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Godet G, Bertrand M, Fléron MH, Goarin JP, Colson P, Cardon A, Koskas F, Verhoye JP, Kieffer E. Cerebrospinal fluid drainage and thoracic endovascular aneurysm repair. Asian Cardiovasc Thorac Ann 2017; 25:608-617. [DOI: 10.1177/0218492317739472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Spinal cord complications including paraplegia and partial neurologic deficits remain a frequent problem during repair of descending thoracic or thoracoabdominal aortic aneurysms. Effective prevention of this dreaded complication is of paramount importance. Among the many adjuncts that have been proposed to prevent spinal cord complications, spinal fluid drainage is one that has been used by numerous teams. The aim of this review is to answer the following question: does spinal fluid drainage afford spinal cord protection during both open and endovascular repair of thoracic or thoracoabdominal aortic aneurysms?
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Affiliation(s)
- Gilles Godet
- Department of Anesthesiology and Intensive Care, and Vascular Surgery Unit, Pontchaillou University Hospital, Rennes, France
| | - Michèle Bertrand
- Department of Anesthesiology and Intensive Care, and Vascular Surgery Unit, Pitié Salpétrière University Hospital, Paris, France
| | - Marie-Hélène Fléron
- Department of Anesthesiology and Intensive Care, and Vascular Surgery Unit, Pitié Salpétrière University Hospital, Paris, France
| | - Jean-Pierre Goarin
- Department of Anesthesiology and Intensive Care, and Vascular Surgery Unit, Pitié Salpétrière University Hospital, Paris, France
| | - Pascal Colson
- Department of Anesthesiology and Intensive Care, Arnaud de Villeneuve University Hospital, Montpellier, France
| | - Alain Cardon
- Department of Cardiovascular and Thoracic Surgery, Pontchaillou University Hospital, Rennes, France
| | - Fabien Koskas
- Department of Vascular Surgery, Pitié Salpétrière University Hospital, Paris, France
| | - Jean-Philippe Verhoye
- Department of Cardiovascular and Thoracic Surgery, Pontchaillou University Hospital, Rennes, France
| | - Edouard Kieffer
- Department of Vascular Surgery, Pitié Salpétrière University Hospital, Paris, France
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Clinical approach for thoracoabdominal aortic aneurysm repair. Int J Angiol 2011. [DOI: 10.1007/bf01616233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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3
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Morales JP, Taylor PR, Bell RE, Chan YC, Sabharwal T, Carrell TWG, Reidy JF. Neurological Complications Following Endoluminal Repair of Thoracic Aortic Disease. Cardiovasc Intervent Radiol 2007; 30:833-9. [PMID: 17508247 DOI: 10.1007/s00270-007-9017-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2006] [Accepted: 11/14/2006] [Indexed: 11/26/2022]
Abstract
Open surgery for thoracic aortic disease is associated with significant morbidity and the reported rates for paraplegia and stroke are 3%-19% and 6%-11%, respectively. Spinal cord ischemia and stroke have also been reported following endoluminal repair. This study reviews the incidence of paraplegia and stroke in a series of 186 patients treated with thoracic stent grafts. From July 1997 to September 2006, 186 patients (125 men) underwent endoluminal repair of thoracic aortic pathology. Mean age was 71 years (range, 17-90 years). One hundred twenty-eight patients were treated electively and 58 patients had urgent procedures. Anesthesia was epidural in 131, general in 50, and local in 5 patients. Seven patients developed paraplegia (3.8%; two urgent and five elective). All occurred in-hospital apart from one associated with severe hypotension after a myocardial infarction at 3 weeks. Four of these recovered with cerebrospinal fluid (CSF) drainage. One patient with paraplegia died and two had permanent neurological deficit. The rate of permanent paraplegia and death was 1.6%. There were seven strokes (3.8%; four urgent and three elective). Three patients made a complete recovery, one had permanent expressive dysphasia, and three died. The rate of permanent stroke and death was 2.1%. Endoluminal treatment of thoracic aortic disease is an attractive alternative to open surgery; however, there is still a risk of paraplegia and stroke. Permanent neurological deficits and death occurred in 3.7% of the patients in this series. We conclude that prompt recognition of paraplegia and immediate insertion of a CSF drain can be an effective way of recovering spinal cord function and improving the prognosis.
