in predicting this event are rather poor or unknown, these tests are commonly used to allow or advise against the insertion of an epidural or spinal catheter. Furthermore, the role of viscoelastic point-of-care tests, which are widely used to monitor coagulation in the perioperative setting, is unexplored. CASE REPORT We report a patient presenting for endovascular repair of a dissecting thoracoabdominal aortic aneurysm, in which we placed a subarachnoid catheter for continuous cerebrospinal fluid drainage because of the high risk of spinal cord ischemia associated with the procedure. Unfortunately, the patient presented with an overt consumption coagulopathy that would have advised against performing any central neuraxial technique. Bedside monitoring, diagnosis, and goal-directed hemostatic therapy guided by thromboelastometry documented improved coagulation both at the time of insertion and removal of the subarachnoid device. No catheter-related complications occurred. CONCLUSIONS Thromboelastometry proved useful to guide hemostatic therapy before subarachnoid catheter placement and extraction in a patient with severe coagulopathy when standard coagulation tests were of less benefit.
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Wong AI, Gao S, Bain MD, Fitzsimons B, Hui FK. Physical characteristics of catheters used for subarachnoid drainage. J Neurointerv Surg 2015; 8:865-7. [DOI: 10.1136/neurintsurg-2015-011864] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 06/11/2015] [Indexed: 11/03/2022]
Abstract
BackgroundCerebrospinal fluid diversion through lumbar drainage catheters is a routine procedure that is used in a variety of clinical applications. Fracture of catheters during insertion or removal may result in retained foreign bodies that may lead to patient morbidity with potential legal ramifications. Fracture resistance is an important component of drain selection.ObjectiveTo analyze catheter integrity to determine which commercially available catheters are most robust and resistant to fracture.MethodsPhysical properties of the commercially available drainage catheters that can be advanced through a Touhy needle were assessed using laboratory equipment and reported. Five types of catheter were analyzed for break load, tensile strength, extension at break, and shear strength.Results and conclusionsOf the five types of catheter, the Arrow catheter showed the greatest resistance to fracture. Of the drainage catheters, the Codman catheter showed the greatest resistance to fracture.
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Wynn MM, Sebranek J, Marks E, Engelbert T, Acher CW. Complications of Spinal Fluid Drainage in Thoracic and Thoracoabdominal Aortic Aneurysm Surgery in 724 Patients Treated From 1987 to 2013. J Cardiothorac Vasc Anesth 2015; 29:342-50. [DOI: 10.1053/j.jvca.2014.06.024] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Indexed: 11/11/2022]
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Martínez-Saniger A, López-Herrera-Rodríguez D, Guerrero-Domínguez R, Sánchez-Carrillo F. Spinal cord ischaemia after endovascular thoracic aneurysm repair. Neurologia 2015; 31:501-3. [PMID: 25728957 DOI: 10.1016/j.nrl.2014.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 12/15/2014] [Accepted: 12/19/2014] [Indexed: 10/23/2022] Open
Affiliation(s)
- A Martínez-Saniger
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen del Rocío, Sevilla, España.
