201
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Geisbüsch S, Stefanovic A, Koruth JS, Lin HM, Morgello S, Weisz DJ, Griepp RB, Di Luozzo G. Endovascular coil embolization of segmental arteries prevents paraplegia after subsequent thoracoabdominal aneurysm repair: an experimental model. J Thorac Cardiovasc Surg 2013; 147:220-6. [PMID: 24220154 DOI: 10.1016/j.jtcvs.2013.09.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 09/04/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To test a strategy for minimizing ischemic spinal cord injury after extensive thoracoabdominal aneurysm (TAAA) repair, we occluded a small number of segmental arteries (SAs) endovascularly 1 week before simulated aneurysm repair in an experimental model. METHODS Thirty juvenile Yorkshire pigs (25.2 ± 1.7 kg) were randomized into 3 groups. All SAs, both intercostal and lumbar, were killed by a combination of surgical ligation of the lumbar SAs and occlusion of intercostal SAs with thoracic endovascular stent grafting. Seven to 10 days before this simulated TAAA replacement, SAs in the lower thoracic/upper lumbar region were occluded using embolization coils: 1.5 ± 0.5 SAs in group 1 (T13/L1), and 4.5 ± 0.5 SAs in group 2 (T11-L3). No SAs were coiled in the controls. Hind limb function was evaluated blindly from daily videotapes using a modified Tarlov score (0 = paraplegia, 9 = full recovery). After death, each segment of spinal cord was graded histologically using the 9-point Kleinman score (0 = normal, 8 = complete necrosis). RESULTS Hind limb function remained normal after coil embolization. After simulated TAAA repair, paraplegia occurred in 6 of 10 control pigs, but in only 2 of 10 pigs in group 1; no pigs in group 2 had a spinal cord injury. Tarlov scores were significantly better in group 2 (control vs group 1, P = .06; control vs group 2, P = .0002; group 1 vs group 2, P = .05). A dramatic reduction in histologic damage, most prominently in the coiled region, was seen when SAs were embolized before simulated TAAA repair. CONCLUSIONS Endovascular coiling of 2 to 4 SAs prevented paraplegia in an experimental model of extensive hybrid TAAA repair, and helped protect the spinal cord from ischemic histopathologic injury. A clinical trial in a selected patient population at high risk for postoperative spinal cord injury may be appropriate.
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Affiliation(s)
- Sarah Geisbüsch
- Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, NY.
| | - Angelina Stefanovic
- Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, NY
| | - Jacob S Koruth
- Department of Cardiology, Mount Sinai Medical Center, New York, NY
| | - Hung-Mo Lin
- Department of Health Evidence and Policy, Mount Sinai Medical Center, New York, NY
| | - Susan Morgello
- Department of Neuropathology, Mount Sinai Medical Center, New York, NY
| | - Donald J Weisz
- Department of Neurology, Mount Sinai Medical Center, New York, NY
| | - Randall B Griepp
- Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, NY
| | - Gabriele Di Luozzo
- Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, NY
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202
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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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203
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Meffert P, Bischoff MS, Brenner R, Siepe M, Beyersdorf F, Kari FA. Significance and function of different spinal collateral compartments following thoracic aortic surgery: immediate versus long-term flow compensation. Eur J Cardiothorac Surg 2013; 45:799-804. [DOI: 10.1093/ejcts/ezt479] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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204
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Griepp EB, Di Luozzo G, Schray D, Stefanovic A, Geisbüsch S, Griepp RB. The anatomy of the spinal cord collateral circulation. Ann Cardiothorac Surg 2013; 1:350-7. [PMID: 23977520 DOI: 10.3978/j.issn.2225-319x.2012.09.03] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2012] [Accepted: 09/06/2012] [Indexed: 11/14/2022]
Affiliation(s)
- Eva B Griepp
- Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, New York, USA
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205
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Bischoff MS, Brenner RM, Scheumann J, Zoli S, Di Luozzo G, Etz CD, Griepp RB. Staged approach for spinal cord protection in hybrid thoracoabdominal aortic aneurysm repair. Ann Cardiothorac Surg 2013; 1:325-8. [PMID: 23977515 DOI: 10.3978/j.issn.2225-319x.2012.06.03] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Accepted: 06/04/2012] [Indexed: 11/14/2022]
Affiliation(s)
- Moritz S Bischoff
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Germany
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206
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Foerster K, D'Inka M, Beyersdorf F, Benk C, Nguyen-Thanh T, Mader I, Fritsch B, Ihling C, Mueller K, Heilmann C, Trummer G. Prolonged cardiac arrest and resuscitation by extracorporeal life support: favourable outcome without preceding anticoagulation in an experimental setting. Perfusion 2013; 28:520-8. [PMID: 23827862 DOI: 10.1177/0267659113495081] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
State-of-the-art cardiopulmonary resuscitation (CPR) restores circulation with inconsistent blood-flow and pressure. Extracorporeal life support (ECLS) following CPR opens the opportunity for "controlled reperfusion". In animal experiments investigating CPR with ECLS, systemic anticoagulation before induced cardiac arrest is normal, but a major point of dispute, since preliminary heparinization in patients undergoing unwitnessed cardiac arrest is impossible. In this study, we investigated options for ECLS after an experimental 15 minutes normothermic cardiac arrest, without preceding anticoagulation, in pigs. Neurological recovery was assessed by a scoring system, electroencephalography and brain magnetic resonance imaging. Additionally, brain histology was performed on day seven after cardiac arrest. We demonstrated that preliminary heparin administration was not necessary for survival or neurological recovery in this setting. Heparin flushing of the cannulae seemed sufficient to avoid thrombus formation. These findings may ease the way to using ECLS in patients with sudden cardiac arrest.
