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Spratt JR, Walker KL, Neal D, Arnaoutakis GJ, Martin TD, Back MR, Zasimovich Y, Franklin M, Shahid Z, Upchurch GR, Scali ST, Beaver TM. Rescue therapy for symptomatic spinal cord ischemia after thoracic endovascular aortic repair. J Thorac Cardiovasc Surg 2024; 168:15-25.e11. [PMID: 36509568 DOI: 10.1016/j.jtcvs.2022.10.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/11/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) can cause permanent neurologic deficits and poor long-term survival. Targeted treatment of new SCI symptoms after TEVAR (rescue therapy [RT]) might improve/resolve neurologic symptoms but few data characterize the association of specific interventions with SCI outcomes. We evaluated the effectiveness of post-TEVAR RT at our tertiary aortic center. METHODS Our institutional TEVAR database was reviewed for SCI incidence and details of RT. This included cerebrospinal fluid drainage (CSFD), medical therapy, and optimization of spinal cord oxygen delivery. SCI outcomes were categorized at discharge as paralysis/paraparesis and temporary/permanent. RESULTS Nine hundred forty-three TEVAR procedures were performed in 869 patients from 2011 to 2020. Post-TEVAR SCI occurred in 7.8% (n = 74) with permanent paraplegia in 1.5%. Older patient age, chronic obstructive pulmonary disease, and previous abdominal aortic surgery were predictive of SCI. Half (n = 37) of SCI episodes resulted in only temporary paralysis/paraparesis. Rescue postoperative cerebrospinal fluid drains were implanted in 3.7% (n = 35) of procedures and was predicted by higher American Society of Anesthesiologists class, lower serum hemoglobin level, elevated international normalized ratio, bilateral iliac artery occlusion, nonelective procedures, and penetrating atherosclerotic ulcer/intramural hematoma indication. The most commonly used RTs were emergent placement of or increased drainage from an existing cerebrospinal fluid drain (87.8%), induced/permissive hypertension (77.0%), corticosteroid bolus (36.5%), and naloxone infusion (33.8%). Neurologic improvement occurred in 68.9% (n = 51/74). New/increased drainage was associated with improved SCI outcome. CONCLUSIONS Permanent paraplegia from post-TEVAR SCI is rare (1.5%). Older patients with comorbidities carry greater post-TEVAR SCI risk. SCI symptoms improved/resolved with CSFD and multimodal RT in 68.9% of patients, but no intervention was independently associated with improvement. TEVAR centers should have robust protocols for timely and safe CSFD placement to augment RT strategies for SCI.
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Affiliation(s)
- John R Spratt
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla.
| | - Kristen L Walker
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Dan Neal
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - George J Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Tomas D Martin
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Martin R Back
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - Yury Zasimovich
- Acute and Perioperative Pain Medicine Division, Department of Anesthesia, University of Florida, Gainesville, Fla
| | - Michael Franklin
- Acute and Perioperative Pain Medicine Division, Department of Anesthesia, University of Florida, Gainesville, Fla
| | - Zain Shahid
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - Gilbert R Upchurch
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
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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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Kelly H, Herman D, Loo K, Narangoli A, Watson E, Berlant C, Huerta M, Labak CM, Zhou X. Recognition of Significantly Delayed Spinal Cord Ischemia Following Thoracic Endovascular Aortic Repair: A Case Report and Review of the Literature. Cureus 2024; 16:e51522. [PMID: 38304669 PMCID: PMC10831204 DOI: 10.7759/cureus.51522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2023] [Indexed: 02/03/2024] Open
Abstract
Spinal cord ischemia (SCI) is an uncommon but serious complication of thoracic endovascular aortic repair (TEVAR). SCI after TEVAR is thought to result from decreased segmental blood supply to an important network of collateral blood flow in the spinal cord. Little is known about the prevalence and optimal treatment of SCI that occurs beyond the periprocedural period. We report a case of delayed SCI in a 67-year-old patient who underwent TEVAR. The patient presented almost two years after TEVAR with acute paraplegia preceded by pre-syncope. The delayed SCI was likely triggered by pre-syncope, a thrombosed endoleak shown on imaging, and the patient's vascular risk factors. Treatments included cerebrospinal fluid (CSF) drainage, mean arterial pressure (MAP) augmentation, and a naloxone infusion, which resulted in moderate recovery in lower extremity motor function. This case highlights the tenuous nature of spinal cord perfusion after TEVAR and that prompt recognition and early treatment of SCI are critical in preventing the progression from ischemia to infarction.
