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Saitoh D, Yamazaki Y, Tsuji T, Sakoda N, Yakuwa K, Tabayashi A, Koizumi J, Ohsawa S, Kin H. Patterns of collateral arteries to the spinal cord after thoraco-abdominal aortic aneurysm repair. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae087. [PMID: 38696750 PMCID: PMC11193310 DOI: 10.1093/icvts/ivae087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/30/2024] [Indexed: 05/04/2024]
Abstract
OBJECTIVES Our goal was to evaluate postoperative patterns of collateral arteries to the spinal cord during occlusion of the segmental arteries supplying the artery of Adamkiewicz (AKA). METHODS Between April 2011 and December 2022, a total of 179 patients underwent thoraco-abdominal aortic aneurysm repair; 141 had an identifiable AKA on preoperative multidetector computed tomography scans, 40 underwent thoraco-abdominal aortic aneurysm replacement (TAAR) and 101 underwent thoracic endovascular aortic repair (TEVAR). New postoperative collateral blood pathways invisible on preoperative contrast-enhanced computed tomography scans were identified in 42 patients (10 patients who had TAAR vs 32 patients who had TEVAR) who underwent preoperative and postoperative multidetector computed tomography scanning for AKA identification. RESULTS The thoracodorsal and segmental arteries were the main collateral pathways in both groups. Th9-initiated collaterals were the most common. Collaterals from the internal thoracic artery were observed in the TEVAR group but not in the TAAR group. One patient in the TEVAR group experienced postoperative paraparesis, which was not observed in the TAAR group. Postoperative paraplegia was more common in the non-Th9-origin group, but this difference was not significant. CONCLUSIONS Thoracodorsal and segmental arteries may be important collateral pathways after TEVAR and TAAR. For thoracodorsal arteries, preserving the thoracodorsal muscle during the approach would be crucial; for segmental arteries, minimizing the area to be replaced or covered would be paramount. An AKA not initiated at the Th9 level poses a high risk of postoperative paraplegia.
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Affiliation(s)
- Daiki Saitoh
- Department of Cardiovascular Surgery, Iwate Medical University, Iwate, Japan
| | - Yuya Yamazaki
- Department of Cardiovascular Surgery, Iwate Medical University, Iwate, Japan
| | - Tatsunori Tsuji
- Department of Cardiovascular Surgery, Iwate Medical University, Iwate, Japan
| | - Naoya Sakoda
- Department of Cardiovascular Surgery, Iwate Medical University, Iwate, Japan
| | - Kazuki Yakuwa
- Department of Cardiovascular Surgery, Iwate Medical University, Iwate, Japan
| | - Azuma Tabayashi
- Department of Cardiovascular Surgery, Iwate Medical University, Iwate, Japan
| | - Junichi Koizumi
- Department of Cardiovascular Surgery, Iwate Medical University, Iwate, Japan
| | - Satoshi Ohsawa
- Department of Cardiovascular Surgery, San-ai Hospital, Iwate, Japan
| | - Hajime Kin
- Department of Cardiovascular Surgery, Iwate Medical University, Iwate, Japan
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Seike Y, Nishii T, Yoshida K, Yokawa K, Masada K, Inoue Y, Fukuda T, Matsuda H. Covering the intercostal artery branching of the Adamkiewicz artery during endovascular aortic repair increases the risk of spinal cord ischemia. JTCVS OPEN 2024; 17:14-22. [PMID: 38420547 PMCID: PMC10897655 DOI: 10.1016/j.xjon.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/14/2023] [Accepted: 11/20/2023] [Indexed: 03/02/2024]
Abstract
Objectives This study aimed to determine the relationship between covering the intercostal artery branching of the Adamkiewicz artery (ICA-AKA) and spinal cord ischemia (SCI) during thoracic endovascular aortic repair (TEVAR). Methods Patients who underwent TEVAR from 2008 to 2022 were enrolled. Stent grafts covered the ICA-AKA in 108 patients (covered AKA group) and stent grafts didn't cover the ICA-AKA in 114 patients (uncovered AKA group). The characteristics of 58 patients from each group were matched based on propensity scores. Results No significant differences in SCI rates were detected between the covered AKA (10%; 11/108) and uncovered AKA (3.5%; 4/114) groups (P = .061). Shaggy aorta (odds ratio [OR], 5.16; 95% confidence interval [CI], 1.74-15.3, P = .003), iliac artery access (OR, 6.81; 95% CI, 2.22-20.9, P = .001), and procedural time (OR, 1.01; 95% CI, 1.00-1.02, P = .003) were risk factors for SCI in the entire cohort. Although covering the ICA-AKA (OR, 2.60; 95% CI, 0.86-7.88, P = .058) was not a significant risk factor, shaggy aorta (OR, 8.15; 95% CI, 2.07-32.1, P = .003), iliac artery access (OR, 9.09; 95% CI, 2.22-37.2, P = .002), and procedural time (OR, 1.01; 95% CI, 1.01-1.02, P = .008) were risk factors for SCI in the covered AKA group. No significant risk factors were detected in the uncovered AKA group. Conclusions Covering the ICA-AKA was not an independent risk for SCI in TEVAR. However, covering the ICA-AKA was indirectly associated with the risk of SCI in patients with shaggy aorta, iliac access, and procedural time.
