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Orelaru F, Monaghan K, Ahmad RA, Amin K, Titsworth M, Yang J, Kim KM, Fukuhara S, Patel H, Yang B. Midterm outcomes of open repair versus endovascular descending thoracic aortic aneurysm repair. JTCVS OPEN 2023; 16:25-35. [PMID: 38204619 PMCID: PMC10775111 DOI: 10.1016/j.xjon.2023.09.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/27/2023] [Accepted: 09/12/2023] [Indexed: 01/12/2024]
Abstract
Objective The study objective was to evaluate the midterm outcome of thoracic endovascular aortic repair compared with open repair in patients with descending thoracic aortic aneurysm. Methods From August 1993 to February 2023, 499 patients with descending thoracic aortic aneurysms underwent open repair (n = 221) or thoracic endovascular aortic repair (n = 278). Of these, 120 matched pairs were identified using propensity score matching based on age, sex, chronic lung disease, stroke, coronary artery disease, diabetes, ejection fraction, dialysis, peripheral vascular disease, prior cardiac surgery, connective tissue disease, and chronic dissection. Primary outcomes were postoperative paralysis, operative mortality, reoperation, and midterm survival. Results After matching, the preoperative demographics and comorbidities were balanced in both groups. Intraoperatively, open repair had a lower temperature (18 °C vs 36 °C) and more patients required blood products (66% vs 8%), P < .001. Postoperatively, patients undergoing thoracic endovascular aortic repair had fewer strokes (2.5% vs 9.2%; P = .03), less dialysis (0% vs 3.3%; P = .04), and shorter length of stay (5 days vs 12 days, P < .001), but similar lower-extremity paralysis (2.5% vs 2.5%, P = 1.00) compared with open repair. Furthermore, thoracic endovascular aortic repair had higher 7-year incidence of first reoperation (16.1% vs 3.6%, P < .001) but similar operative mortality (0.8% vs 4.2%; P = .10) and 10-year survival outcome (56%; 95% CI, 43-72 vs 58%; 95% CI, 49-68; P = .55) compared with open aortic repair. The hazard ratio was 0.93 (P = .78) for thoracic endovascular aortic repair for midterm mortality and 6.87 (P < .001) for reoperation. Conclusions Open repair could be the first option for patients with descending thoracic aortic aneurysms who were surgical candidates.
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Affiliation(s)
- Felix Orelaru
- Department of General Surgery, Trinity Health Ann Arbor Hospital, Ann Arbor, Mich
| | - Katelyn Monaghan
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | | | - Kush Amin
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Marc Titsworth
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Jie Yang
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Karen M. Kim
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | | | - Himanshu Patel
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Bo Yang
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
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Schachner T, Gottardi R, Schmidli J, Wyss TR, Van Den Berg JC, Tsilimparis N, Bavaria J, Bertoglio L, Martens A, Czerny M. Practice of neuromonitoring in open and endovascular thoracoabdominal aortic repair-an international expert-based modified Delphi consensus study. Eur J Cardiothorac Surg 2023; 63:ezad198. [PMID: 37252816 DOI: 10.1093/ejcts/ezad198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 04/21/2023] [Accepted: 05/12/2023] [Indexed: 06/01/2023] Open
Abstract
OBJECTIVES Spinal cord injury is detrimental for patients undergoing open or endovascular thoracoabdominal aortic aneurysm (TAAA) repair. The aim of this survey and of the modified Delphi consensus was to gather information on current practices and standards in neuroprotection in patients undergoing open and endovascular TAAA. METHODS The Aortic Association conducted an international online survey on neuromonitoring in open and endovascular TAAA repair. In a first round an expert panel put together a survey on different aspects of neuromonitoring. Based on the answers from the first round of the survey, 18 Delphi consensus questions were formulated. RESULTS A total of 56 physicians completed the survey. Of these, 45 perform open and endovascular TAAA repair, 3 do open TAAA repair and 8 do endovascular TAAA repair. At least 1 neuromonitoring or protection modality is utilized during open TAAA surgery. Cerebrospinal fluid (CSF) drainage was used in 97.9%, near infrared spectroscopy in 70.8% and motor evoked potentials or somatosensory evoked potentials in 60.4%. Three of 53 centres do not utilize any form of neuromonitoring or protection during endovascular TAAA repair: 92.5% use CSF drainage; 35.8%, cerebral or paravertebral near infrared spectroscopy; and 24.5% motor evoked potentials or somatosensory evoked potentials. The utilization of CSF drainage and neuromonitoring varies depending on the extent of the TAAA repair. CONCLUSIONS The results of this survey and of the Delphi consensus show that there is broad consensus on the importance of protecting the spinal cord to avoid spinal cord injury in patients undergoing open TAAA repair. Those measures are less frequently utilized in patients undergoing endovascular TAAA repair but should be considered, especially in patients who require extensive coverage of the thoracoabdominal aorta.
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Affiliation(s)
- Thomas Schachner
- University Clinic of Cardiac Surgery and University Clinic of Vascular Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Roman Gottardi
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Friberg, Germany
| | - Jürg Schmidli
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas R Wyss
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Kantonsspital Winterthur, Department of Interventional Radiology and Vascular Surgery, Winterthur, Switzerland
| | - Jos C Van Den Berg
- Centro Vascolare Ticino, Ospedale Regionale di Lugano, sede Civico Inselspital, Universitätsspital Bern Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie, Switzerland
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig Maximilian University Hospital, Munich, Germany
| | - Joseph Bavaria
- Department of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Luca Bertoglio
- Division of Vascular Surgery, Vita Salute San Raffaele University, IRCCS San Raffaele Scientific Institute Milano, Italy
| | - Andreas Martens
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Friberg, Germany
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Norton EL, Orelaru F, Ahmad RA, Clemence J, Wu X, Kim KM, Fukuhara S, Patel HJ, Yang B. Hypothermic circulatory arrest versus aortic clamping in thoracic and thoracoabdominal aortic aneurysm repair. J Card Surg 2022; 37:4351-4358. [PMID: 36321695 PMCID: PMC9812898 DOI: 10.1111/jocs.17054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/29/2022] [Accepted: 08/25/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND To compare perioperative and midterm outcomes in thoracic and thoraco-abdominal aortic aneurysm (TAA and TAAA) repair using hypothermic circulatory arrest (HCA) or aortic clamping (AC) with mild hypothermia. METHODS From 2012 to 2021 there were 180 open repairs of a TAA or TAAA, of which 90 (50%) were done with HCA and 90 (50%) with aortic clamping with mild hypothermia. The indications for HCA were arch aneurysm, TAA from chronic aortic dissection, and inability to clamp the aorta for proximal anastomosis. RESULTS Compared to AC, the HCA group had less prior descending aorta replacement/repair (9.1% vs. 32%, p = 0.0001). Intraoperatively, the HCA group had more TAAs (70% vs. 20%, p < 0.0001) while the AC group had more TAAAs (80% vs. 30%, p < 0.0001). HCA group had longer cardiopulmonary bypass times (242 vs. 181 min, p < 0.0001) but shorter cross-clamp time (39 vs. 120 min, p < 0.0001) and lower temperatures (18°C vs. 34°C, p < 0.0001). Postoperatively, the HCA group had longer intubation times (31 vs. 26 h, p = 0.002), but all other postoperative outcomes including paralysis (2.2% vs. 8.9%, p = 0.08), and operative mortality (4.4% vs. 2.2%, p = 0.68) were similar between HCA and AC groups. Patient age was an independent risk factor for postoperative paralysis (OR 1.07, p = 0.03) while HCA was not significant (OR 0.37, p = 0.21). Five-year survival was similar between HCA and AC groups (85% vs. 80%, p = 0.36). CONCLUSIONS Postoperative outcomes and midterm survival were acceptable in thoracic and thoracoabdominal aneurysm patients after HCA or AC. Both HCA and AC with mild hypothermia were valid approaches in TAA/A repair.
