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von Aspern K, Haunschild J, Garbade J, Etz CD. Near-Infrared Spectroscopy for Spinal Cord Monitoring-A Roadmap to Translational Research in Aortic Medicine. AORTA (STAMFORD, CONN.) 2023; 11:145-151. [PMID: 37949108 PMCID: PMC11038735 DOI: 10.1055/s-0043-1772774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 07/19/2023] [Indexed: 11/12/2023]
Abstract
Extensive aortic aneurysms represent a unique challenge necessitating interdisciplinary efforts for safe and effective treatment. Despite various adjunctive neuroprotective strategies, ischemic spinal cord injury remains a devastating complication. This article describes the implementation of collateral network near-infrared spectroscopy as the first noninvasive spinal cord monitoring modality in the setting of extensive open and endovascular aortic repair, from early conceptualization to clinical utilization. Potential capabilities and remaining uncertainties based on current evidence are outlined and discussed.
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Affiliation(s)
| | - Josephina Haunschild
- Leipzig Heart Center, University Department for Cardiac Surgery, Leipzig, Saxony, Germany
| | - Jens Garbade
- Department for Cardiothoracic Surgery, Klinikum Links der Weser, Bremen, Germany
| | - Christian D. Etz
- Leipzig Heart Center, University Department for Cardiac Surgery, Leipzig, Saxony, Germany
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Rescigno G, Banfi C, Rossella C, Nazari S. Hemodynamic Patterns of Spinal Cord Perfusion in Thoracoabdominal Aortic Aneurysm Repair. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2021; 9:45-55. [PMID: 34619803 PMCID: PMC8526146 DOI: 10.1055/s-0041-1725121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Paraplegia in aortic surgery is due to its impact on spinal cord perfusion whose hemodynamic patterns (SCPHP) are not clearly defined. Detailed morphological analysis of vascular network and collateral network modifications within Monro-Kellie postulate due to the fixed theca confines was performed to identify SCPHP. SCPHP may begin with intraspinal "backflow" (I-BF), that is, hemorrhage from anterior and posterior spinal arteries, backward via the connected anterior and posterior radicular medullary arteries, through the increasing diameter and decreasing resistance of segmental arteries (SAs), off their aortic orifices outside vascular network at 0 operative field pressure. The I-BF blood bypasses both intra- and extraspinal capillary networks and causes depressurization (0 diastolic pressure) and full ischemia of dependent spinal cord. When the occlusion of those SAs orifices arrests I-BF, the hemodynamic pattern of intraspinal "steal" (I-S) may take place. The formerly I-BF blood, in fact, is now variably shared between the fraction maintained in its physiological intraspinal network and that keeping flowing as I-S through the extraspinal capillary network. I-S is, however, counteracted by the extraspinal "steal" from the connected mammary/paraspinous-independent extraspinal feeders, all physically competing for the same room left by the missed physiological SA direct aortic blood inflow. Steal phenomenon evolves within the 120-hour time frame of CNm, whose intraspinal anatomical changes may offer the physical basis within the Monro-Kelly postulate, respectively of the intraoperative and postoperative paraplegia. The current procedures could not prevent the unphysiological SCPHP but awareness of details of their various features may offer the basis for improvements tailored, to the adopted intra- and postoperative procedures.
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Affiliation(s)
| | - Carlo Banfi
- Foundation Alexis Carrel, Basiglio, Milan, Italy
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Evaluation of collateral network near-infrared spectroscopy during and after segmental artery occlusion in a chronic large animal model. J Thorac Cardiovasc Surg 2019; 158:155-164.e5. [DOI: 10.1016/j.jtcvs.2018.11.105] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 11/25/2018] [Accepted: 11/26/2018] [Indexed: 11/19/2022]
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von Aspern K, Haunschild J, Simoniuk U, Kaiser S, Misfeld M, Mohr FW, Borger MA, Etz CD. Optimal occlusion pattern for minimally invasive staged segmental artery coil embolization in a chronic porcine model. Eur J Cardiothorac Surg 2019; 56:126-134. [DOI: 10.1093/ejcts/ezy463] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 11/20/2018] [Accepted: 12/10/2018] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
Minimally invasive staged segmental artery coil- and plug embolization (MIS2ACE) has been introduced for spinal cord injury prevention prior to open or endovascular thoraco-abdominal aortic aneurysm repair. To date, no optimal pattern has been developed. The aim of this study was to identify the optimal MIS2ACE occlusion pattern.
METHODS
Twenty-five juvenile pigs were randomly assigned to 3 MIS2ACE occlusion patterns (2 stages) and a control group [single-stage segmental artery (SA) occlusion, N = 7]. The first pattern started with occlusion of all lumbar segmental arteries in the first stage and the remaining thoracic arteries in the second stage (regional pattern, N = 6). In group 2, an alternating approach with occlusion of every other SA in the first stage and the remainder in the second stage was used (alternating pattern, N = 6). The third pattern started with occluding the watershed area between thoracic level 12 and lumbar level 2 in the first stage and the remaining arteries in the second stage (watershed pattern, N = 6). Neurological assessment at 6-h intervals and spinal cord tissue perfusion measurements via microspheres at 6 time points were performed. At the end of the experiments, the spinal cord was histopathologically examined.
RESULTS
An average of 6 ± 2 coils were used per SA. In the control group a total of 57% (N = 4) of animals experienced permanent paraplegia, 1 animal (16%) of the alternating and watershed intervention group suffered from permanent paraplegia. Animals from the staged regional pattern did not experience permanent paraplegia. Furthermore, no evidence of significant tissue damage was observed (P < 0.05 vs control). Tissue perfusion of the lumbar spinal cord in the regional pattern group recovered within 3 days after the second stage to 89.2 ± 47 percent-of-baseline (P = 0.393), whereas mean perfusion of the other 2 intervention groups and the control remained significantly lower compared to the baseline (35.7 ± 16%, 30.2 ± 11% and 63.2 ± 19, P < 0.05).
CONCLUSIONS
This study provides evidence that MIS2ACE (minimally invasive staging) may result in less ischaemic spinal cord injury and favourable neurological outcomes compared to complete (1 stage) SA occlusion. A regional-based occlusion pattern (starting with the lumbar segmental arteries) seems to be the best 2-stage approach.
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Affiliation(s)
- Konstantin von Aspern
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
- University of Leipzig, Saxonian Incubator for Clinical Translation (SIKT), Leipzig, Germany
| | - Josephina Haunschild
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
- University of Leipzig, Saxonian Incubator for Clinical Translation (SIKT), Leipzig, Germany
| | - Urszula Simoniuk
- University of Leipzig, Saxonian Incubator for Clinical Translation (SIKT), Leipzig, Germany
| | - Sven Kaiser
- University of Leipzig, Medical Faculty, Leipzig, Germany
| | - Martin Misfeld
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Friedrich W Mohr
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Michael A Borger
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Christian D Etz
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
- University of Leipzig, Saxonian Incubator for Clinical Translation (SIKT), Leipzig, Germany
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