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Affiliation(s)
- Hannah Kelly
- Neurology, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Danielle Herman
- Neurology, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Kiana Loo
- Neurology, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Adeeb Narangoli
- Neurology, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Emily Watson
- Neurology, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Corey Berlant
- Emergency Medicine, University Hospitals St. John Medical Center, Westlake, USA
| | - Mina Huerta
- Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Collin M Labak
- Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Xiaofei Zhou
- Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, USA
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4
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Lucas SJ, Johnson KB, Rykhus R, Hora K, VandenHull A, Bates K, Sengos J, Kelly PW. Single-Site Review of Spinal Cord Protection Protocols Including the Utilization of Spinal Drains versus Medical Management with Branched Endovascular Aortic Repair. Ann Vasc Surg 2023; 97:236-247. [PMID: 37659649 DOI: 10.1016/j.avsg.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/26/2023] [Accepted: 08/20/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Spinal cord ischemia (SCI) continues to be a devastating complication after repair of thoracoabdominal aortic aneurysms. The objective of this review is to present our single-center outcomes after the implementation of a standardized neuroprotective protocol following branched endovascular aortic repair. METHODS A standardized neuroprotective protocol including preoperative steroids, acetazolamide, intraoperative hemodynamic parameters, and postoperative treatment goals was initiated in November 2019. Physician-modified branched endovascular repairs were completed at a single center from 2012 to 2021 with outcomes reviewed both before (n = 107) and after (n = 67) the implementation of the neuroprotective protocol. The primary end point was the incidence of any SCI event at 30 days. Secondary end points included all-cause mortality, stroke, myocardial infarction, and renal failure at 30 days. Patients with Crawford extents I-III, renal failure, or necessitating emergent repair were deemed high risk for SCI events and underwent a subset analysis. Survivability after SCI was estimated using Kaplan-Meier tables. RESULTS Of the 174 consecutive patients treated, the 67 patients treated following implementation of the neuroprotective protocol were more likely to have experienced a prior myocardial infarction (26.9% vs. 14%; P = 0.0466) and have a history of chronic obstructive pulmonary disease (64.3% vs. 45.8%; P = 0.02). This group was more likely to be treated for paravisceral aneurysms (53.7% vs. 24.3%; P = 0.0002). Postprotocol implementation, spinal drain use was lower (6% vs. 38.3%; P = <0.0001) with 100% of these drains placed in urgent or unstaged thoracoabdominal aortic aneurysm repairs as a part of the protocol. Rates of any SCI event among all patients before and after implementation of the protocol were 9.3% (n = 10 of 107) and 6% (n = 4 of 67; P = 0.57), respectively. In comparison, the protocol significantly reduced SCI rates to 0 (0% vs. 17.1%; P = 0.0407) in high-risk patients. Frequency of renal failure was reduced (3% vs. 14%; P = 0.018) after initiation of the protocol. Patients in the postprotocol group had significantly improved 1-year mortality rate (9% vs. 27.1%; P = 0.0035) and renal failure rates (2% vs. 15%; P = 0.018). Regression models indicated that patients in the postprotocol group had lower likelihood of mortality and renal failure than patients in preprotocol group (P < 0.05) and that spinal drain reduced mortality (P < 0.1). CONCLUSIONS Implementation of a standardized neuroprotective protocol that focuses on medical management and fluid dynamics may significantly reduce risk of SCI after branched endovascular repairs, with the most significant improvement of SCI outcomes involving those at greatest risk for developing SCI. Also noteworthy, there was significant improvement to 1-year survivability after the implementation of this neuroprotective protocol.
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Affiliation(s)
- Spencer J Lucas
- University of South Dakota - Sanford School of Medicine, Sioux Falls, SD
| | | | - Ryan Rykhus
- University of South Dakota - Sanford School of Medicine, Sioux Falls, SD
| | - Kirby Hora
- University of South Dakota - Sanford School of Medicine, Sioux Falls, SD
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5
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Amabile A, Lewis E, Costa V, Tadros RO, Han DK, Di Luozzo G. Spinal cord protection in open and endovascular approaches to thoracoabdominal aortic aneurysms. Vascular 2023; 31:874-883. [PMID: 35507464 DOI: 10.1177/17085381221094411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite advancements in surgical and postoperative management, spinal cord injury has been a persistent complication of both open and endovascular repair of thoracoabdominal and descending thoracic aortic aneurysm. Spinal cord injury can be explained with an ischemia-infarction model which results in local edema of the spinal cord, damaging its structure and leading to reversible or irreversible loss of its function. Perfusion of the spinal cord during aortic procedures can be enhanced by several adjuncts which have been described with a broad variety of evidence in their support. These adjuncts include systemic hypothermia, cerebrospinal fluid drainage, extracorporeal circulation and distal aortic perfusion, segmental arteries reimplantation, left subclavian artery revascularization, and staged aortic repair. The Authors here reviewed and discussed the role of such adjuncts in preventing spinal cord injury from occurring, pinpointing current evidence and outlining future perspectives.
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Affiliation(s)
- Andrea Amabile
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Erin Lewis
- Department of Surgery, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Victor Costa
- Department of Surgery, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Rami O Tadros
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel K Han
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gabriele Di Luozzo
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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7
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Lester LC, Kostibas MP. Anesthetic Management for Open Thoracoabdominal and Abdominal Aortic Aneurysm Repair. Anesthesiol Clin 2022; 40:705-718. [PMID: 36328624 DOI: 10.1016/j.anclin.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Open thoracoabdominal and abdominal aortic aneurysm repairs are some of the most challenging cases for anesthesiologists because of the potential for rapid blood loss combined with clamping and reperfusion, potential use of left heart bypass, the potential need for lung isolation, and potential placement and management of a spinal drain. In addition, patients often present with other significant comorbidities and a detailed understanding of the disease process, the complex physiology throughout the case, and the intricacies of organ protection are critical.
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Affiliation(s)
- Laeben Chola Lester
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Zayed 6212, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Megan P Kostibas
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Zayed 6212, 1800 Orleans Street, Baltimore, MD 21287, USA.