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Affiliation(s)
- Elizabeth L Norton
- Department of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - Felix Orelaru
- Department of General Surgery, St. Joseph Mercy, Ann Arbor, Michigan
| | | | - Jeffrey Clemence
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Karen M Kim
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Shinichi Fukuhara
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Himanshu J Patel
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Bo Yang
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
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Huang L, Chen X, Hu Q, Luo F, Hu J, Duan L, Wang E, Ye Z, Zhang C. The application of modular multifunctional left heart bypass circuit system integrated with ultrafiltration in thoracoabdominal aortic aneurysm repair. Front Cardiovasc Med 2022; 9:944287. [PMID: 36211541 PMCID: PMC9534546 DOI: 10.3389/fcvm.2022.944287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
Open thoracoabdominal aortic aneurysm (TAAA) repair is a complex and challenging operation with a high incidence of serious complications, and high perioperative mortality and morbidity. Left heart bypass (LHB) is a circulatory support system used to perfuse the distal aorta during TAAA operation, and the advantages of LHB include guaranteeing distal perfusion, reducing the use of heparin, and diminishing the risk of bleeding and postoperative neurological deficits. In China, the circuit for TAAA repair is deficient, and far from the perfusion requirements. We designed a modular multifunctional LHB circuit for TAAA repair. The modular circuit consisted of cannulation pipelines, functional consumables connection pipelines, and accessory pipelines. The accessory pipelines make up lines for selective visceral perfusion and kidney perfusion, suckers and rapid infusion. The circuit can be assembled according to surgical requirements. The ultrafilter and heat exchanger are integrated into the circuit to fulfill the basic demands of LHB. The LHB circuit also has pipelines for selective visceral perfusion to the celiac artery and superior mesenteric artery and renal perfusion pipelines. Meanwhile, the reserved pipelines facilitate the quick switch from LHB to conventional cardiopulmonary bypass (CPB). The reserved pipelines reduce the time of reassembling the CPB circuit. Moreover, the rapid infusion was integrated into the LHB circuit, which can rapid infusion when massive hemorrhage during the open procedures such as exposure and reconstruction of the aorta. The ultrafiltration can diminish the consequent hemodilution of hemorrhage and rapid infusion. A hemoperfusion cartridge also can be added to reduce the systemic inflammatory during operation. The circuit can meet the needs of LHB and quickly switch to conventional CPB. No oxygenator was required during LHB, which reduce the use of heparin and reduce the risk of bleeding. The heat exchanger contributes to temperature regulation; ultrafiltration, arterial filter, and rapid-infusion facilitated the blood volume management and are useful to maintain hemodynamic stability. This circuit made the assembly of the LHB circuit more easily, and more efficient, which may contribute to the TAAA repair operation performed in lower volume centers easily. 26 patients who received TAAA repair under the modular multifunctional LHB from January 2018-March 2022 were analyzed, and we achieved acceptable clinical outcomes. The in-hospital mortality and 30-day postoperative mortality were 15.4%, and the postoperative incidences of paraparesis (4%), stroke (4%), and AKI need hemodialysis (12%) were not particularly high, based on the limited patients sample size in short research period duration.
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Affiliation(s)
- Lingjin Huang
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Xuliang Chen
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Qinghua Hu
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Fanyan Luo
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Jiajia Hu
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Lian Duan
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - E. Wang
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Zhi Ye
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Chengliang Zhang
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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Ibrahim M, Chung JCY, Lindsay TF, Ouzounian M. Commentary: Cerebrospinal fluid drainage: One component of a successful distal aortic surgery program. JTCVS Tech 2021; 6:11-12. [PMID: 34318129 PMCID: PMC8300974 DOI: 10.1016/j.xjtc.2021.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 12/30/2020] [Accepted: 01/05/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Marina Ibrahim
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C-Y Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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Currie LA. Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management. Crit Care Nurse 2020; 40:75-80. [PMID: 33257969 DOI: 10.4037/ccn2020684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Linda Ann Currie
- Linda Ann Currie is a clinical nurse specialist in the cardiac surgery intensive care unit at the Virginia Commonwealth University Health System, Richmond, Virginia
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Kunihara T, Vukic C, Sata F, Schäfers HJ. Surgical Thoracoabdominal Aortic Aneurysm Repair in a Non-High-Volume Institution. Thorac Cardiovasc Surg 2020; 69:347-356. [PMID: 32279303 DOI: 10.1055/s-0040-1708470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Surgical thoracoabdominal aortic aneurysm (TAAA) repair remains challenging. Apart from mortality, spinal cord injury (SCI) is a dreaded complication. We analyzed our experience to identify predictors for SCI in a nonhigh-volume institution. PATIENTS AND METHODS All patients who underwent TAAA repair between February 1996 and November 2016 (n = 182) were enrolled. Most were male (n = 121; 66.4%), median age was 68 years (range: 21-84). Elective operations were performed in 153 instances (84.1%). Our approach to minimize SCI includes distal aortic perfusion, mild hypothermia, identification of the Adamkiewicz artery, and sequential aortic clamping. Cerebrospinal fluid drainage was introduced in 2001 and liberal use of selective visceral perfusion in 2006. RESULTS Early mortality was 12.1%; it was 8.5% after elective procedures. Reduced left ventricular function, nonelective setting, older age, and longer bypass time were identified as independent predictors for mortality in multivariable logistic regression model. Permanent SCI was observed in nine patients (4.9%), of whom seven (3.8%) developed paraplegia. In a multivariable logistic regression model for paraplegia, peripheral arterial disease (PAD), Crawford type II repair, smaller body surface area, and era before 2001 were identified as independent predictors, whereas only PAD was significant for SCI. The incidence of paraplegia was 13.8% in extensive repair out of the first 91 cases, whereas it was improved up to 2.7% thereafter. CONCLUSION Using an integrated approach, acceptable outcome of TAAA repair can be achieved, even in a nonhigh-volume center. PAD and extensive involvement of the aorta are strong independent predictors for spinal cord deficit after TAAA repair.