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Affiliation(s)
- J P Morales
- Department of Vascular Surgery, Guy's and St. Thomas' Foundation Hospital NHS Trust, Lambeth Palace Road, London, UK
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Reece TB, Kern JA, Tribble CG, Cassada DC. The role of pharmacology in spinal cord protection during thoracic aortic reconstruction. Semin Thorac Cardiovasc Surg 2003; 15:365-77. [PMID: 14710378 DOI: 10.1053/s1043-0679(03)00088-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Surgery of the thoracic aorta continues to have a significant risk of neurologic complication. Several strategies to minimize this risk are emerging. Pharmacologic protection from these complications continues to be researched, but at this point few medications are being used clinically. This article reviews the pathophysiology of ischemic spinal cord injury and summarizes the investigational pharmacology that may prevent these serious complications.
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Affiliation(s)
- T Brett Reece
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA 22908, USA
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de Haan P, Kalkman CJ, Jacobs MJ. Pharmacologic neuroprotection in experimental spinal cord ischemia: a systematic review. J Neurosurg Anesthesiol 2001; 13:3-12. [PMID: 11145475 DOI: 10.1097/00008506-200101000-00002] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Various surgical procedures may cause temporary interruption of spinal cord blood supply and may result in irreversible ischemic injury and neurological deficits. The cascade of events that leads to neuronal death following ischemia may be amenable to pharmacological manipulations that aim to increase the tolerable duration of ischemia. Many agents have been evaluated in experimental spinal cord ischemia (SCI). In order to investigate whether an agent is available that justifies clinical evaluation, the literature on pharmacological neuroprotection in experimental SCI was systematically reviewed to assess the neuroprotective efficacy of the various agents. In addition, the strength of the evidence for neuroprotection was investigated by analyzing the methodology. The authors used a systematic review to conduct this evaluation. The included studies were analyzed for neuroprotection and methodology. In order to be able to compare the various agents for neuroprotective efficacy, relative risks and confidence intervals were calculated from the data in the results sections. A total of 103 studies were included. Seventy-nine different agents were tested. Only 14 of the agents tested did not afford protection at all. A large variation was observed in the experimental models to produce SCI. This variation limited comparison of the individual agents. In 48 studies involving 31 single agents, the relative risks and confidence intervals could be calculated. An analysis of the methodology revealed poor temperature management and lack of statistical power in the majority of the 103 studies. The results suggest that numerous agents may protect the spinal cord from transient ischemia. However, poor temperature management and lack of statistical power severely weakened the evidence. Consequently, clinical evaluation of pharmacological neuroprotection in surgical procedures that carry a risk of ischemic spinal cord damage is not justified on the basis of this study.
