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Kelani H, Corps K, Mikula S, Fisher LC, Shalaan MT, Sturgill S, Ziolo MT, Abdel-Rasoul M, Basso DM, Awad H. Mouse Model of Spinal Cord Hypoperfusion with Immediate Paralysis Caused by Endovascular Repair of Thoracic Aortic Aneurysm. Anesthesiology 2023; 138:403-419. [PMID: 36716430 PMCID: PMC10977649 DOI: 10.1097/aln.0000000000004515] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND A clinically relevant mouse model of thoracic endovascular aortic repair-induced ischemic spinal cord injury has been lacking since the procedure was first employed in 1991. The hypothesis was that ligation of mouse intercostal arteries would simulate thoracic endovascular aortic repair-induced ischemic spinal cord injury and behavioral deficit. The aim was to create a mouse model of thoracic endovascular aortic repair-induced spinal cord hypoperfusion by ligating five pairs of mouse intercostal vessels. METHODS Mice were divided into sham (n = 53) and ligation (n = 60) groups. The procedures called for double ligation of three pairs and single ligation of two pairs of thoracic intercostal arteries in adult C57BL/6 mice. A laser Doppler probe was used in vivo on the spinal cords and intercostal arteries to document the extent of arterial ligation and spinal cord hypoperfusion. The Basso Mouse Scale for Locomotion, histological studies, and electron microscopy demonstrated postligation locomotive and histopathological changes. RESULTS Ligation induced a significant and instantaneous drop in blood flow in the intercostal arteries (% change; mean = -63.81; 95% CI, -72.28 to -55.34) and the thoracic spinal cord (% change; mean = -68.55; 95% CI, -80.23 to -56.87). Paralysis onset was immediate and of varying degree, with behavioral deficit stratified into three groups: 9.4% exhibited severe paralysis, 37.5% moderate paralysis, and 53.1% mild paralysis at day 1 (n = 32; P < 0.001). Mild and moderate paralysis was transient, gradually improving over time. Severe paralysis showed no improvement and exhibited a higher mortality rate (83%; n = 15 of 18) compared to moderately (33%; n = 6 of 18) and mildly (24%; n = 6 of 25) paralyzed mice (P < 0.001). The overall ligation group survival rate (84%; n = 46 of 55) was significantly lower than the sham group (100%; n = 48 of 48) with P = 0.003. CONCLUSIONS The mouse model generates reproducible spinal cord hypoperfusion and accompanying histopathological ischemic spinal cord damage. The resulting anatomical changes and variable behavioral deficits mimic the variability in radiological and clinical findings in human patients. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Hesham Kelani
- Anesthesiology Department, The Ohio State University, Columbus, Ohio
| | - Kara Corps
- Department of Veterinary Biosciences, The Ohio State University, Columbus, Ohio
| | - Sarah Mikula
- Center for Electron Microscopy and Analysis, The Ohio State University, Columbus, Ohio
| | - Lesley C Fisher
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio
| | - Mahmoud T Shalaan
- Department of Emergency Medicine, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Sarah Sturgill
- Dorothy M. Davis Heart and Lung Research Institute, Department of Physiology and Cell Biology, The Ohio State University, Columbus, Ohio
| | - Mark T Ziolo
- Dorothy M. Davis Heart and Lung Research Institute, Department of Physiology and Cell Biology, The Ohio State University, Columbus, Ohio
| | - Mahmoud Abdel-Rasoul
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio
| | - D Michele Basso
- Neuroscience Department, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio
| | - Hamdy Awad
- Anesthesiology Department, The Ohio State University, Columbus, Ohio
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Ellauzi H, Arora H, Elefteriades JA, Zaffar MA, Ellauzi R, Popescu WM. Cerebrospinal Fluid Drainage for Prevention of Spinal Cord Ischemia in Thoracic Endovascular Aortic Surgery-Pros and Cons. AORTA (STAMFORD, CONN.) 2022; 10:290-297. [PMID: 36539146 PMCID: PMC9767776 DOI: 10.1055/s-0042-1757792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 04/14/2022] [Indexed: 06/17/2023]
Abstract
Thoracic endovascular aortic repair (TEVAR) carries a risk of spinal cord ischemia (SCI) which exerts a devastating impact on patient's quality of life and life expectancy. Although routine prophylactic cerebrospinal fluid (CSF) drainage is not unequivocally supported by current data, several studies have demonstrated favorable outcomes. Patients at high risk for SCI following TEVAR likely will benefit from prophylactic CSF drains. However, the intervention is not risk free, and thorough risk/benefit analysis should be individualized to each patient.