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8
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Marturano F, Nisi F, Giustiniano E, Benedetto F, Piccioni F, Ripani U. Prevention of Spinal Cord Injury during Thoracoabdominal Aortic Aneurysms Repair: What the Anaesthesiologist Should Know. J Pers Med 2022; 12:jpm12101629. [PMID: 36294768 PMCID: PMC9605294 DOI: 10.3390/jpm12101629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 11/06/2022] Open
Abstract
Thoraco-abdominal aortic repair is a high-risk surgery for both mortality and morbidity. A major complication is paraplegia-paralysis due to spinal cord injury. Modern thoracic and abdominal aortic aneurysm repair techniques involve multiple strategies to reduce the risk of spinal cord ischemia during and after surgery. These include both surgical and anaesthesiologic approaches to optimize spinal cord perfusion by staging the procedure, guaranteeing perfusion of the distal aorta through various techniques (left atrium–left femoral artery by-pass) by pharmacological and monitoring interventions or by maximizing oxygen delivery and inducing spinal cord hypothermia. Lumbar CSF drainage alone or in combination with other techniques remains one of the most used and effective strategies. This narrative review overviews the current techniques to prevent or avoid spinal cord injury during thoracoabdominal aortic aneurysms repair.
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Affiliation(s)
- Federico Marturano
- Department of Anaesthesia, Analgesia and Intensive Care, Vito Fazzi Hospital, 73100 Lecce, Italy
| | - Fulvio Nisi
- Department of Anaesthesia and Intensive Care Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
- Correspondence: ; Tel.: +39-02-8224-4115; Fax: +39-02-8224-4190-12
| | - Enrico Giustiniano
- Department of Anaesthesia and Intensive Care Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Francesco Benedetto
- Department of Anaesthesia and Intensive Care Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
| | - Federico Piccioni
- Department of Anaesthesia and Intensive Care Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Umberto Ripani
- Division of Clinic Anaesthesia, Department of Emergency Hospital Riuniti, Conca Street 71, 60126 Ancona, Italy
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9
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Dias-Neto M, Tenorio ER, Baumgardt Barbosa Lima G, Baghbani-Oskouei A, Oderich GS. Postoperative management in patients with complex aortic aneurysms. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:587-596. [PMID: 35687066 DOI: 10.23736/s0021-9509.22.12359-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Patients with complex aortic aneurysms (CAA) are often high risk due to advanced age and widespread atherosclerosis affecting numerous vascular territories. Therefore, a thorough perioperative evaluation is needed prior to performing in any type of aortic repair, regardless of whether an endovascular or open surgical approach is selected. Because these operations are technically demanding and often result in end organ ischemia, it is not surprising that complex aortic repair carries significant risk of morbidity and mortality. Disabling complications such as dialysis, major stroke and paraplegia constitute the main limitation of complex aortic repair. The aim of this article was to review postoperative management to mitigate complications after CAA repair.
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Affiliation(s)
- Marina Dias-Neto
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Emanuel R Tenorio
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Guilherme Baumgardt Barbosa Lima
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Aidin Baghbani-Oskouei
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Gustavo S Oderich
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA -
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10
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Motyl CM, Beck AW. Strategies for prevention and treatment of spinal cord ischemia during F/BEVAR. Semin Vasc Surg 2022; 35:297-305. [DOI: 10.1053/j.semvascsurg.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 11/11/2022]
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11
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Matar A, Arnaoutakis DJ. Endovascular treatment of thoracoabdominal aortic aneurysms. Semin Vasc Surg 2021; 34:205-214. [PMID: 34911626 DOI: 10.1053/j.semvascsurg.2021.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 10/08/2021] [Accepted: 10/10/2021] [Indexed: 11/11/2022]
Abstract
Endovascular repair of thoracoabdominal aneurysms using fenestrated and/or branched stent grafts is technically feasible and efficacious but carries a steep learning curve. This innovative surgical approach is associated with less perioperative morbidity than traditional open repair and its early and mid-term outcomes are very favorable. Spinal cord ischemia remains a devastating complication after these procedures, hence the importance of various neuroprotective strategies. Widespread applicability remains limited in the United States, as no custom-made or off-the-shelf endografts are commercially available. Access to these devices remains limited to physician-sponsored or industry-sponsored clinical trials, but results from the Cook p-Branch and Gore Thoracoabdominal Branch Endoprosthesis trials are on the horizon.
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Affiliation(s)
- Andrew Matar
- Division of Vascular Surgery, University of South Florida, 2 Tampa General Circle, 7th Floor, Room 7007, Tampa, FL 33629
| | - Dean J Arnaoutakis
- Division of Vascular Surgery, University of South Florida, 2 Tampa General Circle, 7th Floor, Room 7007, Tampa, FL 33629.