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Affiliation(s)
- Takashi Kunihara
- Department of Cardiac Surgery, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Claudia Vukic
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
| | | | - Hans-Jaochim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
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Lee JC, Tae HJ, Cho JH, Kim IS, Lee TK, Park CW, Park YE, Ahn JH, Park JH, Yan BC, Lee HA, Hong S, Won MH. Therapeutic hypothermia attenuates paraplegia and neuronal damage in the lumbar spinal cord in a rat model of asphyxial cardiac arrest. J Therm Biol 2019; 83:1-7. [PMID: 31331507 DOI: 10.1016/j.jtherbio.2019.04.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/24/2019] [Accepted: 04/24/2019] [Indexed: 01/27/2023]
Abstract
Spinal cord ischemia can result from cardiac arrest. It is an important cause of severe spinal cord injury that can lead to serious spinal cord disorders such as paraplegia. Hypothermia is widely acknowledged as an effective neuroprotective intervention following cardiac arrest injury. However, studies on effects of hypothermia on spinal cord injury following asphyxial cardiac arrest and cardiopulmonary resuscitation (CA/CPR) are insufficient. The objective of this study was to examine effects of hypothermia on motor deficit of hind limbs of rats and vulnerability of their spinal cords following asphyxial CA/CPR. Experimental groups included a sham group, a group subjected to CA/CPR, and a therapeutic hypothermia group. Severe motor deficit of hind limbs was observed in the control group at 1 day after asphyxial CA/CPR. In the hypothermia group, motor deficit of hind limbs was significantly attenuated compared to that in the control group. Damage/death of motor neurons in the lumbar spinal cord was detected in the ventral horn at 1 day after asphyxial CA/CPR. Neuronal damage was significantly attenuated in the hypothermia group compared to that in the control group. These results indicated that therapeutic hypothermia after asphyxial CA/CPR significantly reduced hind limb motor dysfunction and motoneuronal damage/death in the ventral horn of the lumbar spinal cord following asphyxial CA/CPR. Thus, hypothermia might be a therapeutic strategy to decrease motor dysfunction by attenuating damage/death of spinal motor neurons following asphyxial CA/CPR.
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Affiliation(s)
- Jae-Chul Lee
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea
| | - Hyun-Jin Tae
- Bio-Safety Research Institute, College of Veterinary Medicine, Chonbuk National University, Chonbuk, Iksan, 54596, Republic of Korea
| | - Jeong Hwi Cho
- Bio-Safety Research Institute, College of Veterinary Medicine, Chonbuk National University, Chonbuk, Iksan, 54596, Republic of Korea
| | - In-Shik Kim
- Bio-Safety Research Institute, College of Veterinary Medicine, Chonbuk National University, Chonbuk, Iksan, 54596, Republic of Korea
| | - Tae-Kyeong Lee
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea
| | - Cheol Woo Park
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea
| | - Young Eun Park
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea
| | - Ji Hyeon Ahn
- Department of Biomedical Science and Research Institute for Bioscience and Biotechnology, Hallym University, Chuncheon, Gangwon, 24252, Republic of Korea
| | - Joon Ha Park
- Department of Biomedical Science and Research Institute for Bioscience and Biotechnology, Hallym University, Chuncheon, Gangwon, 24252, Republic of Korea
| | - Bing Chun Yan
- Institute of Integrative Traditional and Western Medicine, Medical College, Yangzhou University, Yangzhou, Jiangsu, 225001, PR China
| | - Hyang-Ah Lee
- Department of Obstetrics and Gynecology, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea
| | - Seongkweon Hong
- Department of Surgery, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea.
| | - Moo-Ho Won
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea.
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Tenorio ER, Eagleton MJ, Kärkkäinen JM, Oderich GS. Prevention of spinal cord injury during endovascular thoracoabdominal repair. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60. [DOI: 10.23736/s0021-9509.18.10739-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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10
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Mohebali J, Carvalho S, Lancaster RT, Ergul EA, Conrad MF, Clouse WD, Cambria RP, Patel VI. Use of extracorporeal bypass is associated with improved outcomes in open thoracic and thoracoabdominal aortic aneurysm repair. J Vasc Surg 2018; 68:941-947. [DOI: 10.1016/j.jvs.2017.12.072] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 12/21/2017] [Indexed: 11/26/2022]
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11
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Tenorio ER, Mirza AK, Kärkkäinen JM, Oderich GS. Lessons learned and learning curve of fenestrated and branched endografts. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 60:23-34. [PMID: 30221895 DOI: 10.23736/s0021-9509.18.10728-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Fenestrated and branched endovascular repair (F-BEVAR) has been increasingly used to treat patients with complex aortic aneurysms involving the renal-mesenteric arteries. As with any new procedure, there is a learning curve associated with mastering the technique. However, proficiency with deployment is only one aspect of the learning process, and ultimately, this curve is defined not by one quality parameter, but by patient selection, the performance of the entire team, the surgeon's ability to adapt to unexpected events, and the durability of the repair. This article reviews the importance of novel training paradigms, learning curve, and factors affecting outcomes of complex endovascular aneurysm repair.
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Affiliation(s)
- Emanuel R Tenorio
- Division of Vascular and Endovascular Surgery, Mayo Clinic Aortic Center, Rochester, MN, USA
| | - Aleem K Mirza
- Division of Vascular and Endovascular Surgery, Mayo Clinic Aortic Center, Rochester, MN, USA
| | - Jussi M Kärkkäinen
- Division of Vascular and Endovascular Surgery, Mayo Clinic Aortic Center, Rochester, MN, USA
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, Mayo Clinic Aortic Center, Rochester, MN, USA -
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12
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Oderich GS. Evidence of use of multilayer flow modulator stents in treatment of thoracoabdominal aortic aneurysms and dissections. J Vasc Surg 2018; 65:935-937. [PMID: 28342519 DOI: 10.1016/j.jvs.2016.12.092] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 12/22/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Gustavo S Oderich
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
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13
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Waked K, Schepens M. State-of the-art review on the renal and visceral protection during open thoracoabdominal aortic aneurysm repair. J Vis Surg 2018; 4:31. [PMID: 29552513 DOI: 10.21037/jovs.2018.01.12] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 01/10/2018] [Indexed: 12/13/2022]
Abstract
During open thoracoabdominal aortic aneurysm repair (OTAAAR), there is an inevitable organ ischemic period that occurs when the abdominal arteries are being reattached to the aortic graft. Despite various protective techniques, the incidence of renal and visceral complications remains substantial. This state-of-the-art review gives an overview of the current and most evidence-based organ protection methods during OTAAAR, based on the most recent publications and personal experience. An electronic search was performed in four medical databases, using the following MeSH terms: thoracoabdominal aneurysm, TAAAR, visceral protection, renal protection, kidney, perfusion, and intestines. Every publication type was considered. The literature search was ended on August 31st, 2017. The left heart bypass (LHB) is currently the most frequent adjunct to provide distal aortic perfusion (DAP) during aortic clamping. Together with systemic hypothermia, it forms the cornerstone in organ protection during aortic clamping. Further renal protection can be obtained by selective renal perfusion (SRP) with cold blood or cold crystalloid solution, the latter enriched with mannitol. The perfusion should be administered in a volume- and pressure-controlled way and, if possible, by use of a pulsatile pump. Selective visceral perfusion (SVP) is not routinely used, as it does not provide adequate blood flow for visceral protection. The best way to protect the intestines is by minimizing the ischemic time. The preservation of renal and visceral function after OTAAAR can only be obtained with specific strategies before, during, and after the operation. This involves a series of measures, including selective digestive decontamination (SDD), avoidance of nephrotoxic drugs, minimizing the renal and intestinal ischemic time, systemic cooling, avoidance of hemodynamic instability, and regional protective perfusion of the kidneys. Future innovations in catheters, cardiac bypass flow types, mechanical components, hybrid vascular grafts, and pharmaceutical protection measures will hopefully further reduce organ complications.
