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Aru RG, Stonko DP, Tan LT, Sorber RA, Hicks CW, Black JH. Utility of motor-evoked potentials in contemporary open thoracoabdominal aortic repair. J Vasc Surg 2024:S0741-5214(24)00984-4. [PMID: 38614141 DOI: 10.1016/j.jvs.2024.04.022] [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: 02/26/2024] [Revised: 03/31/2024] [Accepted: 04/07/2024] [Indexed: 04/15/2024]
Abstract
OBJECTIVE Paraplegia remains one of the major complications of contemporary open thoracoabdominal aortic aneurysm (TAAA) repair. Intraoperative motor-evoked potentials (MEPs) act as a surrogate measure for spinal cord homeostasis. The purpose of this study was to evaluate the results of intraoperative neuromonitoring in contemporary TAAA repair and its association with postoperative spinal cord ischemia (SCI). METHODS Patients who underwent open type 2 or 3 TAAA or completion aortic repair using intraoperative neuromonitoring were identified between May 2006 and November 2023. Patient demographics, comorbidities, indication for the procedure, procedural details, and outcomes were recorded. The groups were divided based on type of repair, and univariate statistics were then used to evaluate the association of these metrics vs the type of repair. RESULTS Seventy-nine patients underwent open type 2 (N = 41) and 3 (N = 23) TAAA and completion aortic (N = 15; open in 14 and endovascular in 1) repairs by a single surgeon. The cohort was predominantly male (N = 48, 60.8%) with a mean age of 52.5 ± 16.2 years. There was a high incidence of hypertension (N = 53, 67.1%), smoking history (N = 42, 53.1%), and connective tissue disorders (N = 37, 46.8%). Operative indications included dissection-related (N = 50, 63.3%) and degenerative (N = 26, 32.9%) TAAA and dissection-related malperfusion (N = 3, 3.8%). Left heart bypass was often (N = 73, 92.4%) used for distal aortic perfusion, and cerebrospinal fluid drainage (N = 77, 97.5%) was a common adjunct. MEPs were classified as no change (N = 43, 54.4%), reversible change (N = 26, 32.9%), irreversible change (N = 4, 5.1%), and unreliable (N = 6, 7.6%). MEP changes were predominantly bilateral (N = 70, 88.6%) and occurred most often during repair of the abdominal aortic segment (N = 13, 16.5%). The median number of replaced vertebral levels was associated with MEP changes (P = .013). SCI was only observed in repairs greater than 6 replaced vertebral levels with an overall frequency of 17.7%. It was most prevalent in completion aortic repairs (26.7%). Immediate and delayed SCI occurred in 10.1% and 7.6% of patients, respectively; it was most commonly (71.8%) reversible. Permanent paraplegia occurred in four patients (5.1%), with equal immediate and delayed onsets. MEPs demonstrated poor sensitivity (53.9%) and specificity (62.3%) for SCI; however, there was a high negative predictive value (86.4%) in this population. In-hospital mortality occurred in five (6.3%) patients. CONCLUSIONS No changes in intraoperative MEPs are highly predictive of spinal cord homeostasis. The number of replaced vertebral levels and previous aortic repair should guide intraoperative neuroprotective measures including intercostal reimplantation and should take precedence over intraoperative monitoring, especially when MEP changes occur.
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Affiliation(s)
- Roberto G Aru
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David P Stonko
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Li T Tan
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebecca A Sorber
- Division of Vascular Surgery, University of Washington, Seattle, WA
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
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Busch DR, Lin W, Goh CC, Gao F, Larson N, Wahl J, Bilfinger TV, Yodh AG, Floyd TF. Towards rapid intraoperative axial localization of spinal cord ischemia with epidural diffuse correlation monitoring. PLoS One 2021; 16:e0251271. [PMID: 33970932 PMCID: PMC8109798 DOI: 10.1371/journal.pone.0251271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/23/2021] [Indexed: 11/19/2022] Open
Abstract
Spinal cord ischemia leads to iatrogenic injury in multiple surgical fields, and the ability to immediately identify onset and anatomic origin of ischemia is critical to its management. Current clinical monitoring, however, does not directly measure spinal cord blood flow, resulting in poor sensitivity/specificity, delayed alerts, and delayed intervention. We have developed an epidural device employing diffuse correlation spectroscopy (DCS) to monitor spinal cord ischemia continuously at multiple positions. We investigate the ability of this device to localize spinal cord ischemia in a porcine model and validate DCS versus Laser Doppler Flowmetry (LDF). Specifically, we demonstrate continuous (>0.1Hz) spatially resolved (3 locations) monitoring of spinal cord blood flow in a purely ischemic model with an epidural DCS probe. Changes in blood flow measured by DCS and LDF were highly correlated (r = 0.83). Spinal cord blood flow measured by DCS caudal to aortic occlusion decreased 62%. This monitor demonstrated a sensitivity of 0.87 and specificity of 0.91 for detection of a 25% decrease in flow. This technology may enable early identification and critically important localization of spinal cord ischemia.