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12
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Johnson EG, Nguyen J, Oyler D, Davenport DL, Endean E, Tyagi S. Naloxone Continuous Infusion for Spinal Cord Protection in Endovascular Aortic Surgery Leads to Higher Opioid Administration and More Pain. J Cardiothorac Vasc Anesth 2020; 35:1143-1148. [PMID: 33334650 DOI: 10.1053/j.jvca.2020.11.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/02/2020] [Accepted: 11/18/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Compare total perioperative opioid use in patients receiving naloxone continuousinfusion (NCI) for spinal cord ischemia prophylaxis, versus patients not receiving NCI, in endovascular aortic repair. DESIGN Single-center, retrospective cohort review. SETTING Academic medical center. PARTICIPANTS Patients undergoing elective thoracic, thoracoabdominal, or abdominal aortic endovascular repair. INTERVENTIONS Patients were separated based on the use of naloxone continuous infusion as part of a spinal protection protocol. Primary endpoint was opioid requirements, in milligram morphine equivalents (MME), during the first 48 hours or during NCI. Secondary endpoints included: postoperative pain scores during the same interval; opioid requirements during hours 48 to 72; and pain scores during hours 48 to 72. MEASUREMENTS AND MAIN RESULTS Ninety-five procedures were included; 43 received naloxone continuous infusion and 52 patients were in the non-naloxone group. Opioid use from a linear mixed model was elevated across the entire continuum in the naloxone group (18 MMEs, 95% CI 13-24), with the greatest difference seen at the 24-to-48-hour interval (51 MMEs, 95% CI 26-75) after adjustment for age, incisions, and prehospital opioid use. In the naloxone group, pain score estimates were elevated at each postoperative interval of evaluation, with similar adjustment. Across the continuum this was 0.7 higher (95% CI 0.2-1.3); the zero-six-hour and six-to-12-hour intervals were 0.9 (95% CI 0.4-1.4) and 1.2 higher (95% CI 0.7-1.7). CONCLUSIONS Patients receiving anloxone continuous infusion to prevent spinal cord ischemia required greater quantities of opioids and had higher postoperative pain, compared with patients not requiring naloxone.
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Affiliation(s)
- Eric G Johnson
- University of Kentucky HealthCare, Department of Pharmacy Services, Lexington, KY; University of Kentucky College of Pharmacy, Lexington, KY.
| | - Jonny Nguyen
- University of Kentucky College of Pharmacy, Lexington, KY
| | - Doug Oyler
- University of Kentucky HealthCare, Department of Pharmacy Services, Lexington, KY; University of Kentucky College of Pharmacy, Lexington, KY
| | - Daniel L Davenport
- University of Kentucky College of Medicine, Department of Surgery, Lexington, KY
| | - Eric Endean
- University of Kentucky College of Medicine, Department of Surgery, Lexington, KY
| | - Samuel Tyagi
- University of Kentucky College of Medicine, Department of Surgery, Lexington, KY
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Lazar HL. Commentary: Determining the role of priming for spinal cord protection during open aneurysm surgery: Have we used the right model? J Thorac Cardiovasc Surg 2020; 164:811-813. [PMID: 33131887 DOI: 10.1016/j.jtcvs.2020.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 10/03/2020] [Accepted: 10/05/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Harold L Lazar
- Division of Cardiac Surgery, Boston University School of Medicine, Boston, Mass.
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Vandiver MS, Vacas S. Interventions to improve perioperative neurologic outcomes. Curr Opin Anaesthesiol 2020; 33:661-667. [PMID: 32769748 DOI: 10.1097/aco.0000000000000905] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW Few outcomes in surgery are as important to patients as that of their neurologic status. The purpose of this review is to discuss and categorize the most common perioperative neurologic complications. We will also discuss strategies to help prevent and mitigate these complications for our patients. RECENT FINDINGS There are several strategies the anesthesiologist can undertake to prevent or treat conditions, such as perioperative neurocognitive disorders, spinal cord ischemia, perioperative stroke, and postoperative visual loss. SUMMARY A thorough understanding of threats to patients' neurologic well-being is essential to excellent clinical practice.
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Affiliation(s)
- Matthew S Vandiver
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA, USA
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15
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Spinal cord perfusion protection for thoraco-abdominal aortic aneurysm surgery. Curr Opin Anaesthesiol 2019; 32:72-79. [DOI: 10.1097/aco.0000000000000670] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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16
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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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Tanaka A, Safi HJ, Estrera AL. Current strategies of spinal cord protection during thoracoabdominal aortic surgery. Gen Thorac Cardiovasc Surg 2018; 66:307-314. [DOI: 10.1007/s11748-018-0906-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 03/05/2018] [Indexed: 10/17/2022]
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18
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Olsen PL, Hoffman CR, Green MS. Naloxone Infusion During Thoracic Endovascular Aortic Aneurysm Repair to Prevent Spinal Cord Injury. J Cardiothorac Vasc Anesth 2018; 32:e37. [PMID: 29325844 DOI: 10.1053/j.jvca.2017.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Patrick L Olsen
- Department of Anesthesiology and Perioperative Medicine, Drexel University College of Medicine, Philadelphia, PA
| | - Christopher R Hoffman
- Department of Anesthesiology and Perioperative Medicine, Drexel University College of Medicine, Philadelphia, PA
| | - Michael Stuart Green
- Department of Anesthesiology and Perioperative Medicine, Drexel University College of Medicine, Philadelphia, PA
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Lesniak A, Leszczynski P, Bujalska-Zadrozny M, Pick CG, Sacharczuk M. Naloxone exacerbates memory impairments and depressive-like behavior after mild traumatic brain injury (mTBI) in mice with upregulated opioid system activity. Behav Brain Res 2017; 326:209-216. [PMID: 28284950 DOI: 10.1016/j.bbr.2017.03.015] [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: 01/04/2017] [Revised: 03/02/2017] [Accepted: 03/07/2017] [Indexed: 12/13/2022]
Abstract
The neuroprotective role of the endogenous opioid system in the pathophysiological sequelae of brain injury remains largely ambiguous. Noteworthy, almost no data is available on how its genetically determined activity influences the outcome of mild traumatic brain injury. Thus, the aim of our study was to examine the effect of opioid receptor blockage on cognitive impairments produced by mild traumatic brain injury in mice selectively bred for high (HA) and low (LA) swim-stress induced analgesia that show innate divergence in opioid system activity. Mild traumatic brain injury was induced with a weight-drop device on anaesthetized mice. Naloxone (5mg/kg) was intraperitoneally delivered twice a day for 7days to non-selectively block opioid receptors. Spatial memory performance and manifestations of depressive-like behavior were assessed using the Morris Water Maze and tail suspension tests, respectively. Mild traumatic brain injury resulted in a significant deterioration of spatial memory performance and severity of depressive-like behavior in the LA mouse line as opposed to HA mice. Opioid receptor blockage with naloxone unmasked cognitive deficits in HA mice but was without effect in the LA line. The results suggest a protective role of genetically predetermined enhanced opioid system activity in suppression of mild brain trauma-induced cognitive impairments. Mice selected for high and low swim stress-induced analgesia might therefore be a useful model to study the involvement of the opioid system in the pathophysiology and neurological outcome of traumatic brain injury.