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Affiliation(s)
- Karl Waked
- Department of Cardiovascular Surgery, AZ Sint Jan Hospital, Brugge, Belgium
| | - Marc Schepens
- Department of Cardiovascular Surgery, AZ Sint Jan Hospital, Brugge, Belgium
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14
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Sueda T, Takahashi S. Spinal cord injury as a complication of thoracic endovascular aneurysm repair. Surg Today 2017; 48:473-477. [PMID: 28921013 DOI: 10.1007/s00595-017-1588-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/17/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Spinal cord ischemia (SCI) is a devastating complication of thoracic aortic aneurysm repair in the era of thoracic endovascular aneurysm repair (TEVAR). This review aims to clarify the causes of SCI during TEVAR and to propose ways that it may be prevented. METHODS AND RESULTS We performed an extensive literature search of SCI during TEVAR. Based on the existing literature, we examined the anatomy of the anterior spinal cord artery, which supplies blood to the anterior aspect of the spinal cord, and discuss reported effective ways to prevent SCI during TEVAR, including augmentation of arterial blood pressure and drainage of cerebrospinal fluid. CONCLUSION After reviewing the mechanism of SCI during TEVAR, we evaluated promising preventative measures.
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Affiliation(s)
- Taijiro Sueda
- Department of Cardiovascular Surgery, Graduate School of Medicine, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Graduate School of Medicine, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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Sugiura J, Oshima H, Abe T, Narita Y, Araki Y, Fujimoto K, Mutsuga M, Usui A. The efficacy and risk of cerebrospinal fluid drainage for thoracoabdominal aortic aneurysm repair: a retrospective observational comparison between drainage and non-drainage. Interact Cardiovasc Thorac Surg 2017; 24:609-614. [PMID: 28108577 DOI: 10.1093/icvts/ivw436] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 11/30/2016] [Indexed: 11/12/2022] Open
Abstract
Objectives We reviewed our experiences with thoracoabdominal aortic aneurysm (TAAA) repair to assess the efficacy of cerebrospinal fluid drainage (CSFD) to prevent the neurological deficits and complications associated with CSFD. Methods Between 2002 and 2015, 118 patients underwent TAAA repair. Seventy-eight patients underwent CSFD for 2.7 ± 1.1 days after surgery. CSFD was not performed for the other 40 patients due to an urgent situation, chronic disseminated intravascular coagulation or anatomical difficulties. Results There were 5 in-hospital deaths (4.2%). The neurological complications included paraplegia ( n = 14, 11.9%), paraparesis ( n = 3, 2.5%), cerebral infarction ( n = 11, 9.3%) and intracranial haemorrhage ( n = 1, 0.85%), none related to CSFD. The complications related to CSFD included headaches ( n = 13, 11.0%), subdural haematoma (which was treated conservatively) ( n = 1, 0.85%), a neurological symptom of the bilateral thighs ( n = 1, 0.85%), pale haemorrhagic discharge ( n = 2, 1.7%) and a fractured catheter ( n = 1, 0.85%). Eight patients had paraplegia and 1 patient had paraparesis among the 78 patients who underwent CSFD (9/78, 11.5%); among the 40 patients who did not undergo CSFD, 6 had paraplegia and 2 had paraparesis (8/40, 20.0%). A multivariate analysis demonstrated that CSFD had a significant protective effect for the spinal cord (odds ratio = 0.045, P = 0.007). Conclusions CSFD effectively prevented spinal cord dysfunction in TAAA repair. However, some serious complications occurred, including subdural haematoma and a fractured catheter. It is therefore important to recognize both the efficacy and the risks of CSFD in TAAA repair.
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Affiliation(s)
- Junya Sugiura
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hideki Oshima
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomonobu Abe
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuji Narita
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshimori Araki
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuro Fujimoto
- Department of Cardiology, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Masato Mutsuga
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Tshomba Y, Leopardi M, Mascia D, Kahlberg A, Carozzo A, Magrin S, Melissano G, Chiesa R. Automated pressure-controlled cerebrospinal fluid drainage during open thoracoabdominal aortic aneurysm repair. J Vasc Surg 2017; 66:37-44. [DOI: 10.1016/j.jvs.2016.11.057] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 11/24/2016] [Indexed: 01/03/2023]
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Touma J, Benamara B, Kobeiter H, Desgranges P. Decision to Interrupt Second-Stage Side-Branch Completion in Thoracoabdominal Branched Aortic Stent Grafting to Prevent Spinal Cord Ischemia. Ann Vasc Surg 2017; 42:303.e1-303.e4. [PMID: 28389286 DOI: 10.1016/j.avsg.2017.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 12/09/2016] [Accepted: 01/11/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Spinal cord ischemia (SCI) is a severe complication of extended endovascular repair of thoracoabdominal aneurysms. We describe voluntary interruption of side-branch completion in staged branched endovascular aneurysm treatment due to uncertainty regarding SCI possible onset, based on intraoperative angiography findings. METHODS We report a case of a staged endovascular treatment of thoracoabdominal aortic aneurysm in a 64-year-old patient using a branched endograft with an additional side branch that allows temporary sac perfusion to prevent SCI. The third operative step was intended to occlude the side branch. Intraoperative angiography through the side branch demonstrated circulating aneurysm sac, with patent inferior intercostal and superior lumbar arteries giving direct blood supply to a clearly visible anterior spinal artery. The procedure was stopped. RESULTS One month later, sac thrombosis occurred spontaneously and was clinically responsible for neurogenic claudication that resolved during follow-up. CONCLUSION Interrupting side-branch completion seems to have allowed additional ischemic conditioning of the spinal cord as the spontaneous sac thrombosis induced mild neurological event.