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Affiliation(s)
- Hesham Ellauzi
- Aortic Institute at Yale New-Haven, Department of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
- Department of Surgery, Istishari Hospital, Amman, Jordan
| | - Harendra Arora
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - John A. Elefteriades
- Aortic Institute at Yale New-Haven, Department of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Mohammad A. Zaffar
- Aortic Institute at Yale New-Haven, Department of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Rama Ellauzi
- Department of Surgery, Istishari Hospital, Amman, Jordan
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan.
| | - Wanda M. Popescu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
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Awad H, Efanov A, Rajan J, Denney A, Gigax B, Kobalka P, Kelani H, Basso DM, Bozinovski J, Tili E. Histological Findings After Aortic Cross-Clamping in Preclinical Animal Models. J Neuropathol Exp Neurol 2021; 80:895-911. [PMID: 34534333 PMCID: PMC8783616 DOI: 10.1093/jnen/nlab084] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Spinal cord ischemic injury and paralysis are devastating complications after open surgical repair of thoracoabdominal aortic aneurysms. Preclinical models have been developed to simulate the clinical paradigm to better understand the neuropathophysiology and develop therapeutic treatment. Neuropathological findings in the preclinical models have not been comprehensively examined before. This systematic review studies the past 40 years of the histological findings after open surgical repair in preclinical models. Our main finding is that damage is predominantly in the grey matter of the spinal cord, although white matter damage in the spinal cord is also reported. Future research needs to examine the neuropathological findings in preclinical models after endovascular repair, a newer type of surgical repair used to treat aortic aneurysms.
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Affiliation(s)
- Hamdy Awad
- From the Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Alexander Efanov
- From the Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Jayanth Rajan
- From the Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Andrew Denney
- From the Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Bradley Gigax
- From the Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Peter Kobalka
- Department of Pathology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Hesham Kelani
- From the Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - D Michele Basso
- Department of Neuroscience, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, USA
| | - John Bozinovski
- Division of Cardiac Surgery, Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Esmerina Tili
- From the Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
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4
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Awad H, Tili E, Nuovo G, Kelani H, Ramadan ME, Williams J, Binzel K, Rajan J, Mast D, Efanov AA, Rasul KB, Moore S, Basso M, Mikhail A, Eltobgy M, Malbrue RA, Bourekas E, Oglesbee M, Bergdall V, Knopp M, Michaille JJ, El-Sayed H. Endovascular repair and open repair surgery of thoraco-abdominal aortic aneurysms cause drastically different types of spinal cord injury. Sci Rep 2021; 11:7834. [PMID: 33837260 PMCID: PMC8035135 DOI: 10.1038/s41598-021-87324-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 03/22/2021] [Indexed: 01/26/2023] Open
Abstract
Both endovascular repair (EVR) and open repair (OR) surgery of thoraco-abdominal aortic aneurysms cause spinal cord (SC) injury that can lead to paraparesis or paraplegia. It has been assumed that mechanisms responsible for SC damage after EVR are similar to those after OR. This pilot study compared the pathophysiology of SC injury after EVR versus OR using a newly developed EVR dog model. An increasing number of stents similar to those used in patients were inserted in the aorta of three dogs to ensure thoracic or thoracic plus lumbar coverage. The aorta of OR dogs was cross-clamped for 45 min. Behavior assessment demonstrated unique patterns of proprioceptive ataxia and evolving paraparesis in EVR versus irreversible paraplegia in OR. MRI showed posterior signal in lumbar SC after EVR versus central cord edema after OR. Histopathology showed white matter edema in L3-L5 localized to the dorsal column medial lemniscus area associated with loss of myelin basic protein but not neurons after EVR, versus massive neuronal loss in the gray matter in L3-L5 after OR. Metabolome analysis demonstrates a distinctive chemical fingerprint of cellular processes in both interventions. Our results call for the development of new therapeutics tailored to these distinct pathophysiologic findings.