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Affiliation(s)
- K Foerster
- 1Heart Center Freiburg University, Freiburg, Germany
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207
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Luehr M, Bachet J, Mohr FW, Etz CD. Modern temperature management in aortic arch surgery: the dilemma of moderate hypothermia. Eur J Cardiothorac Surg 2013; 45:27-39. [PMID: 23628950 DOI: 10.1093/ejcts/ezt154] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Arch surgery is undoubtedly among the most technically and strategically challenging endeavours in aortic surgery, requiring thorough understanding not only of cardiovascular physiology, but also in particular, of neurophysiology (cerebral and spinal cord), and is still associated with significant mortality and morbidity. In the late 1980s, when deep hypothermic circulatory arrest (HCA) had gained widespread acceptance as the standard approach for arch surgery, antegrade selective cerebral perfusion (SCP), as an adjunct to deep HCA, began its triumphal march, offering excellent neuroprotection and improved overall outcome. This encouraged the use of antegrade SCP in combination with steadily increasing body core temperatures--a trend culminating in the progressive advocation of moderate-to-mild temperatures up to 35 °C, and even normothermia. The impetus for progressive temperature elevation was the limitation of adverse effects of profound hypothermia and the most welcome side effect of significantly shorter cooling and rewarming periods on cardiopulmonary bypass (CPB), and thereby, potentially, the alleviation of the systemic inflammatory response and, in particular, the risk of severe postoperative bleeding (and other organ dysfunctions). The safe limits of prolonged distal circulatory arrest, particularly with regard to the ischaemic tolerance of the viscera and the spinal cord, have not yet been clearly defined. Adverse outcomes due to inappropriate temperature management (core temperatures too high for the required duration of distal arrest) are probably highly underreported. Complications historically associated with hypothermia, namely excessive bleeding, are possibly overestimated. Trading effective neuroprotection and excellent outcomes for the risk of prolonged 'warm' distal ischaemia might constitute a significant step back, jeopardizing visceral and, in particular, spinal cord integrity, with unpredictable consequences for long-term outcome and quality of life, particularly affecting those in need of more complex surgery or with previous neurological deficits.
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Affiliation(s)
- Maximilian Luehr
- Department of Cardiac Surgery, Leipzig Heart Center - University of Leipzig, Leipzig, Germany
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208
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Marfan-Syndrom. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2013. [DOI: 10.1007/s00398-012-0986-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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209
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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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210
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Di Luozzo G. Visceral and spinal cord protection during thoracoabdominal aortic aneurysm repair: Clinical and laboratory update. J Thorac Cardiovasc Surg 2013; 145:S135-8. [DOI: 10.1016/j.jtcvs.2012.11.053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Revised: 10/12/2012] [Accepted: 11/28/2012] [Indexed: 11/28/2022]
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211
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Geisbüsch S, Schray D, Bischoff MS, Lin HM, Griepp RB, Di Luozzo G. Imaging of vascular remodeling after simulated thoracoabdominal aneurysm repair. J Thorac Cardiovasc Surg 2012; 144:1471-8. [PMID: 23010582 DOI: 10.1016/j.jtcvs.2012.08.062] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 07/30/2012] [Accepted: 08/23/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE A better understanding of the response of the spinal cord blood supply to segmental artery (SA) sacrifice should help minimize the risk of paraplegia after both open and endovascular repair of thoracoabdominal aortic (TAA) aneurysms. METHODS Twelve female juvenile Yorkshire pigs were randomized into 3 groups and perfused with a barium-latex solution. Pigs in group 1 (control) had infusion without previous intervention. Pigs in group 2 were infused 48 hours after ligation of all SAs (T4-L5) and those in group 3 at 120 hours after ligation. Postmortem computed tomographic scanning of the entire pig enabled overall comparisons and measurement of vessel diameters in the spinal cord circulation. RESULTS We ligated 14.5 ± 0.8 SAs: all filled retrograde to the ligature. Paraplegia occurred in 38% of operated pigs. A significant increase in the mean diameter of the anterior spinal artery (ASA) was evident after SA sacrifice (P < .0001 for 48 hours and 120 hours). The internal thoracic and intercostal arteries also increased in diameter. Quantitative assessment showed an increase in vessel density 48 hours after ligation of SAs, reflected by an obvious increase in small collateral vessels seen on 3-dimensional reconstructions of computed tomographic scans at 120 hours. CONCLUSIONS Remodeling of the spinal cord blood supply--including dilatation of the ASA and proliferation of small collateral vessels--is evident at 48 and 120 hours after extensive SA sacrifice. It is likely that exploitation of this process will prove valuable in the quest to eliminate paraplegia after TAA aneurysm repair.