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Affiliation(s)
- Joseph Touma
- Department of Vascular Surgery, Henri Mondor University Hospital, Créteil, France.
| | - Bachir Benamara
- Department of Vascular Surgery, Henri Mondor University Hospital, Créteil, France
| | - Hicham Kobeiter
- Department of Interventional Radiology, Henri Mondor University Hospital, Créteil, France
| | - Pascal Desgranges
- Department of Vascular Surgery, Henri Mondor University Hospital, Créteil, France
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Nienaber CA, Clough RE. Management of Acute Aortic Syndromes. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] 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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20
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Constantinou J, Kelay A, Mastracci TM. Open surgery for chronic dissection. J Vasc Surg 2016; 63:1377-83. [DOI: 10.1016/j.jvs.2016.01.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 01/17/2016] [Indexed: 10/21/2022]
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Khan NR, Smalley Z, Nesvick CL, Lee SL, Michael LM. The use of lumbar drains in preventing spinal cord injury following thoracoabdominal aortic aneurysm repair: an updated systematic review and meta-analysis. J Neurosurg Spine 2016; 25:383-93. [PMID: 27058497 DOI: 10.3171/2016.1.spine151199] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Paraplegia and paraparesis following aortic aneurysm repair occur at a substantially high rate and are often catastrophic to patients, their families, and the overall health care system. Spinal cord injury (SCI) following open thoracoabdominal aortic aneurysm (TAAA) repair is reported to be as high as 20% in historical controls. The goal of this study was to determine the impact of CSF drainage (CSFD) on SCI following TAAA repair. METHODS In August 2015 a systematic literature search was performed using clinicaltrials.gov , the Cochrane Library, PubMed/MEDLINE, and Scopus that identified 3478 articles. Of these articles, 10 met inclusion criteria. Random and fixed-effect meta-analyses were performed using both pooled and subset analyses based on study type. RESULTS The meta-analysis demonstrated that CSFD decreased SCI by nearly half (relative risk 0.42, 95% confidence interval 0.25-0.70; p = 0.0009) in the pooled analysis. This effect remained in the subgroup analysis of early SCI but did not remain significant in late SCI. CONCLUSIONS This meta-analysis showed that CSFD could be an effective strategy in preventing SCI following aortic aneurysm repair. Care should be taken to prevent complications related to overdrainage. No firm conclusions can be drawn about the newer endovascular procedures at the current time.
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Affiliation(s)
| | - Zachary Smalley
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Cody L Nesvick
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Siang Liao Lee
- Department of Surgery, Metropolitan Group Hospitals, University of Illinois at Chicago, Illinois; and
| | - L Madison Michael
- Department of Neurosurgery.,Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee
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Kim JH. Thoracoabdominal aortic aneurysm (extent II) repair in a patient with systemic vasculitis. J Vis Surg 2016; 2:35. [PMID: 29078463 DOI: 10.21037/jovs.2016.02.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 01/18/2016] [Indexed: 11/06/2022]
Abstract
Conventional open repair is a gold standard for treating thoracoabdominal aortic aneurysm (TAAA) in patients with connective tissue disorders or systemic vasculitis. In a 42-year-old male patient with systemic vasculitis, TAAA extent II open repair was performed at our hospital. Here, we present the case with a video clip and technical tips.
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Affiliation(s)
- Jae Hyun Kim
- Department of Thoracic and Cardiovascular Surgery, Keimyung University Dongsan Medical Center, Daegu, South Korea
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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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Banga PV, Oderich GS, Reis de Souza L, Hofer J, Cazares Gonzalez ML, Pulido JN, Cha S, Gloviczki P. Neuromonitoring, Cerebrospinal Fluid Drainage, and Selective Use of Iliofemoral Conduits to Minimize Risk of Spinal Cord Injury During Complex Endovascular Aortic Repair. J Endovasc Ther 2016; 23:139-149. [DOI: 10.1177/1526602815620898] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Purpose: To review outcomes of continuous motor/somatosensory-evoked potential (MEP/SSEP) monitoring, cerebrospinal fluid drainage, and selective use of iliofemoral conduits in patients undergoing endovascular repair of descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysms (TAAAs). Methods: The clinical data of 49 patients (mean age 75±8 years; 38 men) who underwent endovascular repair of DTA and TAAAs (2011–2014) were reviewed. All patients had cerebrospinal fluid drainage, permissive hypertension (mean arterial pressure ≥80 mm Hg), and MEP/SSEP monitoring. There were 44 (90%) patients with TAAAs and 5 (10%) with DTA. Types I and II TAAAs were repaired in staged procedures. Iliofemoral conduits were used for small iliac arteries and to minimize time of lower extremity ischemia in patients with difficult anatomy. In patients with changes in MEP/SSEPs, a standardized protocol was employed to optimize spinal cord perfusion and restore lower extremity blood flow. Endpoints were mortality, spinal cord injury (SCI), and lower extremity ischemic complications. Results: Sixteen (33%) patients had staged TAAA repair. A total of 163 visceral arteries were targeted by fenestrations and branches (mean 3.7±1.0 vessels/patient). Temporary iliofemoral conduits were used in 16 limbs/14 patients. A stable MEP/SSEP was achieved in all patients. Thirty-one (63%) patients had a ≥75% decrease in MEP/SSEP amplitude in 50 limbs starting on average 75±28 minutes after obtaining vascular access. MEP/SSEP amplitude improved with maneuvers in 12 (39%) patients and returned to baseline with restoration of lower extremity flow in all except 1 patient who developed immediate SCI. Thirty-day mortality was 4%. Three (6%) patients had SCI, 2 permanent and 1 temporary at 14 days. There were no lower extremity ischemic complications. Conclusion: Neuromonitoring predicted immediate SCI and allowed use of a protocol to optimize spinal cord and lower extremity perfusion during complex endovascular aortic repair. Larger clinical experience is needed to evaluate the efficacy of neuromonitoring to prevent SCI.
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Affiliation(s)
- Peter V. Banga
- Advanced Endovascular Aortic Research Program and Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Vascular Surgery, Cardiovascular Center, Semmelweis University, Budapest, Hungary
| | - Gustavo S. Oderich
- Advanced Endovascular Aortic Research Program and Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Leonardo Reis de Souza
- Advanced Endovascular Aortic Research Program and Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Surgery, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Jan Hofer
- Advanced Endovascular Aortic Research Program and Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Juan N. Pulido
- Division of Cardiovascular Anesthesia, Mayo Clinic, Rochester, MN, USA
| | - Stephen Cha
- Department of Epidemiology and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Peter Gloviczki
- Advanced Endovascular Aortic Research Program and Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
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Management of Recurrent Delayed Neurologic Deficit After Thoracoabdominal Aortic Operation. Ann Thorac Surg 2015; 101:346-8. [PMID: 26694274 DOI: 10.1016/j.athoracsur.2015.03.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 03/12/2015] [Accepted: 03/16/2015] [Indexed: 11/22/2022]
Abstract
Delayed neurologic deficit (DND) is a devastating adverse event after thoracoabdominal aortic aneurysm repair. Multiple adjuncts have been devised to counteract the development of DND, most notably cerebrospinal fluid (CSF) drainage. We report a case of a 63-year-old woman in whom DND developed four times during the first 10 days after her thoracoabdominal aortic operation. This necessitated lumbar drain "weaning" to allow for a slowly rising CSF pressure and preservation of lower extremity motor function.