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Affiliation(s)
- Anna Lesniak
- Department of Pharmacodynamics, Faculty of Pharmacy, Medical University of Warsaw, Centre for Preclinical Research and Technology (CePT), Banacha 1B, 02-097 Warsaw, Poland
| | - Pawel Leszczynski
- Department of Genomics, Institute of Genetics and Animal Breeding, Polish Academy of Sciences, Jastrzebiec, Postepu 36A, 05-552 Magdalenka, Poland
| | - Magdalena Bujalska-Zadrozny
- Department of Pharmacodynamics, Faculty of Pharmacy, Medical University of Warsaw, Centre for Preclinical Research and Technology (CePT), Banacha 1B, 02-097 Warsaw, Poland
| | - Chaim G Pick
- Department of Anatomy, and Anthropology, Sackler Faculty of Medicine, and Sagol School of Neuroscience, Tel Aviv University, Ramat-Aviv, 69978 Tel Aviv, Israel
| | - Mariusz Sacharczuk
- Department of Pharmacodynamics, Faculty of Pharmacy, Medical University of Warsaw, Centre for Preclinical Research and Technology (CePT), Banacha 1B, 02-097 Warsaw, Poland; Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland; Department of Genomics, Institute of Genetics and Animal Breeding, Polish Academy of Sciences, Jastrzebiec, Postepu 36A, 05-552 Magdalenka, Poland.
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Dias-Neto M, Reis PV, Rolim D, Ramos JF, Teixeira JF, Sampaio S. Strategies to prevent TEVAR-related spinal cord ischemia. Vascular 2016; 25:307-315. [DOI: 10.1177/1708538116671235] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Spinal cord ischemia remains the Achilles’ heel of thoracic and thoracoabdominal diseases management. Great improvements in morbidity and mortality have been obtained with the endovascular approach TEVAR (Thoracic Endovascular Aortic Repair) but this devastating complication continues to severely affect the quality of life, even if the primary success of the procedure – dissection/aneurysm exclusion – has been achieved. Several strategies to deal with this complication have been published in the literature over the time. Knowledge and technology have been evolving from identification of the risk factors associated with spinal cord ischemia, including lessons learned from open surgery, and from developments in the collateral network concept for spinal cord perfusion. In this comprehensive review, the authors cover several topics from the traditional measures comprising haemodynamic control, cerebrospinal drainage and neuroprotective drugs, to the staged-procedures approach, the emerging MISACE (minimally invasive selective segmental artery coil-embolization) and innovative neurologic monitoring such as NIRS (near-infrared spectroscopy) of the collateral network.
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Affiliation(s)
- Marina Dias-Neto
- Department of Angiology and Vascular Surgery, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal
- Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Alameda Professor Hernani Monteiro, Portugal
| | - Pedro Videira Reis
- Department of Anaesthesiology, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal
| | - Dalila Rolim
- Department of Angiology and Vascular Surgery, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal
| | - José Fernando Ramos
- Department of Angiology and Vascular Surgery, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal
| | - José Fernando Teixeira
- Department of Angiology and Vascular Surgery, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal
| | - Sérgio Sampaio
- Department of Angiology and Vascular Surgery, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal
- Faculty of Medicine, Department of Information and Decision Sciences in Health (CIDES), Research Center in Health Technologies and Information systems (CINTESIS), University of Porto, Alameda Professor Hernani Monteiro, Portugal
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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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22
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Morisaki K, Matsumoto T, Matsubara Y, Inoue K, Aoyagi Y, Matsuda D, Tanaka S, Okadome J, Maehara Y. A Rare Complication of Spinal Cord Ischemia Following Endovascular Aneurysm Repair of an Infrarenal Abdominal Aortic Aneurysm with Arteriosclerosis Obliterans: Report of a Case. Ann Vasc Dis 2016; 9:255-257. [PMID: 27738476 DOI: 10.3400/avd.cr.16-00063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/01/2016] [Indexed: 11/13/2022] Open
Abstract
We herein report a case of a rare complication of spinal cord ischemia (SCI) following endovascular aneurysm repair (EVAR). Computed tomography showed stenosis and calcification of bilateral iliac arteries and a saccular aneurysm of the terminal aorta. Paraplegia occurred soon after balloon angioplasty of iliac arteries and EVAR. Cerebrospinal fluid drainage was not performed because the patient was on dual antiplatelet drugs. The patient was treated with intravenous methylpredonisolone and naloxone; however, this did not improve his paraplegia. SCI after EVAR is extremely rare and unpredictable complication, however, physicians should be aware of SCI after EVAR in patients with atherosclerosis.
