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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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Kise Y, Kuniyoshi Y, Ando M, Miyaishi K, Higa S, Maeda T, Nakaema M, Inafuku H, Furukawa K. Simultaneous upper and lower body perfusion using hypothermia during thoracoabdominal aortic surgery. J Cardiothorac Surg 2023; 18:331. [PMID: 37964285 PMCID: PMC10648722 DOI: 10.1186/s13019-023-02439-3] [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] [Received: 04/12/2023] [Accepted: 11/04/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND In open thoracoabdominal aortic aneurysm (TAAA) repair, we have been performing vascular reconstruction under moderate to deep hypothermia and assisted circulation using simultaneous upper and lower body perfusion. This method is effective for protecting the spinal cord and the brain, heart, and abdominal organs and for avoiding lung damage. METHODS TAAA repair was performed under hypothermia at 20-28 °C in 18 cases (Crawford type I in 0 cases, type II in 5, type III in 3, type IV in 4, and Safi V in 6) between October 2014 and January 2023. Cardiopulmonary bypass was conducted by combined upper and lower body perfusion, with perfusion both via the femoral artery and either transapically or via the descending aorta or the left brachial artery. RESULTS The ischemic time for the artery of Adamkiewicz and the main segmental arteries was 40-124 min (75 ± 33 min). No spinal cord ischemic injury or brain or heart complications occurred. One patient with postoperative right renal artery occlusion and one with an infected aneurysm required tracheostomy, but the intubation time for the other 16 was 32 ± 33 h. The duration of postoperative intensive care unit stay was 6.5 ± 6.2 days, the length of hospital stay was 29 ± 15 days, and no in-hospital deaths occurred. CONCLUSIONS Simultaneous upper and lower body perfusion under moderate to deep hypothermia during thoracoabdominal aortic surgery may avoid not only spinal cord injury, but also cardiac and brain complications.
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Affiliation(s)
- Yuya Kise
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan.
| | - Yukio Kuniyoshi
- Department of Cardiovascular Surgery, Urasoe General Hospital, Urasoe, Okinawa, Japan
| | - Mizuki Ando
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Keita Miyaishi
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Shotaro Higa
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Tatuya Maeda
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Moriyasu Nakaema
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Hitoshi Inafuku
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Kojiro Furukawa
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
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Rustum S, Lübeck S, Beckmann E, Wilhelmi M, Haverich A, Shrestha ML. Open surgical replacement of the descending aorta: single-center experience. Indian J Thorac Cardiovasc Surg 2023; 39:137-144. [PMID: 36785612 PMCID: PMC9918630 DOI: 10.1007/s12055-022-01443-x] [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: 05/25/2022] [Revised: 11/08/2022] [Accepted: 11/15/2022] [Indexed: 01/04/2023] Open
Abstract
Background This study presents a single center's experience and analyzes clinical outcomes following elective open surgical descending aortic replacement. Methods Between January 2000 and August 2019, 96 patients with mean age 64 years (range, 49.5-71 years) (62.5% (n=60) male) underwent elective descending aortic replacement due to aneurysm (n=60) or chronic dissection (n=36). Marfan syndrome was present in 12 patients (12.5%). Results In-hospital mortality rate was 3.1% (n= 3. 2 in the aneurysm group, 1 in the dissection group). New-onset renal insufficiency postoperatively with (creatinine ≥ 2.5 mg/dl) manifested in 10 patients (10.8%). One patient (1%) suffered from stroke, and paraplegia developed in 1 pts (1%). The median follow-up time was 7 years (IQR: 2.5-13 years). The 5- and 10-year survival rates were 70.8% and 50.7% respectively. We did not observe any early or late prosthetic graft infection. The Cox proportional hazards regression analysis identified age (HR: 1.044, 95% CI: 1.009-1.080, p-value: 0.014), diabetes (HR: 2.544, 95% CI: 1.009-6.413, p-value: 0.048), and chronic obstructive pulmonary disease (COPD) (HR: 2.259, 95% CI: 1.044-4.890, p-value: 0.039) as risk factors for late mortality. Conclusions This study showed that the elective open surgical replacement of the descending aorta can be achieved with excellent outcomes in terms of perioperative mortality and morbidity. Prosthetic graft is not a problem with open surgical descending aortic replacement, even in the long term. Supplementary Information The online version contains supplementary material available at 10.1007/s12055-022-01443-x.