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Affiliation(s)
- Yoshimasa Seike
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tatsuya Nishii
- Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazufumi Yoshida
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Koki Yokawa
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kenta Masada
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yosuke Inoue
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
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Barral PA, De Masi M, Bartoli A, Beunon P, Gallon A, Tradi F, Hak JF, Gaudry M, Jacquier A. Angio Cone-Beam CT (Angio-CBCT) and 3D Road-Mapping for the Detection of Spinal Cord Vascularization in Patients Requiring Treatment for a Thoracic Aortic Lesion: A Feasibility Study. J Pers Med 2022; 12:1890. [PMID: 36422066 PMCID: PMC9692974 DOI: 10.3390/jpm12111890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/03/2022] [Accepted: 11/05/2022] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Spinal cord ischemia is a major complication of treatment for descending thoracic aorta (DTA) disease. Our objectives were (1) to describe the value of angiographic cone-beam CT (angio-CBCT) and 3D road-mapping to visualize the Adamkiewicz artery (AA) and its feeding artery and (2) to evaluate the impact of AA localization on the patient surgical strategy. METHODS Between 2018 and 2020, all patients referred to our institution for a surgical DTA disorder underwent a dedicated AA evaluation by angio-CBCT. If the AA feeding artery was not depicted on angio-CBCT, selective artery catheterization was performed, guided by 3D road-mapping. Intervention modifications, based on AA location and one month of neurologic follow-up after surgery, were recorded. RESULTS Twenty-one patients were enrolled. AA was assessable in 100% of patients and in 15 (71%) with angio-CBCT alone. Among them, 10 patients needed 3D road-mapping-guided DSA angiography to visualize the AA feeding artery. The amount of contrast media, irradiation dose, and intervention length were not significantly different whether the AA was assessable or not by angio-CBCT. AA feeding artery localization led to surgical sketch modification for 11 patients. CONCLUSIONS Angio-CBCT is an efficient method for AA localization in the surgical planning of DTA disorders.
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Affiliation(s)
- Pierre-Antoine Barral
- Department of Radiology, CHU Timone, AP-HM, 264, Rue Saint-Pierre, 13005 Marseille, France
| | - Mariangela De Masi
- Department of Vascular Surgery, CHU Timone, 264, Rue Saint-Pierre, AP-HM, 13005 Marseille, France
- Aortic Center, CHU Timone, AP-HM, 264, Rue Saint-Pierre, 13005 Marseille, France
| | - Axel Bartoli
- Department of Radiology, CHU Timone, AP-HM, 264, Rue Saint-Pierre, 13005 Marseille, France
- CRMBM-UMR CNRS 7339, Aix-Marseille University, 27, Boulevard Jean Moulin, CEDEX 05, 13385 Marseille, France
| | - Paul Beunon
- Department of Radiology, CHU Timone, AP-HM, 264, Rue Saint-Pierre, 13005 Marseille, France
| | - Arnaud Gallon
- Department of Visceral and Vascular Radiology, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France Aortic Center, CHU Timone, AP-HM, 264, Rue Saint-Pierre, CEDEX 1, 13005 Marseille, France
| | - Farouk Tradi
- Department of Radiology, CHU Timone, AP-HM, 264, Rue Saint-Pierre, 13005 Marseille, France
| | - Jean-François Hak
- Department of Neuroradiology, CHU Timone, AP-HM, 264, Rue Saint-Pierre, 13005 Marseille, France
| | - Marine Gaudry
- Department of Vascular Surgery, CHU Timone, 264, Rue Saint-Pierre, AP-HM, 13005 Marseille, France
- Aortic Center, CHU Timone, AP-HM, 264, Rue Saint-Pierre, 13005 Marseille, France
| | - Alexis Jacquier
- Department of Radiology, CHU Timone, AP-HM, 264, Rue Saint-Pierre, 13005 Marseille, France
- CRMBM-UMR CNRS 7339, Aix-Marseille University, 27, Boulevard Jean Moulin, CEDEX 05, 13385 Marseille, France
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6561271. [DOI: 10.1093/ejcts/ezac196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 02/23/2022] [Accepted: 03/24/2022] [Indexed: 11/13/2022] Open