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Affiliation(s)
- Koichi Morisaki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Higashi-Ku, Fukuoka, Japan
| | - Takuya Matsumoto
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Higashi-Ku, Fukuoka, Japan
| | - Yutaka Matsubara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Higashi-Ku, Fukuoka, Japan
| | - Kentaro Inoue
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Higashi-Ku, Fukuoka, Japan
| | - Yukihiko Aoyagi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Higashi-Ku, Fukuoka, Japan
| | - Daisuke Matsuda
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Higashi-Ku, Fukuoka, Japan
| | - Shinichi Tanaka
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Higashi-Ku, Fukuoka, Japan
| | - Jun Okadome
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Higashi-Ku, Fukuoka, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Higashi-Ku, Fukuoka, Japan
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Acher C, Acher C, Marks E, Wynn M. Intraoperative neuroprotective interventions prevent spinal cord ischemia and injury in thoracic endovascular aortic repair. J Vasc Surg 2016; 63:1458-65. [DOI: 10.1016/j.jvs.2015.12.062] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 12/30/2015] [Indexed: 11/16/2022]
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Michael FM, Mohapatra AN, Venkitasamy L, Chandrasekar K, Seldon T, Venkatachalam S. Contusive spinal cord injury up regulates mu-opioid receptor (mor)gene expression in the brain and down regulates its expression in the spinal cord: possible implications in spinal cord injury research. Neurol Res 2015; 37:788-96. [DOI: 10.1179/1743132815y.0000000057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Wynn MM, Acher C. A Modern Theory of Spinal Cord Ischemia/Injury in Thoracoabdominal Aortic Surgery and Its Implications for Prevention of Paralysis. J Cardiothorac Vasc Anesth 2014; 28:1088-99. [DOI: 10.1053/j.jvca.2013.12.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Indexed: 11/11/2022]
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26
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Low incidence of paraplegia after thoracic endovascular aneurysm repair with proactive spinal cord protective protocols. J Vasc Surg 2013; 57:1537-42. [DOI: 10.1016/j.jvs.2012.12.032] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 12/05/2012] [Accepted: 12/06/2012] [Indexed: 11/17/2022]
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27
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Yanase Y, Kawaharada N, Maeda T, Koyanagi T, Ito T, Kurimoto Y, Higami T. Treatment of Delayed Neurological Deficits after Surgical Repair of Thoracic Aortic Aneurysm. Ann Thorac Cardiovasc Surg 2012; 18:271-4. [DOI: 10.5761/atcs.cr.11.01741] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Ullery BW, Wang GJ, Low D, Cheung AT. Neurological complications of thoracic endovascular aortic repair. Semin Cardiothorac Vasc Anesth 2011; 15:123-40. [PMID: 22025398 DOI: 10.1177/1089253211424224] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Thoracic endovascular aortic repair (TEVAR) has decreased the morbidity and mortality associated with open surgical repair of descending thoracic aortic diseases, but important complications unique to the procedure remain. Spinal cord ischemia and infarction is a recognized complication caused by endovascular coverage or injury to spinal cord collateral vessels. Stroke is a consequence of thromboembolism or coverage of aortic arch branch vessels with insufficient collateral circulation. Understanding the risk factors and the pathophysiology of neurological complications of TEVAR are important for the successful anesthetic and surgical management and treatment of patients undergoing endovascular procedures involving the thoracic aorta.
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Affiliation(s)
- Brant W Ullery
- Department of Anesthesiology and Critical Care, University of Pennsylvania, 3400 Spruce Street, Dulles 680, Philadelphia, PA 19104-4283, USA
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29
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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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30
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Acher C. It is not just assisted circulation, hypothermic arrest, or clamp and sew. J Thorac Cardiovasc Surg 2010; 140:S136-41; discussion S142-S146. [DOI: 10.1016/j.jtcvs.2010.07.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 07/12/2010] [Indexed: 10/18/2022]
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Reilly LM, Chuter TAM. Reversal of Fortune: Induced Endoleak to Resolve Neurological Deficit After Endovascular Repair of Thoracoabdominal Aortic Aneurysm. J Endovasc Ther 2010; 17:21-9. [DOI: 10.1583/09-2887.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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33
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A modern theory of paraplegia in the treatment of aneurysms of the thoracoabdominal aorta: An analysis of technique specific observed/expected ratios for paralysis. J Vasc Surg 2009; 49:1117-24; discussion 1124. [DOI: 10.1016/j.jvs.2008.10.074] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2008] [Revised: 10/30/2008] [Accepted: 10/30/2008] [Indexed: 10/20/2022]
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Hawryluk GWJ, Rowland J, Kwon BK, Fehlings MG. Protection and repair of the injured spinal cord: a review of completed, ongoing, and planned clinical trials for acute spinal cord injury. Neurosurg Focus 2009; 25:E14. [PMID: 18980474 DOI: 10.3171/foc.2008.25.11.e14] [Citation(s) in RCA: 185] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Over the past 2 decades, advances in understanding the pathophysiology of spinal cord injury (SCI) have stimulated the recent emergence of several therapeutic strategies that are being examined in Phase I/II clinical trials. Ten randomized controlled trials examining methylprednisolone sodium succinate, tirilizad mesylate, monosialotetrahexosylganglioside, thyrotropin releasing hormone, gacyclidine, naloxone, and nimodipine have been completed. Although the primary outcomes in these trials were laregely negative, a secondary analysis of the North American Spinal Cord Injury Study II demonstrated that when administered within 8 hours of injury, methylprednisolone sodium succinate was associated with modest clinical benefits, which need to be weighed against potential complications. Thyrotropin releasing hormone (Phase II trial) and monosialotetrahexosylganglioside (Phase II and III trials) also showed some promise, but we are unaware of plans for future trials with these agents. These studies have, however, yielded many insights into the conduct of clinical trials for SCI. Several current or planned clinical trials are exploring interventions such as early surgical decompression (Surgical Treatment of Acute Spinal Cord Injury Study) and electrical field stimulation, neuroprotective strategies such as riluzole and minocycline, the inactivation of myelin inhibition by blocking Nogo and Rho, and the transplantation of various cellular substrates into the injured cord. Unfortunately, some experimental and poorly characterized SCI therapies are being offered outside a formal investigational structure, which will yield findings of limited scientific value and risk harm to patients with SCI who are understandably desperate for any intervention that might improve their function. Taken together, recent advances suggest that optimism for patients and clinicians alike is justified, as there is real hope that several safe and effective therapies for SCI may become available over the next decade.