| | | | - R Guerrero-Domínguez
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - F Sánchez-Carrillo
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen del Rocío, Sevilla, España
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Abstract
OPINION STATEMENT Spinal cord injury (SCI) causes significant morbidity and mortality. Clinical management in the acute setting needs to occur in the intensive care unit in order to identify, prevent, and treat secondary insults from local ischemia, hypotension, hypoxia, and inflammation. Maintenance of adequate perfusion and oxygenation is quintessential and a mean arterial pressure >85-90 mm Hg should be kept for at least 1 week. A cervical collar and full spinal precautions (log-roll, flat, holding C-spine) should be maintained until the spinal column has been fully evaluated by a spine surgeon. In patients with SCI, there is a high incidence of other bodily injuries, and there should be a low threshold to assess for visceral, pelvic, and long bone injuries. Computed tomography of the spine is superior to plain films, as the former rarely misses fractures, though caution needs to be exerted as occipitocervical dislocation can still be missed. To reliably assess the spinal neural elements, soft tissues, and ligamentous structures, magnetic resonance imaging is indicated and should be obtained within 48-72 h from the time of injury. All patients should be graded daily using the American Spinal Injury Association classification, with the first prognostic score at 72 h postinjury. Patients with high cervical cord (C4 or higher) injury should be intubated immediately, and those with lower cord injuries should be evaluated on a case-by-case basis. However, in the acute setting, respiratory mechanics will be disrupted with any spinal cord lesion above T11. Steroids have become extremely controversial, and the professional societies for neurosurgery in the United States have given a level 1 statement against their use in all patients. We, therefore, do not advocate for them at this time. With every SCI, a spine surgeon must be consulted to discuss operative vs nonoperative management strategies. Indications for surgery include a partial or progressive neurologic deficit, instability of the spine not allowing for mobilization, correction of a deformity, and prevention of potential neurologic compromise. Measures to prevent pulmonary emboli from deep venous thromboembolisms are necessary: IVC filters are recommended in bedbound patients and low-molecular weight heparins are superior to unfractionated heparin. Robust prevention of pressure ulcers as well as nutritional support should be a mainstay of treatment. Lastly, it is important to note that neurologic recovery is a several-year process. The most recovery occurs in the first year following injury, and therefore aggressive rehabilitation is crucial.
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Miles LF, Hu R, Jones RM, Carson S, McCall PR. Inferior Vena Cava Resection and Hemihepatectomy for Leiomyosarcoma, Utilizing Cardiopulmonary Bypass, in Situ Hepatic Perfusion, and Distal Hypothermic Circulatory Arrest. J Cardiothorac Vasc Anesth 2015; 30:169-75. [PMID: 26002188 DOI: 10.1053/j.jvca.2015.01.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | - Scott Carson
- Department of Cardiac Surgery, Austin Health, Melbourne, Australia
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Hnenny L, Sabry HA, Raskin JS, Liu JJ, Roundy NE, Dogan A. Migrating lumbar intrathecal catheter fragment associated with intracranial subarachnoid hemorrhage. J Neurosurg Spine 2015; 22:47-51. [DOI: 10.3171/2014.9.spine147] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intrathecal catheter placement into the lumbar cistern has varied indications, including drug delivery and CSF diversion. These Silastic catheters are elastic and durable; however, catheter-associated malfunctions are well reported in the literature. Fractured catheters are managed with some variability, but entirely intradural retained fragments are often managed conservatively with observation.
The authors describe a case of a 70-year-old man with an implanted intrathecal morphine pump for failed back surgery syndrome who presented to an outside hospital with a history of headache, neck pain, nausea, and photophobia of 3 days' duration. He also described mild weakness and intermittent numbness of both legs. Unenhanced head CT demonstrated subarachnoid hemorrhage (SAH). A right C-5 hemilaminectomy was performed.
This case is unique in that there was no indication that the lumbar intrathecal catheter had fractured prior to the patient's presentation with SAH. This case demonstrates that intrathecal catheter fragments are mobile and can precipitate intracranial morbidity. Extrication of known fragments is safe and should be attempted to prevent further neurosurgical morbidity.
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77
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Ural K, Jakob K, Lato S, Gilly G, Landreneau R. Spinal cord ischemia resulting in paraplegia following extrapleural pneumonectomy. Chest 2014; 146:e38-e40. [PMID: 25091760 DOI: 10.1378/chest.13-3062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
A patient undergoing radical extrapleural pneumonectomy for epithelioid malignant mesothelioma developed acute paraplegia postoperatively related to long-segment spinal cord ischemia. The usual area of concern for this complication is the T9 to T12 area where the artery of Adamkiewicz is most likely to originate. In this patient, there was ligation of only upper thoracic, ipsilateral segmental arteries from the T3 to T6 level, yet he still developed paraplegia. Our hypothesis is variant mid-thoracic vascular anatomy. Previously unreported, to our knowledge, this should be understood as a rare complication of this surgery.