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Affiliation(s)
- Hamdy Awad
- Department of Anesthesiology, Wexner Medical Center, College of Medicine, The Ohio State University, 410 W. 10th Ave, Columbus, OH, 43210, USA.
| | - Esmerina Tili
- Department of Anesthesiology, Wexner Medical Center, College of Medicine, The Ohio State University, 410 W. 10th Ave, Columbus, OH, 43210, USA
- Department of Cancer Biology and Genetics, College of Medicine, Wexner Medical Center, The Ohio State University, 460 W 10th Ave, Columbus, OH, 43210, USA
| | - Gerard Nuovo
- Phylogeny, 1476 Manning Pkwy, Powell, OH, 43065, USA
| | - Hesham Kelani
- Department of Anesthesiology, Wexner Medical Center, College of Medicine, The Ohio State University, 410 W. 10th Ave, Columbus, OH, 43210, USA
| | | | - Jim Williams
- Phylogeny, 1476 Manning Pkwy, Powell, OH, 43065, USA
| | - Katherine Binzel
- Department of Radiology, Wexner Medical Center, College of Medicine, The Ohio State University, 410 W. 10th Ave, Columbus, OH, 43210, USA
| | - Jayanth Rajan
- Department of Anesthesiology, Wexner Medical Center, College of Medicine, The Ohio State University, 410 W. 10th Ave, Columbus, OH, 43210, USA
| | - David Mast
- ECMO Coordinator, Wexner Medical Center, The Ohio State University, Columbus, OH, 43210, USA
| | - Alexander A Efanov
- Department of Anesthesiology, Wexner Medical Center, College of Medicine, The Ohio State University, 410 W. 10th Ave, Columbus, OH, 43210, USA
| | - Kareem B Rasul
- Department of Anesthesiology and Perioperative Medicine, University Hospitals, Cleveland, OH, 44106, USA
| | - Sarah Moore
- Department of Veterinary Clinical Sciences, The Ohio State University, 601 Vernon Tharp St., Columbus, OH, 43210, USA
| | - Michele Basso
- School of Health and Rehabilitation Sciences, The Ohio State University, 106A Atwell Hall, 453 W. 10th Ave., Columbus, OH, 43210, USA
| | - Adel Mikhail
- Phylogeny, 1476 Manning Pkwy, Powell, OH, 43065, USA
| | - Mostafa Eltobgy
- Department of Anesthesiology, Wexner Medical Center, College of Medicine, The Ohio State University, 410 W. 10th Ave, Columbus, OH, 43210, USA
| | - Raphael A Malbrue
- Department of Veterinary Preventive Medicine, University Laboratory Animal Resources, The Ohio State University, 111 Wiseman Hall, 400 West 12th Avenue, Columbus, OH, 43210, USA
| | - Eric Bourekas
- Department of Radiology, Wexner Medical Center, College of Medicine, The Ohio State University, 410 W. 10th Ave, Columbus, OH, 43210, USA
| | - Michael Oglesbee
- Department of Veterinary Biosciences, The Ohio State University, 205 Goss Laboratory, 1925 Coffey Rd, Columbus, OH, 43210, USA
| | - Valerie Bergdall
- Department of Veterinary Preventive Medicine, University Laboratory Animal Resources, The Ohio State University, 111 Wiseman Hall, 400 West 12th Avenue, Columbus, OH, 43210, USA
| | - Michael Knopp
- Department of Radiology, Wexner Medical Center, College of Medicine, The Ohio State University, 410 W. 10th Ave, Columbus, OH, 43210, USA
| | - Jean-Jacques Michaille
- Department of Cancer Biology and Genetics, College of Medicine, Wexner Medical Center, The Ohio State University, 460 W 10th Ave, Columbus, OH, 43210, USA
- BioPerox-IL, Faculté des Sciences Gabriel, Université de Bourgogne-Franche Comté, 6 Bd. Gabriel, 21000, Dijon, France
| | - Hosam El-Sayed
- Department of Surgery, Division of Vascular and Endovascular Surgery, Eastern Virginia Medical School, 600 Gresham Dr, Norfolk, VA, 23507, USA