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Affiliation(s)
- P de Haan
- Department of Anesthesiology, Academic Hospital, University of Amsterdam, The Netherlands
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Posner M, Gelman S. Pathophysiology of aortic cross-clamping and unclamping. Best Pract Res Clin Anaesthesiol 2000. [DOI: 10.1053/bean.2000.0067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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7
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Larry Harold Hollier, MD: A Conversation with the Editor. Proc (Bayl Univ Med Cent) 1999. [DOI: 10.1080/08998280.1999.11930160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Ehrlich M, Knolle E, Ciovica R, Böck P, Turkof E, Grabenwöger M, Cartes-Zumelzu F, Kocher A, Pockberger H, Fang WC, Wolner E, Havel M. Memantine for prevention of spinal cord injury in a rabbit model. J Thorac Cardiovasc Surg 1999; 117:285-91. [PMID: 9918969 DOI: 10.1016/s0022-5223(99)70424-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND This study was conducted to investigate the effect of memantine, a noncompetitive N-methyl-d-aspartate receptor antagonist, on the neurologic outcome of spinal cord ischemia after aortic occlusion. MATERIALS AND METHODS New Zealand White rabbits were anesthetized and spinal cord ischemia was induced for 40 minutes by infrarenal aortic occlusion. Animals were randomly allocated to 3 groups. Group 1 (n = 8, control) received no pharmacologic intervention, group 2 (n = 8) received intra-aortic memantine infusion (20 mg/kg) after aortic crossclamping, and group 3 (n = 8) was treated with systemic memantine infusion (20 mg/kg) 45 minutes before aortic occlusion. Neurologic status was scored by the Tarlov system (in which 4 is normal and 0 is paraplegia) at 12, 24, 36, and 48 hours after the operation. Lumbar spinal root stimulation potentials and motor evoked potentials from lower limb muscles were monitored before, during, and after the operation. After the animals were killed, the spinal cords were studied histopathologically. RESULTS All potentials disappeared shortly after aortic crossclamping. They returned earlier in both memantine-treated groups than in the placebo group. Histologic examination of spinal cords revealed a few abnormal motor neurons in memantine-treated rabbits but found extensive injury in the control group. At 12 hours the median Tarlov scores were 0 in the control group (group 1), 2 in the intra-aortic memantine group (group 2, P =.001 versus control), and 3 in the systemic group (group 3, P =.0002 versus control). At 24 hours median Tarlov scores were 0, 2.5 (P =.0002), and 4 (P =. 0002), respectively. Finally, at both 36 and 48 hours median Tarlov scores were 0, 3 (P =.0006), and 4 (P =.0002), respectively. CONCLUSION Memantine significantly reduced neurologic injury related to spinal cord ischemia and reperfusion after aortic occlusion.
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Affiliation(s)
- M Ehrlich
- Department of Cardiothoracic Surgery, University of Vienna, Austria
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Gharagozloo F, Neville RF, Cox JL. Spinal cord protection during surgical procedures on the descending thoracic and thoracoabdominal aorta: a critical overview. Semin Thorac Cardiovasc Surg 1998; 10:73-86. [PMID: 9469783 DOI: 10.1016/s1043-0679(98)70022-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
During the past three decades, significant advances have been made in the surgical treatment of the diseases affecting the aorta. Despite these important advances, paraplegia remains a devastating complication of the surgical procedures on the thoracic and thoracoabdominal aorta. Paraparesis and paraplegia occur as a direct result of the interruption of blood flow to the spinal cord during the surgical procedures. A number of techniques have been advocated for the prevention of spinal cord ischemic injury. This article critically reviews our current understanding of the extent of this problem, the mechanism of injury, and the methods that have been devised to reduce the frequency of paraplegia following surgical procedures on the descending aorta.
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Affiliation(s)
- F Gharagozloo
- Georgetown Cardiovascular Institute, Georgetown University Medical Center, Washington, DC 20007, USA
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Abstract
BACKGROUND Although rare, paralysis secondary to spinal cord ischaemia after aortic aneurysm surgery is a devastating complication. Many papers have been published on this topic but without a clear consensus on the best way of minimizing the problem. Recent articles have included advanced pharmacological approaches and the literature has been reviewed in light of these. METHODS Relevant papers were identified by an extensive text word search of the Medline database and a review of quoted articles. RESULTS Spinal cord complications are commoner after the repair of Crawford type II aneurysms than less extensive aneurysms. The presence of dissection, rupture and prolonged clamp times are associated with an increased incidence. About a quarter of all cord problems develop over 24 h after surgery and this may be due to a reperfusion type injury, although the exact mechanisms are by no means clear. CONCLUSION A combination of rapid surgery, left heart bypass for the repair of more extensive aneurysms, free spinal drainage and the avoidance of postoperative hypoxia and hypotension help to minimize spinal cord ischaemia. No pharmacological agent has yet been shown conclusively to improve outcome in the clinical setting.