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Lella SK, Waller HD, Pendleton A, Latz CA, Boitano LT, Dua A. A Systematic Review of Spinal Cord Ischemia Prevention and Management After Open and Endovascular Aortic Repair. J Vasc Surg 2021; 75:1091-1106. [PMID: 34740806 DOI: 10.1016/j.jvs.2021.10.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 10/24/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Spinal cord ischemia (SCI) is one of the most devastating complications after descending thoracic aortic (DTA) and thoracoabdominal aortic (TAA) repairs. Patients who develop SCI have a poor prognosis with mortality rates reaching 75% within the first year after surgery. Many factors have been shown to increase the risk of this complication, including extent of TAA repair, length of aortic and collateral network coverage, embolization, and reduced spinal cord perfusion pressure. As a result, a variety of treatment strategies have evolved. We aimed to provide an up-to-date review of SCI rates with associated treatment algorithms from open and endovascular DTA and TAA repairs. METHODS Using PRISMA guidelines, a literature review with the Medical Subject Headings (MeSH) terms "spinal cord ischemia; spinal cord ischemia prevention and mitigation strategies; spinal cord ischemia rates; spinal cord infarction" was performed in the Cochrane and PubMed databases to seek all peer-reviewed studies of DTA and TAA repairs with SCI complications, limited to 2012-2021 and the English language. MeSH subheadings including diagnosis, complications, physiopathology, surgery, mortality, and therapy were used to further restrict the articles. Studies were excluded if they were not in humans, not pertaining to SCI in DTA/TAA operative repairs, and if the study primarily discussed neuromonitoring techniques. Additionally, studies with <40 patients or limited information regarding SCI protection strategies were excluded. Each study was individually reviewed by two researchers to assess for type and extent of aortic pathology, operative technique, SCI protection or mitigation strategies, rates of overall and permanent SCI symptoms, associations with SCI on multivariate analysis, and mortality. RESULTS Of 450 studies returned by the MeSH search strategy, 41 met inclusion criteria and were included in the final analysis. For endovascular DTA repair patients, overall SCI rates ranged from 0-10.6% with permanent SCI symptoms ranging from 0-5.1%. Endovascular and open TAA repairs had rates of overall SCI of 0-35%. Permanent SCI symptom rate was reported by only one open study at 1.1% while endovascular TAA repairs had between 2-20.5%. CONCLUSION This review provides an up-to-date review of current rates of SCI as well as prevention and mitigation strategies for DTA and TAA repairs. We find that a multimodal approach, including a bundled institutional protocol, staging of multiple repairs, preservation of collateral blood flow network, augmented spinal cord perfusion, selective cerebrospinal fluid drainage, and distal aortic perfusion in open TAA repairs, appears to be important in reducing the risk of SCI.
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Affiliation(s)
- Srihari K Lella
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass.
| | - Harold D Waller
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Alaska Pendleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Christopher A Latz
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
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Tan L, Xiao J, Zhou X, Shen K, Li F, Luo J, Tang H. Untreated distal intimal tears may be associated with paraplegia after total arch replacement and frozen elephant trunk treatment of acute Stanford type A aortic dissection. J Thorac Cardiovasc Surg 2019; 158:343-350.e1. [DOI: 10.1016/j.jtcvs.2018.08.111] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 08/09/2018] [Accepted: 08/22/2018] [Indexed: 01/16/2023]
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Late-Onset Paraplegia After Endovascular Repair of Type B Aortic Dissection Managed by Urgent Left Subclavian Artery Revascularization: A Case Report. Ann Vasc Surg 2019; 58:384.e9-384.e14. [PMID: 30769073 DOI: 10.1016/j.avsg.2018.11.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/11/2018] [Accepted: 11/12/2018] [Indexed: 11/20/2022]
Abstract
Spinal cord ischemia is one of the most unpredictable and feared complications after open surgical or endovascular thoracic aortic repair. Protection of collateral network branches that contribute blood supply to spinal cord is fundamental in the prevention of this catastrophic condition. We report the case of a patient who underwent emergent endovascular treatment for a type B aortic dissection complicated by rupture of the false lumen, with intentional coverage of the left subclavian artery without revascularization. The patient developed paraplegia on the 10th postoperative day, which did not significantly improve with immediate cerebrospinal fluid drainage but fully recovered after urgent left carotid-subclavian bypass.