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Affiliation(s)
- Saad Rustum
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Sebastian Lübeck
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Erik Beckmann
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Mathias Wilhelmi
- Center for Competence for Cardiovascular Implants, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Malakh Lal Shrestha
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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Gülmez A, Kuru Bektaşoğlu P, Tönge Ç, Yaprak A, Türkoğlu ME, Önder E, Ergüder Bİ, Sargon MF, Gürer B, Kertmen H. Neuroprotective Effects of Dexpanthenol on Rabbit Spinal Cord Ischemia/Reperfusion Injury Model. World Neurosurg 2022; 167:e172-e183. [PMID: 35948219 DOI: 10.1016/j.wneu.2022.07.109] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 07/23/2022] [Accepted: 07/25/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Dexpanthenol (DXP) reportedly protects tissues against oxidative damage in various inflammation models. This study aimed to evaluate its effects on oxidative stress, inflammation, apoptosis, and neurological recovery in an experimental rabbit spinal cord ischemia/reperfusion injury (SCIRI) model. METHODS Rabbits were randomized into 5 groups of 8 animals each: group 1 (control), group 2 (ischemia), group 3 (vehicle), group 4 (methylprednisolone, 30 mg/kg), and group 5 (DXP, 500 mg/kg). The control group underwent laparotomy only, whereas other groups were subjected to spinal cord ischemia by aortic occlusion (just caudal to the 2 renal arteries) for 20 min. After 24 h, a modified Tarlov scale was employed to record neurological examination results. Malondialdehyde and caspase-3 levels and catalase and myeloperoxidase activities were analyzed in tissue and serum samples. Xanthine oxidase activity was measured in the serum. Histopathological and ultrastructural evaluations were also performed in the spinal cord. RESULTS After SCIRI, serum and tissue malondialdehyde and caspase-3 levels and myeloperoxidase and serum xanthine oxidase activities were increased (P < 0.05-0.001). However, serum and tissue catalase activity decreased significantly (P < 0.001). DXP treatment was associated with lower malondialdehyde and caspase-3 levels and reduced myeloperoxidase and xanthine oxidase activities but increased catalase activity (P < 0.05-0.001). Furthermore, DXP was associated with better histopathological, ultrastructural, and neurological outcome scores. CONCLUSIONS This study was the first to evaluate antioxidant, anti-inflammatory, antiapoptotic, and neuroprotective effects of DXP on SCIRI. Further experimental and clinical investigations are warranted to confirm that DXP can be administered to treat SCIRI.
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Affiliation(s)
- Ahmet Gülmez
- Department of Neurosurgery, University of Health Sciences, Dışkapı Education and Research Hospital, Ankara, Turkey
| | | | - Çağhan Tönge
- Department of Neurosurgery, University of Health Sciences, Dışkapı Education and Research Hospital, Ankara, Turkey
| | - Ahmet Yaprak
- Department of Neurosurgery, University of Health Sciences, Dışkapı Education and Research Hospital, Ankara, Turkey
| | - M Erhan Türkoğlu
- Department of Neurosurgery, University of Health Sciences, Dışkapı Education and Research Hospital, Ankara, Turkey
| | - Evrim Önder
- Department of Pathology, University of Health Sciences, Dışkapı Education and Research Hospital, Ankara, Turkey
| | - Berrin İmge Ergüder
- Department of Biochemistry, Ankara University School of Medicine, Ankara, Turkey
| | | | - Bora Gürer
- Department of Neurosurgery, Istinye University Faculty of Medicine, Istanbul, Turkey
| | - Hayri Kertmen
- Department of Neurosurgery, University of Health Sciences, Dışkapı Education and Research Hospital, Ankara, Turkey
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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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Papanikolaou D, Savio C, Zafar MA, Freudzon L, Wu J, Abdelbaky M, Pelletier KJ, Buntin J, Faggion Vinholo T, Ziganshin BA, Schwartz B, Elefteriades JA. Left Atrial to Femoral Artery Full Cardiopulmonary Bypass: A Novel Technique for Descending and Thoracoabdominal Aortic Surgery. Int J Angiol 2020; 29:19-26. [PMID: 32132812 PMCID: PMC7054066 DOI: 10.1055/s-0039-3400479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Left atrial-femoral artery (LA-FA) bypass with a centrifugal pump and no oxygenator is commonly used for descending and thoracoabdominal aortic (DTAA) operations, mitigating the deleterious effects of cross-clamping. We present our initial experience performing DTAA replacement under LA-FA (left-to-left) cardiopulmonary bypass (CPB) with an oxygenator. DTAA replacement under LA-FA bypass with an oxygenator was performed in 14 consecutive patients (CPB group). The pulmonary vein and femoral artery (or distal aorta) were cannulated and the full CPB machine were used, including oxygenator, roller pump, pump suckers, and kinetically enhanced drainage. The CPB group was compared with 50 consecutive patients who underwent DTAA replacement utilizing traditional LA-FA bypass without an oxygenator (LA-FA group). Perioperative data were collected and statistical analyses were performed. All CPB patients maintained superb cardiopulmonary stability. The pump sucker permitted immediate salvage and return of shed blood. Superb oxygenation was maintained at all times. High-dose full CPB heparin was reversed without difficulty. The CPB group required markedly fewer blood transfusions than the LA-FA group (2.21 vs. 5.88 units, p < 0.004). The 30-day mortality rate was 7.1% ( n = 1) and there were no paraplegia cases in the CPB group versus 7 (14%) deaths and 3 (6%) paraplegia cases in the LA-FA group. Traditional LA-FA bypass without an oxygenator avoids high-dose heparin. In the present era, heparin reversal is more secure. Our experience finds that the novel application of LA-FA CPB with an oxygenator is safe and suggests improved hemodynamics (immediate return of shed blood) and a hemostatic advantage (avoidance of loss of coagulation factors in the cell saver).