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Affiliation(s)
- Kelly Ural
- Department of Anesthesiology, Ochsner Health System, New Orleans, LA.
| | - Kyle Jakob
- Department of Surgery, Ochsner Health System, New Orleans, LA
| | - Scott Lato
- Department of Anesthesiology, Ochsner Health System, New Orleans, LA
| | - George Gilly
- Department of Anesthesiology, Ochsner Health System, New Orleans, LA
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78
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Results of using cardiopulmonary bypass for spinal cord protection during surgical repair of complex aortic coarctation. Cardiol Young 2014; 24:113-9. [PMID: 23388381 DOI: 10.1017/s1047951113000115] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the surgical treatment of complex aortic coarctation using partial cardiopulmonary bypass to increase the spinal cord protection. METHODS A total of 15 patients (age range from 7 to 48 years) underwent coarctation repair through a left posterolateral thoracotomy with cardiopulmonary bypass. Cannulation was performed via the descending aorta and the main pulmonary artery. In all, six surgeries were performed under hypothermic circulatory arrest and nine repairs were performed under mild hypothermia. The clinical outcome regarding the development of restenosis, as well as major neurologic complication, was studied. RESULTS There was no mortality. None of the patients developed paraplegia. Of the 15 patients, two developed a recurrent stenosis at the proximal anastomosis between the aortic arch and the aortic prothesis at a mean follow-up of 5.5 years. In the remaining 13 patients, echocardiography and magnetic resonance imaging showed no evidence of a significant gradient. CONCLUSION Complex aortic coarctation without hypoplasia of the proximal aortic arch and intra-cardiac anomalies can be repaired with low mortality and neurologic morbidity via a left thoracotomy using cardiopulmonary bypass. The use of cardiopulmonary bypass goes along with a low risk of spinal cord and lower body ischaemia and provides a sufficient amount of time for the anastomoses.
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79
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Novel approaches to spinal cord protection during thoracoabdominal aortic interventions. Curr Opin Anaesthesiol 2014; 27:98-105. [DOI: 10.1097/aco.0000000000000033] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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80
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Lee JJ, Gim GH, Jang JS, Hwang SM. Shearing of an intrathecal catheter during insertion for cerebrospinal fluid drainage. Korean J Anesthesiol 2014; 65:S47-8. [PMID: 24478869 PMCID: PMC3903857 DOI: 10.4097/kjae.2013.65.6s.s47] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jae Jun Lee
- Department of Anesthesiology and Pain Medicine, School of Medicine, Hallym University, Chuncheon, Korea
| | - Gi Ho Gim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Hallym University, Chuncheon, Korea
| | - Ji Su Jang
- Department of Anesthesiology and Pain Medicine, School of Medicine, Hallym University, Chuncheon, Korea
| | - Sung Mi Hwang
- Department of Anesthesiology and Pain Medicine, School of Medicine, Hallym University, Chuncheon, Korea
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81
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Lühr M, Mohr FW, Etz C. Spinales und paraspinales Kollateralnetzwerk. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2013. [DOI: 10.1007/s00398-012-0987-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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82
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Brahmbhatt A, Hall NDP, Bradley WPL. Severe hypotension related to high negative pressure suction drainage on a thoracic epidural drain during multilevel spinal fixation. A & A CASE REPORTS 2013; 1:62-63. [PMID: 25611959 DOI: 10.1097/acc.0b013e3182977186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Hypotension or bradycardia or both related to intracranial hypotension after craniotomy has been reported in the literature. However, such reports are uncommon with thoracic epidural drains. We describe a case in which application of high negative pressure suction to a thoracic epidural drain caused a sudden decrease in arterial blood pressure.
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Affiliation(s)
- Anjalee Brahmbhatt
- From the Departments of *Anaesthesia and Perioperative Medicine and †Neurosurgery, The Alfred Hospital, Melbourne, Australia
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83
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Appoo JJ, Tse LW, Pozeg ZI, Wong JK, Hutchison SJ, Gregory AJ, Herget EJ. Thoracic aortic frontier: review of current applications and directions of thoracic endovascular aortic repair (TEVAR). Can J Cardiol 2013; 30:52-63. [PMID: 24365190 DOI: 10.1016/j.cjca.2013.10.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 10/10/2013] [Accepted: 10/10/2013] [Indexed: 10/26/2022] Open
Abstract
Thoracic endovascular aortic repair, a minimally invasive technique is replacing the maximally invasive gold standard of thoracotomy and replacement of the descending thoracic aorta. With experience, indications have expanded to encroach on the arch and even ascending aorta. This review highlights the current state of technology, discusses controversies, and takes the perspective of a forward-thinking review to describe novel, innovative techniques that might make the entire thoracic aorta amenable to minimally invasive repair.