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Shimoyama S, Nishii T, Watanabe Y, Kono AK, Kagawa K, Takahashi S, Sugimura K. Advantages of 70-kV CT Angiography for the Visualization of the Adamkiewicz Artery: Comparison with 120-kV Imaging. AJNR Am J Neuroradiol 2017; 38:2399-2405. [PMID: 28912277 DOI: 10.3174/ajnr.a5372] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 07/07/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND PURPOSE Preprocedural identification of the Adamkiewicz artery is crucial in patients with aortic diseases. This study aimed to compare 70-kV CTA with conventional 120-kV CTA for the identification of the Adamkiewicz artery, examining differences in radiation dose and image quality. MATERIALS AND METHODS We retrospectively analyzed 2 equal groups of 60 patients who had undergone 70-kV or 120-kV CTA to detect the Adamkiewicz artery before aortic repair. Size-specific dose estimate, the CT number of the aorta, and the contrast-to-noise ratio of the anterior spinal artery to the spinal cord were recorded. Furthermore, detectability of the Adamkiewicz artery was evaluated by using a 4-point continuity score (3, definite to 0, undetectable). RESULTS There was significantly lower radiation exposure with 70-kV CTA than 120-kV CTA (median size-specific dose estimate, 23.1 versus 61.3 mGy, respectively; P < .001). CT number and contrast-to-noise ratio were both significantly higher in the 70-kV CTA group than the 120-kV group (999.1 HU compared with 508.7 HU, and 5.6 compared with 3.4, respectively; P < .001 for both). Detectability of the Adamkiewicz artery was not impaired in the 70-kV CTA group (90.0% versus 83.3% in the 120-kV group, P = .28). Moreover, the Adamkiewicz artery was detected with greater confidence with 70-kV CTA, reflected by a significantly superior continuity score (median, 3) compared with 120-kV CTA (median, 2; P = .001). CONCLUSIONS Seventy-kilovolt CTA has substantial advantages for the identification of the Adamkiewicz artery before aortic repair, with a significantly lower radiation exposure and superior image quality than 120-kV CTA.
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Affiliation(s)
- S Shimoyama
- From the Department of Radiology (S.S., T.N., Y.W., A.K.K., S.T., K.S.), Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - T Nishii
- From the Department of Radiology (S.S., T.N., Y.W., A.K.K., S.T., K.S.), Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Y Watanabe
- From the Department of Radiology (S.S., T.N., Y.W., A.K.K., S.T., K.S.), Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
- Department of Radiology (Y.W., A.K.K.), National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - A K Kono
- From the Department of Radiology (S.S., T.N., Y.W., A.K.K., S.T., K.S.), Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
- Department of Radiology (Y.W., A.K.K.), National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - K Kagawa
- Division of Radiology (K.K.), Center for Radiology and Radiation Oncology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - S Takahashi
- From the Department of Radiology (S.S., T.N., Y.W., A.K.K., S.T., K.S.), Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - K Sugimura
- From the Department of Radiology (S.S., T.N., Y.W., A.K.K., S.T., K.S.), Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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Nasser R, Nakhla J, Sharif S, Kinon M, Yassari R. Penetrating thoracic spinal cord injury with ice pick extending into the aorta. A technical note and review of the literature. Surg Neurol Int 2016; 7:S763-S766. [PMID: 27904758 PMCID: PMC5114855 DOI: 10.4103/2152-7806.193729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 05/02/2016] [Indexed: 11/05/2022] Open
Abstract
Background: Penetrating spinal cord injuries pose a great challenge to both patients and the treating physicians. Although the overall incidence of penetrating spinal cord injury is the highest in the military, the ubiquity of guns in our society continues to make penetrating spinal cord injury prevalent in the civilian population. These types of injuries are particularly complicated because, beyond the trauma to the neural elements and supporting structures, other organs can be affected and a team approach is required for successful treatment. Case Description: In this report, the authors present a unique case of an ice pick penetrating posteriorly through the spinal canal into the aorta. The described surgical management involved careful consideration and planning to prevent worsening vascular and neurological compromise. Among the challenges faced are neurological compromise, vascular injury, spinal instability, and cerebrospinal fluid leak. Conclusion: To the author’s knowledge, this challenging case represents the first description of a successful removal of a penetrating thoracic spinal foreign body that terminated within the lumen of the thoracic aorta.
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Affiliation(s)
- Rani Nasser
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, USA
| | - Jonathan Nakhla
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, USA
| | - Saadat Sharif
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, USA
| | - Merritt Kinon
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, USA
| | - Reza Yassari
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, USA
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