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Busch DR, Lin W, Cai C, Cutrone A, Tatka J, Kovarovic BJ, Yodh AG, Floyd TF, Barsi J. Multi-Site Optical Monitoring of Spinal Cord Ischemia during Spine Distraction. J Neurotrauma 2020; 37:2014-2022. [PMID: 32458719 DOI: 10.1089/neu.2020.7012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Optimal surgical management of spine trauma will restore blood flow to the ischemic spinal cord. However, spine stabilization may also further exacerbate injury by inducing ischemia. Current electrophysiological technology is not capable of detecting acute changes in spinal cord blood flow or localizing ischemia. Further, alerts are delayed and unreliable. We developed an epidural optical device capable of directly measuring and immediately detecting changes in spinal cord blood flow using diffuse correlation spectroscopy (DCS). Herein we test the hypothesis that our device can continuously monitor blood flow during spine distraction. Additionally, we demonstrate the ability of our device to monitor multiple sites along the spinal cord and axially resolve changes in spinal cord blood flow. DCS-measured blood flow in the spinal cord was monitored at up to three spatial locations (cranial to, at, and caudal to the distraction site) during surgical distraction in a sheep model. Distraction was halted at 50% of baseline blood flow at the distraction site. We were able to monitor blood flow with DCS in multiple regions of the spinal cord simultaneously at ∼1 Hz. The distraction site had a greater decrement in flow than sites cranial to the injury (median -40 vs. -7%,). This pilot study demonstrated high temporal resolution and the capacity to axially resolve changes in spinal cord blood flow at and remote from the site of distraction. These early results suggest that this technology may assist in the surgical management of spine trauma and in corrective surgery of the spine.
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Affiliation(s)
- David R Busch
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas, USA.,Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas, Texas, USA
| | - Wei Lin
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Chunyu Cai
- Department of Pathology, University of Texas Southwestern, Dallas, Texas, USA
| | - Alissa Cutrone
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, Tennessee, USA
| | - Jakub Tatka
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York, USA
| | - Brandon J Kovarovic
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Arjun G Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas F Floyd
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas, USA.,Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern, Dallas, Texas, USA.,Department of Radiology, University of Texas Southwestern, Dallas, Texas, USA
| | - James Barsi
- Department of Orthopedic Surgery, Stony Brook University, Stony Brook, New York, USA
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6
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Mousa AY, Morcos R, Broce M, Bates MC, AbuRahma AF. New Preoperative Spinal Cord Ischemia Risk Stratification Model for Patients Undergoing Thoracic Endovascular Aortic Repair. Vasc Endovascular Surg 2020; 54:487-496. [PMID: 32495704 DOI: 10.1177/1538574420929135] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Our objective was to determine significant predictors of spinal cord ischemia (SCI) following Thoracic Endovascular Aortic Repair (TEVAR) and to further develop a simple and clinically orientated risk score model. METHODS A retrospective review of data from the Society of Vascular Surgery/Vascular Quality Initiative national data set was performed for all patients undergoing TEVAR from January, 2014 to June 2018. Preoperative demographics, procedure-related variables, and clinical details