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Affiliation(s)
- Jehangir J Appoo
- Division of Cardiac Surgery, Libin Cardiovascular Institute, Department of Cardiac Sciences and Surgery, University of Calgary, Calgary, Alberta, Canada.
| | - Leonard W Tse
- Division of Vascular Surgery, Toronto General Hospital, PMCC, UHN, University of Toronto, Toronto, Ontario, Canada
| | - Zlatko I Pozeg
- Division of Cardiac Surgery, St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jason K Wong
- Division of Interventional Radiology, Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Stuart J Hutchison
- Division of Cardiology, Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Alex J Gregory
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anaesthesiology, University of Calgary, Calgary, Alberta, Canada
| | - Eric J Herget
- Division of Interventional Radiology, Department of Radiology, University of Calgary, Calgary, Alberta, Canada
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84
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Mehmedagic I, Resch T, Acosta S. Complications to Cerebrospinal Fluid Drainage and Predictors of Spinal Cord Ischemia in Patients With Aortic Disease Undergoing Advanced Endovascular Therapy. Vasc Endovascular Surg 2013; 47:415-22. [DOI: 10.1177/1538574413495461] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To study the complications after cerebrospinal fluid (CSF) drainage and predictors of spinal cord ischemia (SCI) after advanced endovascular therapy with CSF drainage for complex aortic disease. Methods: Between 2009 and 2012, 88 attempts of CSF drainage insertions/84 operations/83 patients, of the 658 operations for aortoiliac diseases, were performed. Results: Indications for therapy were aortic dissection (n = 13) and aortic aneurysm (n = 70), of whom 38 had thoracoabdominal aortic aneurysm (TAAA). In all, 10 had ruptured aorta. The CSF drainages were inserted preoperatively (n = 75) and postoperatively (n = 9). In all, 14 CSF drainages were nonfunctioning. The SCI was present in 29 patients, transient/permanent in 12/17. Intraoperative circulatory instability ( P = .001) and operation for TAAA, type II ( P = .036), were associated with SCI. Meningitis (n = 1), epidural (n = 1), and subdural (n = 2) hematoma and needle-mediated paresis in 1 leg (n = 1) occurred after CSF drainage. Conclusions: Complication to CSF drainage occurred too frequently in this selected group of patients with high rate of SCI.
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Affiliation(s)
| | - Timothy Resch
- Vascular Center, Skåne University Hospital, Malmö, Sweden
| | - Stefan Acosta
- Vascular Center, Skåne University Hospital, Malmö, Sweden
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85
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Youngblood SC, Tolpin DA, LeMaire SA, Coselli JS, Lee VV, Cooper JR. Complications of cerebrospinal fluid drainage after thoracic aortic surgery: A review of 504 patients over 5 years. J Thorac Cardiovasc Surg 2013; 146:166-71. [DOI: 10.1016/j.jtcvs.2013.01.041] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 01/04/2013] [Accepted: 01/28/2013] [Indexed: 11/16/2022]
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86
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Nicolaou G, Ismail M, Cheng D. Thoracic endovascular aortic repair: update on indications and guidelines. Anesthesiol Clin 2013; 31:451-478. [PMID: 23711653 DOI: 10.1016/j.anclin.2013.01.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Thoracic endovascular aortic repair (TEVAR) has revolutionized thoracic aortic surgery and has increased the options available to the aortic specialist in treating thoracic aortic disease. TEVAR is less invasive, and is associated with a decrease in perioperative morbidity and mortality when compared with open surgical repair. The dramatic expansion of TEVAR activity has necessitated a better definition for the indications, contraindications, and limitations of this new technology. Ideally TEVAR should be performed in specialized aortic centers providing a full range of diagnostic and treatment options, using a multidisciplinary team approach.