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Affiliation(s)
- Gregory W J Hawryluk
- Division of Genetics and Development, Toronto Western Research Institute, Toronto, Ontario, Canada
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A quantitative assessment of the impact of intercostal artery reimplantation on paralysis risk in thoracoabdominal aortic aneurysm repair. Ann Surg 2008; 248:529-40. [PMID: 18936565 DOI: 10.1097/sla.0b013e318187a792] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We previously demonstrated an 80% reduction in paraplegia risk using hypothermia, naloxone, steroids, spinal fluid drainage, intercostal ligation, and optimizing hemodynamic parameters. This report demonstrates that intercostal revascularization for the last 3 years further reduced our paraplegia risk index by 75%. METHODS We evaluated 655 patients who had thoracic or thoracoabdominal aneurysm repair for factors that affected paraplegia risk including aneurysm extent, acuity, cardiac function, blood pressure mean arterial pressure, and spinal fluid drainage with naloxone (SFDN). Eighteen patients died during or shortly after surgery leaving 637 patients for analysis of paralysis. We evaluated the effect of intercostal reimplantation (IRP) using a highly accurate (r(2) > 0.88) paraplegia risk index we developed and published previously. RESULTS Fifty-eight percent of patients were male with a mean age of 67. Thirty-three percent were acute with rupture, acute dissection, mycotic aortitis, and trauma. Eighty (12%) had dissections. Thirty-five patients had paraplegia or paraparesis (5.4%). Significant factors by univariate analysis (P < 0.05) were Crawford type 2, acuity, SFDN, cardiac index after unclamping, mean arterial pressure during crossclamping, and IRP. In multivariate modeling, aneurysm extent, SFDN, acuity, and IRP remained significant (P < 0.02). The paraplegia risk index declined from 0.20 to 0.05 (P < 0.03). CONCLUSIONS The incidence of paralysis after TAAA repair decreased from 4.83% to 0.88% and paralysis risk index decreased from 0.26 to 0.05 when intercostal artery reimplantation was added to neuroprotective strategies that had already substantially reduced paralysis risk. These findings suggest that factors that affect collateral blood flow and metabolism account for approximately 80% of paraplegia risk and intercostal blood flow accounts for 20% of risk. This suggests a limit to paraplegia risk reduction in thoracoabdominal endograft patients. Early results in this emerging field support this prediction of high paraplegia risk with thoracoabdominal branched endografts with extensive aortic coverage.
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Cho JS, Rhee RY, Makaroun MS. Delayed paraplegia 10 months after endovascular repair of thoracic aortic aneurysm. J Vasc Surg 2008; 47:625-8. [DOI: 10.1016/j.jvs.2007.09.042] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Revised: 09/06/2007] [Accepted: 09/12/2007] [Indexed: 11/29/2022]
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37
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Qian L, Tan KS, Wei SJ, Wu HM, Xu Z, Wilson B, Lu RB, Hong JS, Flood PM. Microglia-Mediated Neurotoxicity Is Inhibited by Morphine through an Opioid Receptor-Independent Reduction of NADPH Oxidase Activity. THE JOURNAL OF IMMUNOLOGY 2007; 179:1198-209. [PMID: 17617613 DOI: 10.4049/jimmunol.179.2.1198] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Recent studies have shown that morphine modulates the function of glia cells through both opioid receptor dependent and independent mechanisms. However, the mechanism by which morphine regulates neuronal disorders through the alteration of microglia activity remains unclear. In this study, using rat primary mesencephalic neuron-glia cultures, we report that both l-morphine and its synthetic stereoenantiomer, d-morphine, an ineffective opioid receptor agonist, significantly reduced LPS- or 1-methyl-4-phenylpyridinium-induced dopaminergic neurotoxicity with similar efficacy, indicating a nonopioid receptor-mediated effect. In addition, using reconstituted neuron and glia cultures, subpicomolar concentrations of morphine were found to be neuroprotective only in the presence of microglia, and significantly inhibited the production of inflammatory mediators from LPS-stimulated microglia cells. Mechanistic studies showed that both l- and d- morphine failed to protect dopaminergic neurons in cultures from NADPH oxidase (PHOX) knockout mice and significantly reduced LPS-induced PHOX cytosolic subunit p47(phox) translocation to the cell membrane by inhibiting ERK phosphorylation. Taken together, our results demonstrate that morphine, even at subpicomolar concentrations, exerts potent anti-inflammatory and neuroprotective effects either through the inhibition of direct microglial activation by LPS or through the inhibition of reactive microgliosis elicited by 1-methyl-4-phenylpyridinium. Furthermore, our study reveals that inhibition of PHOX is a novel site of action for the mu-opioid receptor-independent effect of morphine.