related to SCI were examined. A SCI risk score was developed utilizing a multivariable logistic regression model. RESULTS For the 7889 patients in the final analysis who underwent TEVAR during the study period, the mean age was 67.6 ± 13.9, range 18 to 90 years, and the majority was male (65%). Postoperative outcomes included stroke (3.0%), myocardial infarction (2.9%), inhospital mortality (5.4%), transient SCI (1.5%), and permanent SCI (2.1%). Nearly half of the overall cases were performed in high volume centers. Predictors of increased risk for SCI included age by decade (odds ratio [OR]: 1.2), celiac coverage (OR: 1.5), current smoker (OR: 1.6), dialysis (OR: 1.9), 3 or more aortic implanted devices (OR: 1.7), emergent or urgent surgery (OR: 1.5), adjunct aorta-related procedure (OR: 2.5), adjunct not related (OR: 2.6), total estimated length of aortic device (19-31 cm, OR: 1.9 and ≥32 cm, OR: 3.0), ASA class 4 or 5 (OR: 1.6), and procedure time ≥154 minutes (OR: 1.8). Two predictors decreased the risk of SCI, cases from high-volume centers (OR: 0.6) and eGFR ≥ 60 (OR: 0.6). To evaluate the risk score model, probabilities of SCI from the original regression, raw score, and raw score categories resulted in area under the curve statistics of 0.792, 0.786, and 0.738, respectively. CONCLUSIONS Spinal cord ischemia remains one of the most feared complications of TEVAR. Incidence of SCI in this large series of patients with TEVAR was 3.6% with nearly 60% being permanent. The proposed model provides an assessment tool to guide clinical decisions, patient consent process, risk-assessment, and procedural strategy.
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Affiliation(s)
- Albeir Y Mousa
- Department of Surgery, Robert C. Byrd Health Sciences Center/West Virginia University, Charleston Area Medical Center, Vascular Center of Excellence, WV, USA
| | - Ramez Morcos
- Charles E. Schmidt College of Medicine Florida Atlantic University, Boca Raton, FL, USA
| | - Mike Broce
- Center for Health Services and Outcomes Research, Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA
| | - Mark C Bates
- Department of Surgery, Robert C. Byrd Health Sciences Center/West Virginia University, Charleston Area Medical Center, Vascular Center of Excellence, WV, USA
| | - Ali F AbuRahma
- Department of Surgery, Robert C. Byrd Health Sciences Center/West Virginia University, Charleston Area Medical Center, Vascular Center of Excellence, WV, USA
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Ullery BW, Hobbs RD, Cheung AT. Reversible spinal cord ischemia as a complication of acute aortic intramural hematoma. Vascular 2014; 23:427-31. [PMID: 25193357 DOI: 10.1177/1708538114549067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aortic intramural hematoma is a variant of acute aortic dissection characterized by localized hemorrhage into the aortic media causing a separation of the intimal and adventitial layers of the aorta. Malperfusion represents an unusual presenting sign of acute intramural hematoma. Herein, we describe the case of a patient with an acute Type A IMH who developed reversible ischemic spinal cord syndrome after presenting with paraplegia as a consequence of malperfusion. A decision was made to delay operative repair and, instead, emergently apply medical interventions to increase spinal cord perfusion pressure. Medical treatment was effective for the treatment of spinal cord ischemia and operative repair of the intramural hematoma was accomplished after complete recovery of neurologic function. This is the third case ever reported of an intramural hematoma presenting in the form of spinal cord ischemia.