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Affiliation(s)
- Georghios Nicolaou
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, 339 Windermere Road, Room C3-172, London, Ontario, N6A 5A5, Canada
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87
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Hoffman A, Damberg AL, Schälte G, Mahnken AH, Raweh A, Autschbach R. Thoracic stent graft sizing for frozen elephant trunk repair in acute type A dissection. J Thorac Cardiovasc Surg 2013; 145:964-969.e1. [DOI: 10.1016/j.jtcvs.2012.03.059] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 02/16/2012] [Accepted: 03/20/2012] [Indexed: 10/28/2022]
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88
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Gregory AJ, Prusinkiewicz CA, Herget E, Wong J, Kent WDT, Appoo JJ. Subclavian graft thrombosis as an alternative cause for delayed spinal cord ischemia following hybrid aortic arch repair. J Cardiothorac Vasc Anesth 2013; 28:718-22. [PMID: 23523253 DOI: 10.1053/j.jvca.2012.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Eric Herget
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Jason Wong
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - William D T Kent
- Libin Cardiovascular Institute of Alberta, Division of Cardiac Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Jehangir J Appoo
- Libin Cardiovascular Institute of Alberta, Division of Cardiac Surgery, University of Calgary, Calgary, Alberta, Canada
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89
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Soubeyrand M, Laemmel E, Court C, Dubory A, Vicaut E, Duranteau J. Rat model of spinal cord injury preserving dura mater integrity and allowing measurements of cerebrospinal fluid pressure and spinal cord blood flow. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 22:1810-9. [PMID: 23508337 DOI: 10.1007/s00586-013-2744-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 02/25/2013] [Accepted: 03/05/2013] [Indexed: 01/14/2023]
Abstract
PURPOSES Cerebrospinal fluid (CSF) pressure elevation may worsen spinal cord ischaemia after spinal cord injury (SCI). We developed a rat model to investigate relationships between CSF pressure and spinal cord blood flow (SCBF). METHODS Male Wistar rats had SCI induced at Th10 (n = 7) or a sham operation (n = 10). SCBF was measured using laser-Doppler and CSF pressure via a sacral catheter. Dural integrity was assessed using subdural methylene-blue injection (n = 5) and myelography (n = 5). RESULTS The SCI group had significantly lower SCBF (p < 0.0001) and higher CSF pressure (p < 0.0001) values compared to the sham-operated group. Sixty minutes after SCI or sham operation, CSF pressure was 8.6 ± 0.4 mmHg in the SCI group versus 5.5 ± 0.5 mmHg in the sham-operated group. No dural tears were found after SCI. CONCLUSION Our rat model allows SCBF and CSF pressure measurements after induced SCI. After SCI, CSF pressure significantly increases.
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Affiliation(s)
- Marc Soubeyrand
- Equipe universitaire 3509 Paris VII-Paris XI-Paris XIII, Microcirculation, Bioénergétique, Inflammation et Insuffisance circulatoire aiguë, Paris Diderot-Paris VII University, Paris, France.