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Affiliation(s)
- P Lintott
- Academic Surgical Unit, Imperial College School of Medicine at St Mary's, St Mary's Hospital, London, UK
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Matsuyama K, Chiba Y, Ihaya A, Kimura T, Tanigawa N, Muraoka R. Effect of spinal cord preconditioning on paraplegia during cross-clamping of the thoracic aorta. Ann Thorac Surg 1997; 63:1315-20. [PMID: 9146321 DOI: 10.1016/s0003-4975(97)00104-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Paraplegia is a devastating complication of operations for thoracic or thoracoabdominal aneurysms. Preconditioning the brain with sublethal ischemia induces resistance to subsequent ordinarily lethal ischemia (ischemic tolerance). We investigated whether ischemic tolerance could be induced by preconditioning canine spinal cord. The role of heat-shock proteins (HSP) in this process was investigated. METHODS In experiment 1, the preconditioning group (n = 6) had aortic cross-clamping for 20 minutes, whereas controls (n = 6) had no cross-clamping. After 48 hours the aorta was cross-clamped for 60 minutes in both groups. Neurologic examination was performed 24 hours later and the spinal cord was studied for immunohistochemically. In experiment 2, either 48 hours after 20 minutes of clamping or after sham operation (n = 4), HSP were investigated immunohistochemically. RESULTS In experiment 1, 3 of 6 controls became paraplegic but none of the 6 preconditioning group dogs became paraplegic. The HSP appeared on sections from all 6 PC dogs and 3 control dogs that did not exhibit paraplegia. In experiment 2, HSP were present in clamped animals but could not be detected after sham operation. CONCLUSIONS Ischemic tolerance was induced by preconditioning the canine spinal cord, in which HSP are believed to be involved.
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Affiliation(s)
- K Matsuyama
- Second Department of Surgery, Fukui Medical School, Japan
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Gharagozloo F, Larson J, Dausmann MJ, Neville RF, Gomes MN. Spinal cord protection during surgical procedures on the descending thoracic and thoracoabdominal aorta: review of current techniques. Chest 1996; 109:799-809. [PMID: 8617093 DOI: 10.1378/chest.109.3.799] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- F Gharagozloo
- Division of Cardiovascular and Thoracic Surgery, Georgetown University School of Medicine, Washington, DC 20007, USA
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Mauney MC, Blackbourne LH, Langenburg SE, Buchanan SA, Kron IL, Tribble CG. Prevention of spinal cord injury after repair of the thoracic or thoracoabdominal aorta. Ann Thorac Surg 1995; 59:245-52. [PMID: 7818342 DOI: 10.1016/0003-4975(94)00815-o] [Citation(s) in RCA: 83] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Spinal cord injury occurring as the result of surgical repair of thoracic and thoracoabdominal aortic disease remains a devastating complication. The incidence of postoperative neurologic deficits varies from 4% to 38%. Factors associated with a greater risk for injury include the presence of dissection or extensive thoracoabdominal disease, and a prolonged cross-clamp time. Spinal cord ischemia initiates a deleterious cascade of biochemical events that ultimately result in an increased intracellular calcium concentration. Calcium-activated proteases, lipases, and nucleases mediate the processes that cause cell injury. The accumulation of oxygen-derived free radicals and the occurrence of hyperemia during reperfusion are also contributing causes of spinal cord injury. Increasing the spinal cord blood flow with shunts, oxygenated bypass circuits, cerebrospinal fluid drainage, the intrathecal administration of vasodilators, and the reattachment of intercostal arteries has been tried in an effort to increase spinal cord perfusion. Pharmacologically based measures to prevent spinal cord injury have been pursued, and these have consisted of hypothermia, anesthetic agents, calcium channel blockers, free radical scavengers, and immune system modulation. However, no single technique has proved to be consistently effective in preventing ischemia-induced spinal cord injury.