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Affiliation(s)
- David R. Busch
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Neurology, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Wei Lin
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, United States of America
| | - Chia Chieh Goh
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, United States of America
| | - Feng Gao
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Nicholas Larson
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Joseph Wahl
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Thomas V. Bilfinger
- Department of Surgery, Stony Brook University, Stony Brook, New York, United States of America
| | - Arjun G. Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Thomas F. Floyd
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Department of Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- * E-mail:
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Khachatryan Z, Haunschild J, von Aspern K, Borger MA, Etz CD. Ischemic spinal cord injury - experimental evidence and evolution of protective measures. Ann Thorac Surg 2021; 113:1692-1702. [PMID: 33434541 DOI: 10.1016/j.athoracsur.2020.12.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 11/19/2020] [Accepted: 12/22/2020] [Indexed: 11/01/2022]
Abstract
BACKGROUND Paraplegia remains one of the most devastating complications of descending and thoracoabdominal aortic repair. The aim of this review is to outline the current state of art in the rapidly developing field of spinal cord injury (SCI) research. METHODS A review of PubMed and Web of Science databases was performed using the following terms and their combinations: spinal cord, injury, ischemia, ischemia-reperfusion, ischemic spinal cord injury, paraplegia, paraparesis. Articles published before July 2019 were screened and included if considered relevant. RESULTS The review focuses on the topic of SCI and the developments concerning methods of monitoring, diagnostics and prevention of SCI. CONCLUSIONS Translation of novel technologies from bench to bedside and into everyday clinical practice is challenging, however each of the developing areas hold great promise in SCI prevention.
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Affiliation(s)
- Zara Khachatryan
- University Department for Cardiac Surgery, Leipzig Heart Center, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Josephina Haunschild
- University Department for Cardiac Surgery, Leipzig Heart Center, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Konstantin von Aspern
- University Department for Cardiac Surgery, Leipzig Heart Center, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Michael A Borger
- University Department for Cardiac Surgery, Leipzig Heart Center, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Christian D Etz
- University Department for Cardiac Surgery, Leipzig Heart Center, Struempellstrasse 39, 04289 Leipzig, Germany.