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Etz CD, Weigang E, Hartert M, Lonn L, Mestres CA, Di Bartolomeo R, Bachet JE, Carrel TP, Grabenwöger M, Schepens MA, Czerny M. Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery†. Eur J Cardiothorac Surg 2015; 47:943-57. [DOI: 10.1093/ejcts/ezv142] [Citation(s) in RCA: 173] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
A new appraisal of the management of acute aortic dissection is timely because of recent developments in diagnostic strategies (including biomarkers and imaging), endograft design, and surgical treatment, which have led to a better understanding of the epidemiology, risk factors, and molecular nature of aortic dissection. Although open surgery is the main treatment for proximal aortic repair, use of endovascular management is now established for complicated distal dissection and distal arch repair, and has recently been discussed as a pre-emptive measure to avoid late complications by inducing aortic remodelling.
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Affiliation(s)
| | - Rachel E Clough
- King's College London, Cardiovascular Imaging Department, Lambeth Wing St Thomas, London, UK
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Surgery for thoracic aortic disease in Japan: evolving strategies toward the growing enemies. Gen Thorac Cardiovasc Surg 2014; 63:185-96. [DOI: 10.1007/s11748-014-0476-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Indexed: 01/15/2023]
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Abstract
The management of type B aortic dissection is undergoing profound changes with timely TEVAR accepted as first-line strategy in the setting of complicated dissection; with recent technological advances and in experienced hands this intervention is considered safe and life-saving. With the ability to remodel the dissected aorta as a result of scaffolding even pre-emptive endovascular treatment is being considered and supported by long-term stability and often prevention of aneurysmal expansion. This insight and a growing number of silent risk conditions (resistant hypertension, partial false lumen thrombosis) may lower the threshold for TEVAR in asymptomatic patients in the subacute phase. In the chronic phase of a type B dissection patients are usually free of symptoms, however, with the expanding false lumen at risk of rupture. Advanced TEVAR options (including branches and fenestrations) are likely to be used more often than open surgical replacement of such aneurysmatic segment of the dissected aorta in that chronic phase. All dissection patients should be offered lifelong surveillance.
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Affiliation(s)
- Christoph A Nienaber
- Department of Cardiology, University Heart Centre Rostock, University of Rostock, Rostock, Germany
| | - Dimitar Divchev
- Department of Cardiology, University Heart Centre Rostock, University of Rostock, Rostock, Germany
| | | | - Rachel E Clough
- Cardiovascular Imaging Department, King's College London, London, UK
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Li XQ, Lv HW, Tan WF, Fang B, Wang H, Ma H. Role of the TLR4 pathway in blood-spinal cord barrier dysfunction during the bimodal stage after ischemia/reperfusion injury in rats. J Neuroinflammation 2014; 11:62. [PMID: 24678770 PMCID: PMC3977699 DOI: 10.1186/1742-2094-11-62] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 03/09/2014] [Indexed: 02/06/2023] Open
Abstract
Background Spinal cord ischemia-reperfusion (I/R) involves two-phase injury, including an initial acute ischemic insult and subsequent inflammatory reperfusion injury, resulting in blood-spinal cord barrier (BSCB) dysfunction involving the TLR4 pathway. However, the correlation between TLR4/MyD88-dependent and TLR4/TRIF-dependent pathways in BSCB dysfunction is not fully understood. The aim of this study is to characterize inflammatory responses in spinal cord I/R and the events that define its clinical progression with delayed neurological deficits, supporting a bimodal mechanism of injury. Methods Rats were intrathecally pretreated with TAK-242, MyD88 inhibitory peptide, or Resveratrol at a 12 h interval for 3 days before undergoing 14-minute occlusion of aortic arch. Evan’s Blue (EB) extravasation and water content were detected at 6, 12, 18, 24, 36, 48, and 72 h after reperfusion. EB extravasation, water content, and NF-κB activation were increased with time after reperfusion, suggesting a bimodal distribution, as maximal increasing were detected at both 12 and 48 h after reperfusion. The changes were directly proportional to TLR4 levels determined by Western blot. Double-labeled immunohistochemical analysis was also used to detect the relationship between different cell types of BSCB with TLR4. Furthermore, NF-κB and IL-1β were analyzed at 12 and 48 h to identify the correlation between MyD88-dependent and TRIF-dependent pathways. Results Rats without functional TLR4 and MyD88 attenuated BSCB leakage and inflammatory responses at 12 h, suggesting the ischemic event was largely mediated by MyD88-dependent pathway. Similar protective effects observed in rats with depleted TLR4, MyD88, and TRIF receptor at 48 h infer that the ongoing inflammation which occurred in late phase was mainly initiated by TRIF-dependent pathway and such inflammatory response could be further amplified by MyD88-dependent pathway. Additionally, microglia appeared to play a major role in early phase of inflammation after I/R injury, while in late responding phase both microglia and astrocytes were necessary. Conclusions These findings indicate the relevance of TLR4/MyD88-dependent and TLR4/TRIF-dependent pathways in bimodal phases of inflammatory responses after I/R injury, corresponding with the clinical progression of injury and delayed onset of symptoms. The clinical usage of TLR4 signaling inhibitors at different phases may be a therapeutic option for the prevention of delayed injury.
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Affiliation(s)
| | | | | | | | | | - Hong Ma
- Department of Anesthesiology, First Affiliated Hospital, China Medical University, Shenyang 110001, Liaoning, China.
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Jafarzadeh F, Bashir M, Yan T, Harrington D, Field ML, Kuduvalli M, Oo A, Desmond M. Setting up and utilizing a service for measuring perioperative transcranial motor evoked potentials during thoracoabdominal aortic surgery and thoracic endovascular repair. Interact Cardiovasc Thorac Surg 2014; 18:748-56. [PMID: 24603163 DOI: 10.1093/icvts/ivu036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Paraplegia is a complication that may occur following surgery or endovascular stenting of thoracic and thoracoabdominal aortic pathology. Measuring transcranial motor evoked potentials (tcMEPs) has been shown to provide a reliable measure of spinal cord function during such procedures allowing interventions to protect cord function. In the spirit of sharing experience and eliminating the learning curve for others, this manuscript describes our experience of setting up a service for tcMEP monitoring as well as the documents and algorithms for measuring, recording and acting on the patient data, the so-called 'MEP Pathway'. METHODS Recording and interpretation of tcMEP during thoracoabdominal aortic intervention requires training of staff and close team working in the operating theatre and postoperative intensive care unit. Providing consistent, reliable, specific and sensitive information on spinal cord function and its safe and effective use to alter patient outcomes requires a protocol. The MEP pathway was developed by medical and paramedical staff at our institution based on clinical experience and literature reviews over a 1-year period (2012-2013). RESULTS The tcMEP pathway comprises six documents that guide staff in: (a) assessing suitability of patients, (b) setting up hardware, (c) preparing algorithms for management, (d) documenting intervention (left heart bypass, cardiopulmonary bypass or endovascular stenting) as well as (e) documenting postoperative intensive care processes. CONCLUSIONS The tcMEP pathway acts as a guide for safe introduction and use of tcMEPs in thoracoabdominal aortic interventions. tcMEP-led guidance of intraoperative and postoperative management in thoracic aortic surgery is an important adjunct in caring for this patient group.