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Affiliation(s)
- Brant W Ullery
- Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Reilly D Hobbs
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Albert T Cheung
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Mesquita RC, D’Souza A, Bilfinger TV, Galler RM, Emanuel A, Schenkel SS, Yodh AG, Floyd TF. Optical monitoring and detection of spinal cord ischemia. PLoS One 2013; 8:e83370. [PMID: 24358279 PMCID: PMC3865183 DOI: 10.1371/journal.pone.0083370] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 11/01/2013] [Indexed: 12/14/2022] Open
Abstract
Spinal cord ischemia can lead to paralysis or paraparesis, but if detected early it may be amenable to treatment. Current methods use evoked potentials for detection of spinal cord ischemia, a decades old technology whose warning signs are indirect and significantly delayed from the onset of ischemia. Here we introduce and demonstrate a prototype fiber optic device that directly measures spinal cord blood flow and oxygenation. This technical advance in neurological monitoring promises a new standard of care for detection of spinal cord ischemia and the opportunity for early intervention. We demonstrate the probe in an adult Dorset sheep model. Both open and percutaneous approaches were evaluated during pharmacologic, physiological, and mechanical interventions designed to induce variations in spinal cord blood flow and oxygenation. The induced variations were rapidly and reproducibly detected, demonstrating direct measurement of spinal cord ischemia in real-time. In the future, this form of hemodynamic spinal cord diagnosis could significantly improve monitoring and management in a broad range of patients, including those undergoing thoracic and abdominal aortic revascularization, spine stabilization procedures for scoliosis and trauma, spinal cord tumor resection, and those requiring management of spinal cord injury in intensive care settings.
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Affiliation(s)
- Rickson C. Mesquita
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Institute of Physics, University of Campinas, Campinas, São Paulo, Brazil
| | - Angela D’Souza
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, New York, United States of America
- Department of Biomedical Engineering, Stony Brook University Medical Center, Stony Brook, New York, United States of America
| | - Thomas V. Bilfinger
- Department of Surgery, Stony Brook University Medical Center, Stony Brook, New York, United States of America
| | - Robert M. Galler
- Department of Neurosurgery, Stony Brook University Medical Center, Stony Brook, New York, United States of America
| | - Asher Emanuel
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, New York, United States of America
| | - Steven S. Schenkel
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pennsylvania, 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, Stony Brook University Medical Center, Stony Brook, New York, United States of America
- Department of Biomedical Engineering, Stony Brook University Medical Center, Stony Brook, New York, United States of America
- * E-mail:
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9
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Tshomba Y, Melissano G, Logaldo D, Rinaldi E, Bertoglio L, Civilini E, Psacharopulo D, Chiesa R. Clinical outcomes of hybrid repair for thoracoabdominal aortic aneurysms. Ann Cardiothorac Surg 2013; 1:293-303. [PMID: 23977511 DOI: 10.3978/j.issn.2225-319x.2012.07.15] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 07/31/2012] [Indexed: 11/14/2022]
Abstract
BACKGROUND Thoracoabdominal aortic aneurysm (TAAA) hybrid repair consists of aortic visceral branch rerouting followed by TAAA endograft exclusion. This technique has been shown to represent a technically feasible strategy in selected patients. METHODS We analyzed 52 high-risk patients who underwent hybrid TAAA repair between 2001 and 2012 in our centre with a variety of visceral rerouting configurations and of commercially available thoracic endografts. Thirty-seven simultaneous (71.2%) and 15 staged procedures (21.8%) were performed with a four-vessel revascularization in 18 cases (34.6%), a three-vessel revascularization in 11 cases (21.2%) and a two-vessel revascularization in 23 cases (44.2%). RESULTS No intraoperative deaths were observed. We recorded a perioperative mortality rate of 13.5% (n=7), including deaths from multiorgan failure (n=2), myocardial infarction (n=2), coagulopathy (n=1), pancreatitis (n=1) and bowel infarction (n=1). Perioperative morbidity rate was 28.8% (n=15), including 2 cases of transient paraparesis and 1 case of permanent paraplegia. Renal failure (n=5), pancreatitis (n=3), respiratory failure (n=3) and dysphagia (n=1) were also observed. At median follow-up of 23.9 months procedure-related mortality rate was 9.6%: two patients died from visceral graft occlusion and three from aortic rupture. There were three endoleaks and one endograft migration, none of which resulted in death. Five patients (9.6%) died as a consequence of unrelated events. CONCLUSIONS Typical complications of conventional TAAA open surgery have not been eliminated by hybrid repair, and significant mortality and morbidity rates have been recorded. Fate of visceral bypasses and incidence of endoleak and other endograft-related complications needs to be carefully assessed. Hybrid TAAA repair should currently be limited to high-risk surgical patients with unfit anatomy for endovascular repair.