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Coselli JS, Green SY, Price MD, Zhang Q, Preventza O, de la Cruz KI, Whitlock R, Amarasekara HS, Woodside SJ, Perez-Orozco A, LeMaire SA. Spinal cord deficit after 1114 extent II open thoracoabdominal aortic aneurysm repairs. J Thorac Cardiovasc Surg 2020; 159:1-13. [PMID: 30904252 DOI: 10.1016/j.jtcvs.2019.01.120] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 01/22/2019] [Accepted: 01/25/2019] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Crawford extent II repairs are the most extensive thoracoabdominal aortic aneurysm operations and pose the greatest risk of postoperative spinal cord deficit. We sought to examine spinal cord deficit after open extent II thoracoabdominal aortic aneurysm repair to identify predictors of the most serious type: persistent paraplegia or paraparesis. METHODS We included 1114 extent II thoracoabdominal aortic aneurysm repairs performed from 1991 to 2017. Intercostal/lumbar artery reattachment (n = 959, 86.1%) and cerebrospinal fluid drainage (n = 698, 62.7%) were used to mitigate the risk of postoperative spinal cord deficit. We used univariate and multivariable analyses to examine spinal cord deficit and identify predictors of persistent paraplegia or paraparesis, defined as paraplegia or paraparesis present at the time of early death or hospital discharge. RESULTS Spinal cord deficit developed after 151 (13.6%) repairs: 86 (7.7%) cases of persistent paraplegia or paraparesis (51 paraplegia; 35 paraparesis) and 65 (6.1%) cases of transient paraplegia or paraparesis. Patients with spinal cord deficit were older (median 68 vs 65 years, P < .001) and had more rupture (6.6% vs 2.2%, P = .002) and urgent/emergency repair (25.2% vs 16.9%, P = .01) than those without. Persistent paraplegia or paraparesis developed immediately in 47 patients (4.2%) and was delayed in 39 patients (3.5%). Urgent/emergency repair (relative risk ratio, 2.31; P = .002), coronary artery disease (relative risk ratio, 1.80, P = .01), and chronic symptoms (relative risk ratio, 1.76, P = .02) independently predicted persistent paraplegia or paraparesis. Reattaching intercostal/lumbar arteries (relative risk ratio, 0.38, P < .001) and heritable disease (relative risk ratio, 0.36, P = .01) were protective. Early and late survival were poorer in those with persistent paraplegia or paraparesis than in those without. CONCLUSIONS Spinal cord deficit after extent II thoracoabdominal aortic aneurysm repairs remains concerning; survival is worse in patients with persistent paraplegia or paraparesis. The complexity of spinal cord deficit and persistent paraplegia or paraparesis warrant further study.
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Affiliation(s)
- Joseph S Coselli
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Matt D Price
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Qianzi Zhang
- Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
| | - Kim I de la Cruz
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
| | - Richard Whitlock
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Hiruni S Amarasekara
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Sandra J Woodside
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | | | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex.
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Harky A, Fok M, Fraser H, Howard C, Rimmer L, Bashir M. Could Cerebrospinal Fluid Biomarkers Offer Better Predictive Value for Spinal Cord Ischaemia Than Current Neuromonitoring Techniques During Thoracoabdominal Aortic Aneurysm Repair - A Systematic Review. Braz J Cardiovasc Surg 2019; 34:464-471. [PMID: 31454201 PMCID: PMC6713370 DOI: 10.21470/1678-9741-2018-0375] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Objective Cerebrospinal fluid (CSF) drainage is a technique that has significantly
reduced the incidence of spinal cord ischaemia (SCI). We present results of
a systematic review to assess the literature on this topic in relation to
thoracoabdominal aortic aneurysm repair (TAAR). Methods Major medical databases were searched to identify papers related to CSF
biomarkers measured during TAAAR. Results Fifteen papers reported measurements of CSF biomarkers with 265 patients in
total. CSF biomarkers measured included S-100ß, neuron-specific
endolase (NSE), lactate, glial fibrillary acidic protein A (GFPa), Tau, heat
shock protein 70 and 27 (HSP70, HSP27), and proinflammatory cytokines.
Lactate and S-100ß were reported the most, but did not correlate with
SCI, which was also the case with NSE and TAU. GFPa showed significant CSF
level rises, both intra and postoperative in patients who suffered SCI and
warrants further investigation, similar results were seen with HSP70, HSP27
and IL-8. Conclusions Although there is significant interest in this topic, there still remains a
significant lack of high-quality studies investigating CSF biomarkers during
TAAR to detect SCI. A large and multicentre study is required to identify
the significant role of each biomarker.