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Affiliation(s)
- Fatemeh Jafarzadeh
- Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Mohamad Bashir
- Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Tristan Yan
- Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Deborah Harrington
- Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Mark L Field
- Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Manoj Kuduvalli
- Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Aung Oo
- Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Michael Desmond
- Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
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Wu IH, Chan CY, Liang PC, Huang SC, Chi NS, Wang SS. One-stage Hybrid Repair to Thoracoabdominal Aortic Aneurysm. Ann Vasc Surg 2014; 28:201-8. [DOI: 10.1016/j.avsg.2013.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 04/30/2013] [Accepted: 05/02/2013] [Indexed: 10/26/2022]
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Patel VI, Lancaster RT, Conrad MF, Cambria RP. Open surgical repair of thoracoabdominal aneurysms - the Massachusetts General Hospital experience. Ann Cardiothorac Surg 2013; 1:320-4. [PMID: 23977514 DOI: 10.3978/j.issn.2225-319x.2012.09.02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2012] [Accepted: 09/06/2012] [Indexed: 11/14/2022]
Affiliation(s)
- Virendra I Patel
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Lancaster RT, Conrad MF, Patel VI, Cambria MR, Ergul EA, Cambria RP. Further experience with distal aortic perfusion and motor-evoked potential monitoring in the management of extent I-III thoracoabdominal aortic anuerysms. J Vasc Surg 2013; 58:283-90. [DOI: 10.1016/j.jvs.2013.01.042] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 01/15/2013] [Accepted: 01/16/2013] [Indexed: 10/26/2022]
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Watanabe K, Kawaguchi M, Kitagawa K, Inoue S, Konishi N, Furuya H. Evaluation of the Neuroprotective Effect of Minocycline in a Rabbit Spinal Cord Ischemia Model. J Cardiothorac Vasc Anesth 2012; 26:1034-8. [DOI: 10.1053/j.jvca.2012.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Indexed: 11/11/2022]
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Smith PD, Puskas F, Meng X, Lee JH, Cleveland JC, Weyant MJ, Fullerton DA, Reece TB. The evolution of chemokine release supports a bimodal mechanism of spinal cord ischemia and reperfusion injury. Circulation 2012; 126:S110-7. [PMID: 22965970 DOI: 10.1161/circulationaha.111.080275] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Paraplegia remains a devastating complication of thoracic aortic surgery. The mechanism of the antecedent spinal cord ischemia and reperfusion injury (IR) remains poorly described. IR involves 2 injuries, an initial ischemic insult and subsequent inflammatory amplification of the injury. This mechanism is consistent with the clinical phenomenon of delayed onset paraplegia. This study sought to characterize the inflammatory response in the spinal cord after IR and hypothesized that this would support a bimodal mechanism of injury. METHODS AND RESULTS Male C57Bl/6 mice were subjected to 5 minutes of aortic arch and left subclavian occlusion with subsequent reperfusion to generate spinal cord ischemia. Functional outcomes were scored at 12-hour intervals. Spinal cords were harvested after 0, 6, 12, 18, 24, 36, and 48 hours of reperfusion. Cytokine levels were analyzed using a mouse magnetic bead-based multiplex immunoassay. Inflammatory chemokine concentrations (interleukin [IL]-1β, IL-6, keratinocyte-derived cytokine, macrophage inflammatory protein-1α, monocyte chemotactic protein-1, RANTES, and tumor necrosis factor-α) peaked at 6 hours and 36 to 48 hours after reperfusion. Functional scores reflected initial gain in function with subsequent decline, inversely proportional to cytokine levels. Immunofluorescent staining demonstrated microglia activation at 12 and 48 hours. CONCLUSIONS Spinal cord ischemia and reperfusion injury occurs in 2 phases, correlating to increases in inflammatory chemokines release and microglial activation. These observations chronologically parallel the too-common clinical syndrome of delayed-onset paraplegia. Understanding the molecular pathogenesis of this injury may allow future intervention to prevent this devastating complication.
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Affiliation(s)
- Phillip D Smith
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
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Lobato AC, Camacho-Lobato L. A New Technique to Enhance Endovascular Thoracoabdominal Aortic Aneurysm Therapy—The Sandwich Procedure. Semin Vasc Surg 2012; 25:153-60. [DOI: 10.1053/j.semvascsurg.2012.07.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Degenerative aneurysms of the thoracic aorta are increasing in prevalence; open repair of descending thoracic aortic aneurysms is associated with high rates of morbidity and mortality. Repair of isolated descending thoracic aortic aneurysms using stent grafts was introduced in 1995, and in an anatomically suitable subgroup of patients with thoracic aortic aneurysm, repair with endovascular stent graft provides favorable outcomes, with decreased perioperative morbidity and mortality relative to open repair. The cornerstones of successful thoracic endovascular aneurysm repair are appropriate patient selection, thorough preprocedural planning, and cautious procedural execution, the elements of which are discussed here.
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Affiliation(s)
- Laura K Findeiss
- Department of Radiological Sciences, UCI Medical Center, University of California, Irvine School of Medicine, Orange, California
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Nienaber CA, Kische S, Ince H, Fattori R. Thoracic endovascular aneurysm repair for complicated type B aortic dissection. J Vasc Surg 2011; 54:1529-33. [DOI: 10.1016/j.jvs.2011.06.099] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2011] [Revised: 06/16/2011] [Accepted: 06/25/2011] [Indexed: 11/24/2022]
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Effects of minocycline on hind-limb motor function and gray and white matter injury after spinal cord ischemia in rats. Spine (Phila Pa 1976) 2011; 36:1919-24. [PMID: 21304434 DOI: 10.1097/brs.0b013e3181ffda29] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective, randomized laboratory investigation. OBJECTIVE To investigate whether administration of minocycline attenuates hind-limb motor dysfunction and gray and white matter injury after spinal cord ischemia. SUMMARY OF BACKGROUND DATA Minocycline, a semisynthetic tetracycline antibiotic, has been shown to have neuroprotective effects in models of focal and global cerebral ischemia. However, there have been no data available regarding the effects of minocycline in a model of spinal cord ischemia. METHODS Thirty-six rats were randomly allocated to one of three groups; control (C) group (n = 11), minocycline (M) group (n = 13), or sham group (n = 12). Minocycline or saline was intraperitoneally administered for 3 days beginning at 12 hours before 10 minutes of spinal cord ischemia or sham operation. Spinal cord ischemia was induced with intraaortic balloon catheter and blood withdrawal. Seventy-two hours after reperfusion, hind-limb motor functions were assessed using Basso, Beattie, Bresnahan (BBB) Scale (0 = paraplegia, 21 = normal). For histologic assessments, the gray and white matter injury was evaluated using the number of normal neurons and the extents of vacuolations in the white matter, respectively. Activated microglia was also evaluated using Iba-1 immunohistochemistry. RESULTS BBB scores and the numbers of normal neurons in the M group were significantly higher than those in the C group. The percentage areas of vacuolations in the white matter and the number of Iba-1 positive cells were significantly lower in the M group compared with those in the C group. CONCLUSION The results indicated that minocycline administration improved hind-limb motor function and attenuated gray and white matter injury and microglial activation after spinal cord ischemia in rats.