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90
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Aguilar Lloret C, Sernano Hernando FJ, Baquero MC, Fernández Francos S, López-Timoneda F. [Anesthesia in the surgical repair of thoracoabdominal aneurysms: 17 years experience]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2013; 60:16-22. [PMID: 23062570 DOI: 10.1016/j.redar.2012.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 07/10/2012] [Accepted: 07/13/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To review the results after thoracoabdominal aortic aneurysms repair performed by the same team of surgeons and anesthesiologists over a 17 year period. MATERIAL AND METHODS A prospective and observational study carried out on 65 patients (97% male) who were operated on from 1995 until July 2011 for thoracoabdominal aneurysm, Crawford type i 5 (7.6%), ii 22 (33.8%), iii 17 (26.11%) and iv 21 (32.31%). RESULTS The 30-day mortality was 9.2% (6/65 patients), which was the same as the incidence of paraplegia. This complication only occurred in the Crawford types ii and iii aneurysms. Paraplegia was present in 4.5% (1/22) of patients in whom "left bypass" was used, compared with 29% (5/17) in which the intervention was performed by cross-clamping without distal aortic perfusion (P=.068). The most frequent complication was respiratory, with prolonged mechanical ventilation (>48h) in 20% (13 patients) of cases. The mean hospital stay was 28 days (7-92). DISCUSSION The average mortality in referral centers is 9.7%, ranging between 5% and 16%. In other centres the mortality at 30 days is between 19% and 31% per year. Our group had a 9.2% of mortality rate at 30 days. The incidence of paraplegia in hospitals with greater experience ranges between 2.7% and 16%. Nowadays, an incidence of less than 10% is accepted as good. We had 9.2%. The use of CSF drainage in these patients, as well as the use of left bypass and moderate hypothermia in the Crawford types i, ii and iii appear to be acceptable for prophylaxis of paraplegia.
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Affiliation(s)
- C Aguilar Lloret
- Servicio de Anestesiología y Reanimación, [corrected] Hospital Clínico San Carlos, Madrid, España.
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91
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Lecker I, Wang DS, Romaschin AD, Peterson M, Mazer CD, Orser BA. Tranexamic acid concentrations associated with human seizures inhibit glycine receptors. J Clin Invest 2012. [PMID: 23187124 DOI: 10.1172/jci63375] [Citation(s) in RCA: 135] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Antifibrinolytic drugs are widely used to reduce blood loss during surgery. One serious adverse effect of these drugs is convulsive seizures; however, the mechanisms underlying such seizures remain poorly understood. The antifibrinolytic drugs tranexamic acid (TXA) and ε-aminocaproic acid (EACA) are structurally similar to the inhibitory neurotransmitter glycine. Since reduced function of glycine receptors causes seizures, we hypothesized that TXA and EACA inhibit the activity of glycine receptors. Here we demonstrate that TXA and EACA are competitive antagonists of glycine receptors in mice. We also showed that the general anesthetic isoflurane, and to a lesser extent propofol, reverses TXA inhibition of glycine receptor-mediated current, suggesting that these drugs could potentially be used to treat TXA-induced seizures. Finally, we measured the concentration of TXA in the cerebrospinal fluid (CSF) of patients undergoing major cardiovascular surgery. Surprisingly, peak TXA concentration in the CSF occurred after termination of drug infusion and in one patient coincided with the onset of seizures. Collectively, these results show that concentrations of TXA equivalent to those measured in the CSF of patients inhibited glycine receptors. Furthermore, isoflurane or propofol may prevent or reverse TXA-induced seizures.
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Affiliation(s)
- Irene Lecker
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
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92
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The pressure distribution of cerebrospinal fluid responds to residual compression and decompression in an animal model of acute spinal cord injury. Spine (Phila Pa 1976) 2012; 37:E1422-31. [PMID: 22869059 DOI: 10.1097/brs.0b013e31826ba7cd] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN In vivo large animal (pig) model study of cerebrospinal fluid (CSF) pressures after acute experimental spinal cord injury (SCI). OBJECTIVE To determine how the CSF pressure (CSFP) and CSF pulse pressure amplitude (CSFPPA) cranial and caudal to the injury site change after an acute SCI with subsequent thecal occlusion and decompression. SUMMARY OF BACKGROUND DATA Lowering intrathecal pressure via CSF drainage is currently instituted to prevent ischemia-induced SCI during thoracoabdominal aortic aneurysm surgery and was recently investigated as a potential intervention for acute traumatic SCI. However, in SCI patients, persistent extradural compression commonly occludes the subarachnoid space. This may generate a CSFP differential across the injury site, which cannot be appreciated with lumbar catheter pressure measurements. METHODS Anesthetized pigs were subjected to an acute contusive SCI at T11 and 8 hours of sustained compression (n = 12), or sham surgery (n = 2). CSFP was measured cranial and caudal to the injury site, using miniature pressure transducers, during compression and for 6 hours after decompression. RESULTS The cranial-caudal CSFP differential increased (mean, 0.39 mm Hg/h), predominantly due to increased cranial pressure. On decompression, cranial CSFP decreased (mean, -1.16 mm Hg) and caudal CSFP increased (mean, 0.65 mm Hg). The CSFP differential did not change significantly after decompression. Cranial CSFPPA was greater than caudal CSFPPA, but this differential did not change during compression. On decompression, the caudal CSFPPA increased in some but not all animals. CONCLUSION Although extradural compression exists at the site of injury, lumbar CSFP may not accurately indicate CSFP cranial to the injury. Decompression may provide immediate, though perhaps partial, resolution of the pressure differential. CSFPPA was not a consistent indicator of decompression in this animal model. These findings may have implications for the design of future clinical protocols in which CSFP is monitored after acute SCI.