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Affiliation(s)
- Li Qian
- Comprehensive Center for Inflammatory Disorders, University of North Carolina, Chapel Hill, NC 27599, USA
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Tsai SY, Yang LY, Wu CH, Chang SF, Hsu CY, Wei CP, Leu SJ, Liaw J, Lee YH, Tsai MD. Injury-induced Janus kinase/protein kinase C-dependent phosphorylation of growth-associated protein 43 and signal transducer and activator of transcription 3 for neurite growth in dorsal root ganglion. J Neurosci Res 2007; 85:321-31. [PMID: 17131417 DOI: 10.1002/jnr.21119] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Elevation of corticosteroids and excessive glutamate release are the two major stress responses that occur sequentially during traumatic CNS injury. We have previously reported that sequential application of corticosterone and kainic acid (CORT + KA) mimicking the nerve injury condition results in synergistic enhancement of neurite outgrowth and expression of growth-associated protein 43 (GAP-43) in cultured dorsal root ganglion (DRG). GAP-43 is known to promote neurite extension when phosphorylated by protein kinase C (PKC). In addition, PKC can phosphorylate the signal transducer and activator of transcription 3 (STAT3) at Ser727, which is phosphorylated primarily by Janus kinase (JAK) at Tyr705. In this study, we further examine the role of PKC in this stress-induced growth-promoting effect. In the cultured DRG neurons, the JAK inhibitor AG-490 and the PKC inhibitor Ro-318220 reduced the CORT + KA-enhanced neurite growth effect when applied prior to CORT and KA treatment, respectively. Both AG-490 and Ro-318220 diminished the CORT + KA-enhanced GAP-43 expression, phosphorylation, and axonal localization. Furthermore, CORT + KA treatment synergistically phosphorylated STAT3 at Ser727 but not at Tyr705. Similar phenomena were observed in an animal model of acute spinal cord injury (SCI), in which phosphorylation of GAP-43 and phospho-Ser727-STAT3 was elevated in the injured DRG 4 hr after the impact injury. Further treatment with the therapeutic glucocorticoid methylprednisolone enhanced the phosphorylation of GAP-43 in both the DRG and the spinal cord of SCI rats. These results suggest that elevated glucocorticoids and overexcitation following CNS injury contribute to nerve regeneration via induction of JAK/PKC-mediated GAP-43 and STAT3 activities.
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Affiliation(s)
- Shih-Ying Tsai
- Department of Physiology, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Abstract
This paper is the 27th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning over 30 years of research. It summarizes papers published during 2004 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, USA.
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Lases EC, Schepens MA, Haas FJ, Aarts LP, ter Beek HT, van Dongen EP, Siegers HP, van der Tweel I, Boezeman EH. Clinical prospective study of biochemical markers and evoked potentials for identifying adverse neurological outcome after thoracic and thoracoabdominal aortic aneurysm surgery. Br J Anaesth 2005; 95:651-61. [PMID: 16199420 DOI: 10.1093/bja/aei239] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Neurological deficit after repair of a thoracic or thoracoabdominal aortic aneurysm (TAA/TAAA) remains a devastating complication. The aim of our study was to investigate the clinical value of biochemical markers [S-100B, neurone-specific enolase (NSE) and lactate dehydrogenase (LD)], evoked potentials and their combinations for identifying adverse neurological outcome after TAA/TAAA surgery. METHODS From 69 patients, cerebrospinal fluid and blood samples for biochemical analysis were drawn after the induction of anaesthesia, during the cross-clamp period, 5 min, 2, 4, 6, 8, and 19 h, respectively, after reperfusion. In addition, continuous perioperative recording of motor-evoked potentials after transcranial electrical stimulation (tcMEP) and somatosensory-evoked potentials was carried out. Furthermore, neurological examinations were performed. RESULTS In patients with a defined decrease in lower extremity tcMEP during the cross-clamp period, we found that combinations of the serum concentrations of S-100B and tcMEP ratios at 4, 6, and 8 h after reperfusion had a positive and negative predictive value of 100% in predicting adverse neurological outcome after TAA/TAAA surgery. Furthermore, combinations of the serum concentrations of S-100B and NSE or LD at 19 h after reperfusion had both a positive and negative predictive value of 100% in identifying patients with adverse outcome after TAA/TAAA repair. CONCLUSIONS TcMEP monitoring during TAA/TAAA surgery seems to be an effective but not completely sufficient guide in our protective multi-modality strategy. Combinations of the serum concentrations of S-100B and tcMEP ratios during the early reperfusion period might be associated with adverse neurological complications. Furthermore, biochemical markers could detect central nervous system injury on the first postoperative day and may have prognostic value.
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Affiliation(s)
- E C Lases
- Department of Clinical Chemistry, St Antonius Hospital, PO Box 2500, NL-3430 EM, Nieuwegein, The Netherlands.
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