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Abstract
Acute aortic syndrome (AAS) is a modern term to describe interrelated emergency aortic conditions with similar clinical characteristics and challenges. These conditions include aortic dissection, intramural haematoma (IMH), and penetrating atherosclerotic ulcer (PAU and aortic rupture); trauma to the aorta with intimal laceration may also be considered. The common denominator of AAS is disruption of the media layer of the aorta with bleeding within IMH, along the aortic media resulting in separation of the layers of the aorta (dissection), or transmurally through the wall in the case of ruptured PAU or trauma. Population-based studies suggest that the incidence of acute dissection ranges from 2 to 3.5 cases per 100 000 person-years; hypertension and a variety of genetic disorders with altered connective tissues are the most prevalent risk conditions. Patients with AAS often present in a similar fashion, regardless of the underlying condition of dissection, IMH, PAU, or contained aortic rupture. Pain is the most commonly presenting symptom of acute aortic dissection and should prompt immediate attention including diagnostic imaging modalities (such as multislice computed tomography, transoesophageal ultrasound, or magnetic resonance imaging). Prognosis is clearly related to undelayed diagnosis and appropriate surgical repair in the case of proximal involvement of the aorta; affection of distal segments of the aorta may call for individualized therapeutic approaches favouring endovascular in the presence of malperfusion or imminent rupture, or medical management.
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Affiliation(s)
- Christoph A Nienaber
- Heart Center Rostock, Department of Internal Medicine, University of Rostock, Ernst-Heydemann-Str. 6, 18057 Rostock, Germany.
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Beller C, Kallenbach K, Karck M. Die chirurgische Therapie des thorakoabdominellen Aneurysmas. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2011. [DOI: 10.1007/s00398-011-0864-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Conrad MF, Ergul EA, Patel VI, Cambria MR, LaMuraglia GM, Simon M, Cambria RP. Evolution of operative strategies in open thoracoabdominal aneurysm repair. J Vasc Surg 2011; 53:1195-1201.e1. [DOI: 10.1016/j.jvs.2010.11.055] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Revised: 10/28/2010] [Accepted: 11/06/2010] [Indexed: 10/18/2022]
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Continued favorable results with open surgical repair of type IV thoracoabdominal aortic aneurysms. J Vasc Surg 2011; 53:1492-8. [PMID: 21514769 DOI: 10.1016/j.jvs.2011.01.070] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Revised: 01/25/2011] [Accepted: 01/27/2011] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Type IV thoracoabdominal aortic aneurysm (TAAA) repair, despite low risk of spinal cord ischemia (SCI), is reported to have significant morbidity and mortality. This has led some to apply adjuncts (eg, extracorporeal circulation) used in more extensive TAAA repair or to consider alternative approaches, such as hybrid operations. We have used a consistent, simplified surgical approach to type IV TAAA, and the goal of the present study is to review experience over 2 decades with such treatment and to identify correlates of surgical morbidity. METHODS All type IV repairs at Massachusetts General Hospital from January 1989 through September 2009 were evaluated for clinical features, technical operative details, and 30-day outcomes. Logistic regression identified predictors of morbidity. Survival was assessed using Kaplan-Meier analysis. RESULTS A total of 179 patients underwent type IV repair, with elective repair in 156 (87%) and urgent in 23 (13%). The clamp-and-sew technique was used for all operations, with routine hypothermic renal perfusion. Clinical features were age 73 ± 8 years, coronary artery disease in 89 (50%), and creatinine level >1.8 mg/dL defining chronic renal insufficiency (CRI) in 32 (18%). Operative reconstruction in 166 (93%) consisted of one beveled proximal anastomosis incorporating the descending thoracic aorta, celiac, superior mesenteric artery, and right renal arteries origins (mean visceral clamp time, 36 ± 12 minutes) and a side-arm graft to the left renal artery. Technical details included previous abdominal aortic aneurysm (AAA) repair in 52 (29%), operative time of 290 ± 90 min, estimated blood loss of 2.7 ± 1.4 L, and splenectomy in 57 (32%). The 30-day outcomes were death in 5 (2.8%), myocardial infarction in 6 (3.4%), hemodialysis in 5 (2.8%), and any degree of SCI in 4 (2.2%). Regression analysis identified a history of CRI as an independent predictor of postoperative complication or death (odds ratio, 3.4; 95% confidence interval, 1.4-8). Survival rates at 1, 5, and 10 years were 89% ± 2%, 62% ± 4%, and 36% ± 5%, respectively. CONCLUSIONS A simplified operative approach for type IV TAAA repair is associated with favorable perioperative results. These data refute the need for surgical adjuncts commonly applied in more extensive TAAA and indicate that the hybrid operation is an illogical posture. CRI should figure prominently in clinical decision making. Long-term survival equates that observed after routine AAA repair.
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Sundt TM, Flemming MD, Oderich GS, Torres NE, Li Z, Lenoch J, Kalra M. Spinal Cord Protection During Open Repair of Thoracic and Thoracoabdominal Aortic Aneurysms Using Profound Hypothermia and Circulatory Arrest. J Am Coll Surg 2011; 212:678-83; discussion 684-5. [DOI: 10.1016/j.jamcollsurg.2010.12.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 12/15/2010] [Indexed: 10/18/2022]
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Current strategies for spinal cord protection during thoracic and thoracoabdominal aortic aneurysm repair. Gen Thorac Cardiovasc Surg 2011; 59:155-63. [DOI: 10.1007/s11748-010-0705-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 08/30/2010] [Indexed: 11/26/2022]
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Okita Y. Fighting spinal cord complication during surgery for thoracoabdominal aortic disease. Gen Thorac Cardiovasc Surg 2011; 59:79-90. [DOI: 10.1007/s11748-010-0668-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Indexed: 10/18/2022]
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