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Descending thoracic aortic surgery: update on mortality, morbidity, risk assessment and management. Curr Opin Crit Care 2012; 18:393-8. [PMID: 22710279 DOI: 10.1097/mcc.0b013e32835559a6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the literature on thoracic aortic surgery, as well as key management guidelines in the perioperative period. This is particularly timely, as endovascular techniques continue to evolve and become more available. RECENT FINDINGS Endovascular treatment of thoracic aortic disease is expanding in applications and case complexity. SUMMARY With the expanded use of endovascular techniques to treat aortic disease, midterm and long-term outcome studies and comparisons to open surgical approach are now being published with increasing frequency. This review analyzes the available literature on preventing adverse outcomes after descending thoracic aortic surgery, with specific attention to mortality, morbidity, risk assessment and management in the perioperative setting.
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Lima B, Nowicki ER, Blackstone EH, Williams SJ, Roselli EE, Sabik JF, Lytle BW, Svensson LG. Spinal cord protective strategies during descending and thoracoabdominal aortic aneurysm repair in the modern era: The role of intrathecal papaverine. J Thorac Cardiovasc Surg 2012; 143:945-952.e1. [DOI: 10.1016/j.jtcvs.2012.01.029] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Revised: 10/31/2011] [Accepted: 01/06/2012] [Indexed: 12/01/2022]
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Romagnoli S, Ricci Z, Pinelli F, Stefàno P, Rossi A, Bevilacqua S. Spinal Cord Injury After Ascending Aorta and Aortic Arch Replacement Combined with Antegrade Stent Grafting: Role of Postoperative Cerebrospinal Fluid Drainage. J Card Surg 2012; 27:224-7. [DOI: 10.1111/j.1540-8191.2012.01430.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Keith CJ, Passman MA, Carignan MJ, Parmar GM, Nagre SB, Patterson MA, Taylor SM, Jordan WD. Protocol implementation of selective postoperative lumbar spinal drainage after thoracic aortic endograft. J Vasc Surg 2012; 55:1-8; discussion 8. [DOI: 10.1016/j.jvs.2011.07.086] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 07/06/2011] [Accepted: 07/21/2011] [Indexed: 11/29/2022]
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Ullery BW, Wang GJ, Low D, Cheung AT. Neurological complications of thoracic endovascular aortic repair. Semin Cardiothorac Vasc Anesth 2011; 15:123-40. [PMID: 22025398 DOI: 10.1177/1089253211424224] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Thoracic endovascular aortic repair (TEVAR) has decreased the morbidity and mortality associated with open surgical repair of descending thoracic aortic diseases, but important complications unique to the procedure remain. Spinal cord ischemia and infarction is a recognized complication caused by endovascular coverage or injury to spinal cord collateral vessels. Stroke is a consequence of thromboembolism or coverage of aortic arch branch vessels with insufficient collateral circulation. Understanding the risk factors and the pathophysiology of neurological complications of TEVAR are important for the successful anesthetic and surgical management and treatment of patients undergoing endovascular procedures involving the thoracic aorta.
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Affiliation(s)
- Brant W Ullery
- Department of Anesthesiology and Critical Care, University of Pennsylvania, 3400 Spruce Street, Dulles 680, Philadelphia, PA 19104-4283, USA
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