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Affiliation(s)
- M C Mauney
- Department of Surgery, University of Virginia Health Sciences Center, Charlottesville 22908
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Safi HJ, Bartoli S, Hess KR, Shenaq SS, Viets JR, Butt GR, Sheinbaum R, Doerr HK, Maulsby R, Rivera VM. Neurologic deficit in patients at high risk with thoracoabdominal aortic aneurysms: the role of cerebral spinal fluid drainage and distal aortic perfusion. J Vasc Surg 1994; 20:434-44; discussion 442-3. [PMID: 8084037 DOI: 10.1016/0741-5214(94)90143-0] [Citation(s) in RCA: 134] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE This prospective study evaluated the possible prevention of postoperative neurologic deficit in patients at high risk with thoracoabdominal aortic aneurysms (TAAA), types I and II, by use of perioperative cerebrospinal fluid drainage and distal aortic perfusion. METHODS Between September 18, 1992, and August 8, 1993, 45 consecutive patients underwent TAAA repair (14 type I, 31 type II). Thirty-six were men and nine were women. The median age was 63 years (range 28 to 88). Twenty-four of 45 patients (53%) had dissection and 17 of 45 (38%) had prior proximal aortic replacement. All patients underwent perioperative cerebrospinal fluid drainage and distal aortic perfusion. Median aortic clamping time was 42 minutes. Thirty-five of 45 patients (78%) underwent intercostal artery reattachment. RESULTS The 30-day survival rate was 96% (43 of 45 patients). Early neurologic deficit occurred in two of 45 patients (4%), and late neurologic deficit also occurred in two of 45 patients (4%). We compared the neurologic deficit of our current group of 45 patients with the data of a previously unpublished study of 112 patients also from this center. Total neurologic deficit for the current group was four of 45 (9%) versus the previous group of 35 of 112 (31%) with a p value of 0.0034 (Pearson chi-square test). Neurologic deficit for patients with type I TAAA was 0 of 14 (0%) versus 15 of 73 (21%) (p = 0.062); for patients with type II TAAA 4 of 31 (13%) versus 20 of 39 (51%) (p = 0.0008). In patients with aortic dissection, neurologic deficit was 3 of 24 (12%) versus 9 of 32 (28%) (p = 0.0304); no dissection was 1 of 21 (5%) versus 26 of 80 (32%) (p = 0.011). For aortic clamp times less than 45 minutes, neurologic deficit was 1 of 24 (4%) versus 14 of 68 (21%) (p = 0.061); for aortic clamp times equal to or greater than 45 minutes, neurologic deficit was 3 of 21 (14%) versus 21 of 44 (48%) (p = 0.0090). CONCLUSION Neurologic deficit in patients treated for types I and II TAAA was reduced significantly by perioperative cerebral spinal fluid drainage and distal aortic perfusion.
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Affiliation(s)
- H J Safi
- Baylor College of Medicine, Methodist Hospital, Houston, TX
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Wisselink W, Becker MO, Nguyen JH, Money SR, Hollier LH. Protecting the ischemic spinal cord during aortic clamping: the influence of selective hypothermia and spinal cord perfusion pressure. J Vasc Surg 1994; 19:788-95; discussion 795-6. [PMID: 8170032 DOI: 10.1016/s0741-5214(94)70003-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE We verified the hypothesis that selective deep hypothermia of the spinal cord during double thoracic aortic clamping can prevent postoperative paraplegia in dogs. METHODS Normal saline solution was circulated from the cisterna magna through an extracorporeal perfusion system consisting of a reservoir, a pump, and a heat exchanger, back into the subarachnoid space at the level of the medullary cone at a rate of 25 ml/min, starting 30 minutes before clamping, and ending after removal of the clamps. The thoracic aorta was cross-clamped below the left subclavian artery and above the diaphragm for a period of 45 minutes. Cerebrospinal fluid, intracranial, and central venous pressure and aortic pressure proximal, between, and distal to the clamps were continuously recorded. In five dogs, temperature of the circulating normal saline solution at the inflow level was maintained at 2 degrees +/- 1.5 degrees C (group 1), in five controls at 37 degrees +/- 0.8 degrees C (group 2). Five dogs underwent continuous cerebrospinal fluid drainage starting before clamping until sacrifice (group 3). Dogs were observed for up to 4 days, and neurologic function was graded by an independent observer with the Tarlov scale. Animals were then killed, and their spinal cords were prepared for microscopic examination. RESULTS Hemodynamic parameters were not significantly different between groups. All dogs in groups 2 and 3 were paraplegic with histologic evidence of spinal cord infarction. All animals in group 1 were neurologically normal without microscopic evidence of infarction (p < 0.005). CONCLUSIONS Selective deep hypothermia of the spinal cord prevents paraplegia after 45 minutes of double aortic clamping in dogs. Cerebrospinal fluid drainage was not effective in preventing paraplegia in this model.