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Affiliation(s)
- Amer Harky
- Liverpool Heart and Chest Hospital Department of Cardiothoracic Surgery Liverpool UK Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Matthew Fok
- Royal Liverpool Hospital Department of Vascular Surgery Liverpool UK Department of Vascular Surgery, Royal Liverpool Hospital, Liverpool, UK
| | - Holly Fraser
- University of Liverpool School of Medicine Liverpool UK School of Medicine, University of Liverpool, Liverpool, UK
| | - Callum Howard
- University of Manchester Faculty of Biology, Medicine and Health Manchester UK Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Lara Rimmer
- University of Liverpool School of Medicine Liverpool UK School of Medicine, University of Liverpool, Liverpool, UK
| | - Mohamad Bashir
- Manchester Royal Infirmary Department of Aortovascular Surgery Manchester UK Department of Aortovascular Surgery, Manchester Royal Infirmary, Manchester, UK
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Bignami E, Di Lecce M, Baciarello M, Bellini V, Fanelli M, D'Ospina RM, Perini P, Freyrie A. Direct Intraoperative Neurologic Assessment to Monitor Spinal Cord Ischemia During Thoracoabdominal Aneurysm Endovascular Repair. J Cardiothorac Vasc Anesth 2019; 33:2775-2780. [PMID: 30898423 DOI: 10.1053/j.jvca.2019.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/04/2019] [Accepted: 02/07/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Marco Di Lecce
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Marco Baciarello
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Valentina Bellini
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Mara Fanelli
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Maggiore Hospital, Parma, Italy
| | - Rita Maria D'Ospina
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Maggiore Hospital, Parma, Italy
| | - Paolo Perini
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Maggiore Hospital, Parma, Italy
| | - Antonio Freyrie
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Maggiore Hospital, Parma, Italy
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Parotto M, Ouzounian M, Djaiani G. Spinal Cord Protection in Elective Thoracoabdominal Aortic Procedures. J Cardiothorac Vasc Anesth 2019; 33:200-208. [DOI: 10.1053/j.jvca.2018.05.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Indexed: 11/11/2022]
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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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9
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So V, Poon C. Intraoperative neuromonitoring in major vascular surgery. Br J Anaesth 2016; 117 Suppl 2:ii13-ii25. [DOI: 10.1093/bja/aew218] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2016] [Indexed: 11/14/2022] Open
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Fok M, Jafarzadeh F, Sancho E, Abello D, Rimmer L, Howard C, Kennedy T, Hammoud I, Bashir M. Is There Any Benefit of Neuromonitoring during Descending and Thoracoabdominal Aortic Aneurysm Repair? INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015. [DOI: 10.1177/155698451501000509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Matthew Fok
- School of Built Environment, Liverpool John Moores University, Liverpool, UK
- Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Fatemeh Jafarzadeh
- Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Elena Sancho
- Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - David Abello
- Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Lara Rimmer
- Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Callum Howard
- Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Tom Kennedy
- Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Ibrahim Hammoud
- Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Mohamad Bashir
- Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK
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Is There Any Benefit of Neuromonitoring during Descending and Thoracoabdominal Aortic Aneurysm Repair? INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015; 10:342-8. [DOI: 10.1097/imi.0000000000000187] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective Paraplegia remains the most feared and a devastating complication after descending and thoracoabdominal aneurysm operative repair (DTA and TAAAR). Neuromonitoring, particularly use of motor-evoked potentials (MEPs), for this surgery has gained popularity. However, ambiguity remains regarding its use and benefit. We systematically reviewed the literature to assess the benefit and applicability of neuromonitoring in DTA and TAAAR. Methods Electronic searches were performed on 4 major databases from inception until February 2014 to identify relevant studies. Eligibility decisions, method quality, data extraction, and analysis were performed according to predefined clinical criteria and end points. Results Among the studies matching our inclusion criteria, 1297 patients had MEP monitoring during DTA and TAAAR. In-hospital mortality was low (6.9% ± 3.6). Immediate neurological deficit was low (3.5% ± 2.6). In one third of patients (30.4% ± 14.2), the MEPs dropped below threshold, which were 30.4% and 29.4% with threshold levels of 75% and 50%, respectively. A range of surgical techniques were applied after reduction in MEPs. Most patients whose MEPs dropped and remained below threshold had immediate permanent neurological deficit (92.0% ± 23.6). Somatosensory-evoked potentials were reported in one third of papers with little association between loss of somatosensory-evoked potentials and permanent neurological deficit (16.7% ± 28.9%). Conclusions We demonstrate that MEPs are useful at predicting paraplegia in patients who lose their MEPs and do not regain them intraoperatively. To date, there is no consensus regarding the applicability and use of MEPs. Current evidence does not mandate or support MEP use.