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Affiliation(s)
- Yamume Tshomba
- Department of Vascular Surgery, University Vita-Salute, IRCCS O. San Raffaele, Milan, Italy
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10
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Ullery BW, Quatromoni J, Jackson BM, Woo EY, Fairman RM, Desai ND, Bavaria JE, Wang GJ. Impact of intercostal artery occlusion on spinal cord ischemia following thoracic endovascular aortic repair. Vasc Endovascular Surg 2011; 45:519-23. [PMID: 21576208 DOI: 10.1177/1538574411408742] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate intercostal artery patency following thoracic endovascular aortic repair (TEVAR) and its relationship with spinal cord ischemia (SCI). METHODS Patients with SCI (n = 7) and a matched control cohort (n = 18) were identified from a prospectively maintained database. Radiographic analysis of intercostal patency was assessed using 3-dimensional (3-D)-reconstructed images of pre- and postoperative CT angiograms (1-6 months, 6-12 months, and 1-5 years). RESULTS Patients with SCI had a higher incidence of perioperative hypotension (P < .01) and longer procedure duration (P = .01). While the mean number of patent intercostal arteries at each time interval was not significantly different between groups, both SCI (P = .002) and control (P <.001) groups demonstrated a significant reduction in patent intercostal arteries in the stented area of the aorta following TEVAR. CONCLUSION TEVAR decreases intercostal artery patency in the area of aortic coverage. Our data suggest that intercostal artery patency, in conjunction with perioperative hypotension, is an important contributor to postoperative SCI.
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Affiliation(s)
- Brant W Ullery
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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11
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Dias Perera A, Willis AK, Fernandez JD, Garrett HE, Wolf BA. Staged total exclusion of the aorta for chronic type B aortic dissection. J Vasc Surg 2010; 52:1339-42. [PMID: 20709483 DOI: 10.1016/j.jvs.2010.06.077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Revised: 06/01/2010] [Accepted: 06/05/2010] [Indexed: 11/15/2022]
Abstract
Hybrid techniques using extra-anatomic bypass of critical aortic branches to enable endovascular treatment of complex aortic pathology have been previously described. A staged endograft repair of a complex, chronic Stanford type B aortic dissection with aneurysmal degeneration is reported in a 50-year-old man. The aneurysmal portion of the dissection extended from the distal arch to both common iliac arteries and was covered with an endograft from the ascending aorta to both external iliac arteries. Aortic arch branches, visceral, and renal arteries were bypassed using open technique. The patient had no neurologic complications. This case report illustrates the feasibility of the hybrid technique in selected high-risk patients when confronted with complex aortic pathology.