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Affiliation(s)
- W Wisselink
- Department of Surgery, Ochsner Clinic, New Orleans, Louisiana
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Salzano RP, Ellison LH, Altonji PF, Richter J, Deckers PJ. Regional deep hypothermia of the spinal cord protects against ischemic injury during thoracic aortic cross-clamping. Ann Thorac Surg 1994; 57:65-70; discussion 71. [PMID: 8279921 DOI: 10.1016/0003-4975(94)90366-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We tested in pigs the hypothesis that regional deep hypothermia of the spinal cord achieved by cerebrospinal fluid cooling will protect against ischemic injury during thoracic aortic cross-clamping. Eight control animals underwent aortic cross-clamping at the distal aortic arch and just above the diaphragm for 30 minutes. Eight experimental animals had placement of two subarachnoid perfusion catheters through laminectomies at T4 and the lower lumbar region. The subarachnoid space was perfused with normal saline solution at 6 degrees C delivered by gravity infusion, with infusion rates adjusted to maintain cord temperatures at less than 20 degrees C. After 30 minutes of aortic cross-clamping, the infusion was stopped and the cord allowed to warm to body temperature. Hind limb neurologic function was graded by Tarlov's scale. All of the animals in the control group had complete hind limb paraplegia (Tarlov grade 0) postoperatively. Seven of the 8 animals in the experimental group had preservation of hind limb motor function (Tarlov grade 2), and 1 animal had complete hind limb paraplegia (Tarlov grade 0) (p = 0.002, Fisher's exact test). We conclude that regional deep hypothermia of the spinal cord in pigs does provide some protection from ischemic injury during thoracic aortic cross-clamping. Clinically this may be a useful adjunct for prevention of paraplegia during thoracic aortic operations.
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Affiliation(s)
- R P Salzano
- Department of Surgery, Hartford Hospital, Connecticut
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Thoracoabdominal aortic aneurysms with special reference to technical problems and complications. "The Marstrand Workshop-group". EUROPEAN JOURNAL OF VASCULAR SURGERY 1993; 7:725-30. [PMID: 7903646 DOI: 10.1016/s0950-821x(05)80725-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Mutch WA, Graham MR, Halliday WC, Teskey JM, Thomson IR. Paraplegia following thoracic aortic cross-clamping in dogs. No difference in neurological outcome with a barbiturate versus isoflurane. Stroke 1993; 24:1554-9; discussion 1559-60. [PMID: 8378961 DOI: 10.1161/01.str.24.10.1554] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND PURPOSE We compared the incidence and severity of paraplegia following thoracic aortic cross-clamping in dogs for two anesthetic regimens. Animals were randomly assigned to receive methohexital (group M; n = 9) or isoflurane (group I; n = 9). We expected a better neurological outcome in animals administered methohexital because of superior neuronal protection and greater spinal cord perfusion pressure (mean arterial pressure below the cross-clamp site minus mean cerebrospinal fluid pressure). METHODS After surgical preparation and a 30-minute stabilization period, dogs in group M received 14 +/- 6 mg.kg-1 i.v. methohexital to induce an isoelectric electroencephalogram followed by a continuous infusion of methohexital at 20 mg.kg-1 x h-1. Dogs in group I received 1.4 +/- 0.2% end-tidal isoflurane (1 minimum alveolar concentration). The thoracic aorta was then occluded 2.5 cm distal to the left subclavian artery for 30 minutes and then released. Hemodynamics and cerebrospinal fluid pressure were measured at (1) baseline, (2) 2 minutes after aortic cross-clamping, (3) 20 minutes after aortic cross-clamping, (4) 5 minutes after aortic unclamping, and (5) 30 minutes after resuscitation. At 24 hours a