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Fleissner F, Redwan A, Bisdas T, Boeck AL, Weissenborn K, Haverich A, Teebken OE, Pichlmaier M, Martens A. Intraoperative Changes in Cerebrospinal Fluid Gas Tensions Reflect Paraplegia During Thoracoabdominal Aortic Surgery. Vasc Endovascular Surg 2015; 49:84-92. [DOI: 10.1177/1538574415595210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: In this study, gas tensions in cerebrospinal fluid (CSF) were prospectively evaluated as intraoperative markers for the detection of neurological deficits. Methods: Spinal fluid, serum, and heart lung machine (HLM) perfusate were monitored for gas tensions (po2/pCo2) and related parameters (pH, lactate, and glucose) during thoracoabdominal aortic repair and correlated with perioperative neurological examination and electrophysiological testing. Results: Forty-seven patients were assessed for the study, and 40 consecutive patients were finally included. The patients were divided into 3 groups: group A (23 patients, 57.5%): no clinical or laboratory signs of neurological damage; group B (14 patients, 35%) who developed subclinical deficits; and group C (3 patients, 7.5%) who had paraplegia. Significant intraoperative changes in CSF gas tensions were observed with postoperative paraplegia. Glucose ratio between serum and CSF showed higher variability in group C, confirming a damage of the blood–brain barrier (BBB). Conclusion: Major neurological damage is reflected by early changes in CSF gas tensions and glucose variability, suggesting damage of the BBB in these patients.
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Affiliation(s)
- Felix Fleissner
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Ahmed Redwan
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Theodosios Bisdas
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Anna-Lena Boeck
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Axel Haverich
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Omke E. Teebken
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Maximilian Pichlmaier
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilian-University, Munich
| | - Andreas Martens
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Spinal Near-Infrared Spectroscopy Measurements During and After Thoracoabdominal Aortic Aneurysm Repair: A Pilot Study. Ann Thorac Surg 2015; 99:1267-74. [DOI: 10.1016/j.athoracsur.2014.10.032] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 10/02/2014] [Accepted: 10/07/2014] [Indexed: 11/17/2022]
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Sloan TB, Edmonds HL, Koht A. Intraoperative Electrophysiologic Monitoring in Aortic Surgery. J Cardiothorac Vasc Anesth 2013; 27:1364-73. [DOI: 10.1053/j.jvca.2012.09.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2012] [Indexed: 11/11/2022]
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15
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Doering N, Legido-Quigley H, Glinos IA, McKee M, Maarse H. A success-story in cross-border telemedicine in Europe: The use of intra-operative teleneuromonitoring during aorta surgery. HEALTH POLICY AND TECHNOLOGY 2013. [DOI: 10.1016/j.hlpt.2012.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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16
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Awad H, Elgharably H, Popovich PG. Role of induced hypothermia in thoracoabdominal aortic aneurysm surgery. Ther Hypothermia Temp Manag 2012; 2:119-37. [PMID: 24716449 DOI: 10.1089/ther.2012.0009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
For more than 50 years, hypothermia has been used in aortic surgery as a tool for neuroprotection. Hypothermia has been introduced into thoracoabdominal aortic aneurysm (TAAA) surgery by many cardiovascular centers to protect the body's organs, including the spinal cord. Numerous publications have shown that hypothermia can prevent immediate and delayed motor dysfunction after aortic cross-clamping. Here, we reviewed the historical application of hypothermia in aortic surgery, role of hypothermia in preclinical studies, cellular and molecular mechanisms by which hypothermia confers neuroprotection, and the role of systemic and regional hypothermia in clinical protocols to reduce and/or eliminate the devastating consequences of ischemic spinal cord injury after TAAA repair.
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Affiliation(s)
- Hamdy Awad
- 1 Department of Anesthesiology, Wexner Medical Center at The Ohio State University , Columbus, Ohio
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Edmonds HL, LeMaire SA. Commentary: Advances in noninvasive perispinal oximetry. J Endovasc Ther 2011; 18:96-7. [PMID: 21314356 DOI: 10.1583/10-3224c.1] [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]
Affiliation(s)
- Harvey L Edmonds
- Department of Anesthesiology & Perioperative Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA.
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Estrera AL, Sheinbaum R, Miller CC, Harrison R, Safi HJ. Neuromonitor-guided repair of thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg 2010; 140:S131-5; discussion S142-S146. [DOI: 10.1016/j.jtcvs.2010.07.058] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Accepted: 07/20/2010] [Indexed: 11/26/2022]
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