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Affiliation(s)
- Anton Dias Perera
- Division of Vascular Surgery, University of Tennessee-Memphis, Memphis, Tenn; Cardiovascular Surgery Clinic, PLLC, Memphis, TN 38120, USA
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Is Hybrid Procedure the Best Treatment Option for Thoraco-Abdominal Aortic Aneurysm? Eur J Vasc Endovasc Surg 2009; 38:26-34. [DOI: 10.1016/j.ejvs.2009.03.018] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Accepted: 03/24/2009] [Indexed: 11/21/2022]
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Bicknell C, Riga C, Wolfe J. Prevention of Paraplegia during Thoracoabdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2009; 37:654-60. [DOI: 10.1016/j.ejvs.2009.02.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Accepted: 02/21/2009] [Indexed: 10/20/2022]
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[Traumatic thoracic aorta rupture: preclinical assessment, diagnosis and treatment options]. Anaesthesist 2009; 57:782-93. [PMID: 18463834 DOI: 10.1007/s00101-008-1375-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Traumatic aortic rupture is a life-threatening injury which is frequently associated with blunt thoracic trauma or found coincidentally in heavily traumatized patients. Depending on the degree of disruption of the damaged aortic wall, vascular injury is associated with a high primary mortality rate and a significant risk of secondary aortic rupture. Early clinical signs which may indicate a ruptured thoracic aorta are left sided thoracic pain, reduced ventilation, tachycardia and dyspnoe as well as hypotension in the lower extremities. The primary aim for emergency treatment is to maintain vital organ function and to hemodynamically stabilize the patient. Surgical treatment was previously performed by either direct aortic suture or segmental alloplastic graft interposition using the clamp and sew technique with or without extra-anatomic shunts or extracorporeal circulation. However, endovascular stent graft implantation has now become another treatment option for traumatic aortic rupture. According to the reported data and our own experience there is increasing evidence that endovascular aortic repair might become the treatment of choice for patients with traumatic aortic rupture, with the option of an early, less invasive intervention thus avoiding thoracotomy. Regular follow-up is necessary to detect possible stent graft migration or leakage which could require additional endovascular or open surgical re-interventions.
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Hybrid procedures for thoracoabdominal aortic aneurysms and chronic aortic dissections - a single center experience in 28 patients. J Vasc Surg 2008; 47:724-32. [PMID: 18381133 DOI: 10.1016/j.jvs.2007.12.009] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2007] [Revised: 12/04/2007] [Accepted: 12/06/2007] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We report our 6-year experience with the visceral hybrid procedure for high-risk patients with thoracoabdominal aortic aneurysms (TAAA) and chronic expanding aortic dissections (CEAD). METHODS Hybrid procedure includes debranching of the visceral and renal arteries followed by endovascular exclusion of the aneurysm. A series of 28 patients (20 male, mean age 66 years) were treated between January 2001 and July 2007. Sixteen patients had TAAAs type I-III, one type IV, four thoracoabdominal placque ruptures, and seven patients CEAD. Patients were treated for asymptomatic, symptomatic, and ruptured aortic pathologies in 20, and 4 patients, respectively. Two patients had Marfan's syndrome; 61% had previous infrarenal aortic surgery. The infrarenal aorta was the distal landing zone in 70%. In elective cases, simultaneous approach (n = 9, group I) and staged approach (n = 11, group II) were performed. Mean follow-up is 22 months (range 0.1-78). RESULTS Primary technical success was achieved in 89%. All stent grafts were implanted in the entire thoracoabdominal aorta. Additionally, three patients had previous complete arch vessel revascularization. Left subclavian artery was intentionally covered in three patients (11%). Thirty-day mortality rate was 14.3% (4/28). One patient had a rupture before the staged endovascular procedure and died. Overall survival rate at 3 years was 70%, in group I 80%, and in group II 60% (P = .234). Type I endoleak rate was 8%. Permanent paraplegia rate was 11%. Three patients required long-term dialysis (11%). Peripheral graft occlusion rate was 11% at 30 days. Gut infarction with consecutive bowel resection occurred in two patients. There was no significant difference between group I and II regarding paraplegia and complications. CONCLUSIONS Early results of visceral hybrid repair for high-risk patients with complex and extended TAAAs and CEADs are encouraging in a selected group of high risk patients in whom open repair is hazardous and branched endografts are not yet optional.
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