neurological assessment was performed. After the clinical assessment the dogs were killed and the spinal cord removed immediately for histopathologic study. RESULTS There were no differences in nasopharyngeal temperature, PaCO2, pH, or hemoglobin at any time between groups. With cross-clamping, the spinal cord perfusion pressure decreased precipitously. However, there was no difference in spinal cord perfusion pressure between groups at any time (P = .5555). The neurological outcome, assessed at 24 hours after thoracic aortic cross-clamping by a veterinarian unaware of the anesthetic protocol, was not different between groups (P > .5, two-tailed Mann-Whitney rank-sums test). When anesthetized with methohexital 5 of 9 dogs were paraplegic; with isoflurane 7 of 9 dogs were paraplegic. By Spearman's rank test, a strong inverse correlation between the Tarlov score and the ratio of dead to total lumbar anterior spinal cord neurons was seen (Spearman's correlation coefficient = -.8358; P = .0001). CONCLUSIONS We conclude that no advantage was offered by the choice of anesthesia to neurological outcome after 30 minutes of thoracic aortic cross-clamping in this canine model.
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Affiliation(s)
- W A Mutch
- Department of Anesthesia, Faculty of Medicine, University of Manitoba, Winnipeg, Canada
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Seibel P, Theodore P, Kron IL, Tribble CG. Regional adenosine attenuates postischemic spinal cord injury. J Vasc Surg 1993. [DOI: 10.1016/0741-5214(93)90594-c] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- S A Shenaq
- Department of Anesthesiology and Surgery, Baylor College of Medicine, Houston, TX 77030
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Hollier LH, Money SR, Naslund TC, Proctor CD, Buhrman WC, Marino RJ, Harmon DE, Kazmier FJ. Risk of spinal cord dysfunction in patients undergoing thoracoabdominal aortic replacement. Am J Surg 1992; 164:210-3; discussion 213-4. [PMID: 1415916 DOI: 10.1016/s0002-9610(05)81072-4] [Citation(s) in RCA: 182] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The records of 150 consecutive patients undergoing thoracoabdominal aortic replacement from 1980 to 1991 were retrospectively reviewed. There were 89 men and 61 women; mean age was 67.8 years (range: 33 to 88 years). Since June 1989, a multimodality prospective perioperative protocol was used to reduce the risk of spinal cord dysfunction. Ischemia is minimized by complete intercostal reimplantation whenever possible, cerebrospinal fluid drainage, and maintenance of proximal hypertension during cross-clamping. Spinal cord metabolism is reduced by moderate hypothermia, high-dose barbiturates, and avoidance of hyperglycemia. Reperfusion injury is minimized by the use of mannitol, steroids, and calcium channel blockers. Ninety-seven percent of patients survived long enough for evaluation of their neurologic function. Spinal cord dysfunction was reduced from 6 of 108 (6%) in the preprotocol group to 0 of 42 in the protocol group (0%) (p less than 0.01). The overall 30-day operative mortality was not significantly different between the groups (9% versus 12%, p = NS). A multimodality protocol appears to be effective in reducing the risk of spinal cord injury during thoracoabdominal aortic replacement.
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Affiliation(s)
- L H Hollier
- Department of Surgery, Alton Ochsner Medical Foundation, New Orleans, Louisiana
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Shenaq SA, Svensson LG. Con: cerebrospinal fluid drainage does not afford spinal cord protection during resection of thoracic aneurysms. J Cardiothorac Vasc Anesth 1992; 6:369-72. [PMID: 1611005 DOI: 10.1016/1053-0770(92)90159-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- S A Shenaq
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX 77030
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