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Affiliation(s)
- Sarah Geisbüsch
- Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, NY 10029, USA.
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212
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Spinal cord ischemia after endovascular aortic repair versus open surgical repair for descending thoracic and thoracoabdominal aortic aneurism. J Anesth 2012; 26:805-11. [DOI: 10.1007/s00540-012-1434-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 06/04/2012] [Indexed: 10/28/2022]
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213
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Targeting Landing Zone 0 by Total Arch Rerouting and TEVAR: Midterm Results of a Transcontinental Registry. Ann Thorac Surg 2012; 94:84-9. [DOI: 10.1016/j.athoracsur.2012.03.024] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Revised: 03/07/2012] [Accepted: 03/12/2012] [Indexed: 11/27/2022]
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214
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Niclauss L, Delay D, von Segesser LK. Recovery of paraplegia after type B dissection due to spinal collateral recruitment. J Vasc Surg 2012; 56:205-7. [PMID: 22326576 DOI: 10.1016/j.jvs.2011.12.078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 12/02/2011] [Accepted: 12/24/2011] [Indexed: 11/24/2022]
Abstract
Acute paraplegia could be a symptom of aortic dissection due to sudden compromise of arterial spinal cord blood supply. Complete spontaneous neurologic recovery is possible and was observed in the present case 3 hours after symptom onset. Spontaneous spinal cord reperfusion after acute type B dissection was probably due to two main mechanisms. Reperfusion of false lumen and collateral vascular network recruitment, recently confirmed by anatomic animal studies, serve as potential explanations. Favorable evolution of acute paraplegia after aortic dissection exists, but prognosis is uncertain, probably due to individual variable anatomic distribution of spinal cord blood supply.
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Affiliation(s)
- Lars Niclauss
- Department of Cardiovascular Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
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215
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Bischoff MS, Scheumann J, Brenner RM, Ladage D, Bodian CA, Kleinman G, Ellozy SH, Di Luozzo G, Etz CD, Griepp RB. Staged Approach Prevents Spinal Cord Injury in Hybrid Surgical-Endovascular Thoracoabdominal Aortic Aneurysm Repair: An Experimental Model. Ann Thorac Surg 2011; 92:138-46; discussion 146. [DOI: 10.1016/j.athoracsur.2011.03.098] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2011] [Revised: 02/25/2011] [Accepted: 03/09/2011] [Indexed: 10/18/2022]
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216
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Etz CD, Kari FA, Mueller CS, Brenner RM, Lin HM, Griepp RB. The collateral network concept: remodeling of the arterial collateral network after experimental segmental artery sacrifice. J Thorac Cardiovasc Surg 2011; 141:1029-36. [PMID: 21419904 DOI: 10.1016/j.jtcvs.2010.06.017] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2010] [Revised: 05/25/2010] [Accepted: 06/08/2010] [Indexed: 10/26/2022]
Abstract
OBJECTIVE A comprehensive strategy to prevent paraplegia after open surgical or endovascular repair of thoracoabdominal aortic aneurysms requires a thorough understanding of the response of the collateral network to extensive segmental artery sacrifice. METHODS Ten Yorkshire pigs underwent perfusion with a low-viscosity acrylic resin. With the use of cardiopulmonary bypass, 2 animals each were perfused in the native state and immediately, 6 hours, 24 hours, and 5 days after sacrifice of all segmental arteries (T4-L5). After digestion of surrounding tissue, the vascular cast of the collateral network underwent analysis of arterial and arteriolar diameters and the density and spatial orientation of the vasculature using light and scanning electron microscopy. RESULTS Within 24 hours, the diameter of the anterior spinal artery had increased significantly, and within 5 days the anterior spinal artery and the epidural arterial network had enlarged in diameter by 80% to 100% (P < .0001). By 5 days, the density of the intramuscular paraspinous vessels had increased (P < .0001), a shift of size distribution from small to larger arterioles was seen (P = .0002), and a significant realignment of arterioles parallel to the spinal cord had occurred (P = .0005). CONCLUSIONS Within 5 days after segmental artery occlusion, profound anatomic alterations in the intraspinal and paraspinous arteries and arterioles occurred, providing the anatomic substrate for preservation of spinal cord blood flow via collateral pathways.
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Affiliation(s)
- Christian D Etz
- Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY 10029, USA
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217
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Measuring the collateral network pressure to minimize paraplegia risk in thoracoabdominal aneurysm resection. J Thorac Cardiovasc Surg 2010; 140:S125-30; discussion S142-S146. [DOI: 10.1016/j.jtcvs.2010.07.040] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Accepted: 07/12/2010] [Indexed: 11/17/2022]
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218
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Griepp EB, Griepp RB. The collateral network concept: minimizing paraplegia secondary to thoracoabdominal aortic aneurysm resection. Tex Heart Inst J 2010; 37:672-674. [PMID: 21224942 PMCID: PMC3014112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Eva B Griepp
- Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, New York 10029, USA
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