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Affiliation(s)
- Dimitra Papanikolaou
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Chris Savio
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Mohammad A. Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Leon Freudzon
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Jinlin Wu
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Mohamed Abdelbaky
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Keith J. Pelletier
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Joelle Buntin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Thais Faggion Vinholo
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Bulat A. Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
- Department of Surgical Diseases, Kazan State Medical University, Kazan, Russia
| | - Brian Schwartz
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - John A. Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
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Kise Y, Kuniyoshi Y, Ando M, Maeda T, Inafuku H, Yamashiro S. Direct Monitoring of Reconstructed Segmental Arterial Pressure during Deep Hypothermic Thoracoabdominal Aortic Aneurysm Surgery. Ann Vasc Dis 2019; 12:537-540. [PMID: 31942215 PMCID: PMC6957881 DOI: 10.3400/avd.cr.19-00054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Deep hypothermia in thoracoabdominal aortic aneurysm operations is considered extremely useful for ensuring sufficient time to reconstruct the segmental arteries feeding the spinal cord. However, because the amplitude of motor evoked potentials (MEPs) decrease or disappear during deep hypothermia, feasible methods for assessing spinal cord circulation have not yet been reported. Performing additional segmental arterial reconstructions that rely on MEPs is also impractical. In the present case, to ascertain spinal cord circulation under deep hypothermia, we intraoperatively measured the reconstructed segmental arterial pressure in real time and investigated whether sufficient spinal cord blood flow had been attained.
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Affiliation(s)
- Yuya Kise
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Yukio Kuniyoshi
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Mizuki Ando
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Tatuya Maeda
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Hitoshi Inafuku
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Satoshi Yamashiro
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan
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Kise Y, Kuniyoshi Y, Ando M, Maeda T, Inafuku H, Yamashiro S. Transapical aortic perfusion using a deep hypothermic procedure during descending thoracic or thoracoabdominal aortic surgery. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:749-754. [PMID: 31640318 DOI: 10.23736/s0021-9509.19.11043-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND In descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) surgery, though proximal anastomosis using deep hypothermic circulatory arrest (DHCA) is often selected, there are issues surrounding brain and heart protection. In this study, the usefulness of concomitant upper body perfusion via transapical aortic cannulation during deep hypothermic surgery was examined. METHODS Between October 2014 and May 2019, 5 patients (Crawford extent II chronic dissection, N.=3; extent IV aneurysms, N.=1; DTAA, N.=1) underwent DTAA/TAAA repair under deep hypothermia using transapical aortic perfusion. A proximal anastomosis and artery of Adamkiewicz (AKA) reconstruction were performed under continuous perfusion of the upper and lower body at 20 °C. RESULTS The time from aortic cross-clamping to proximal anastomosis was 69±33 minutes, and it took 86±47 minutes to AKA reperfusion. There was no spinal cord ischemic injury or brain or heart complications. One patient required tracheostomy, and the average postoperative intubation time for the other patients was 57±52 hours. All patients were discharged, and the average postoperative hospital stay was 25.6±8.1 days. CONCLUSIONS Concomitant upper body perfusion by the transapical aortic approach contributes to avoidance of brain and heart complications and maintaining spinal cord circulation under deep hypothermic DTAA/TAAA surgery.
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Affiliation(s)
- Yuya Kise
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan -
| | - Yukio Kuniyoshi
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Mizuki Ando
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tatuya Maeda
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Hitoshi Inafuku
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Satoshi Yamashiro
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
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Kouchoukos NT, Kulik A, Haynes M, Castner CF. Early Outcomes After Thoracoabdominal Aortic Aneurysm Repair With Hypothermic Circulatory Arrest. Ann Thorac Surg 2019; 108:1338-1343. [PMID: 31085168 DOI: 10.1016/j.athoracsur.2019.04.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/14/2019] [Accepted: 04/02/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND A variety of intraoperative strategies are currently used for organ protection during open operations on the thoracoabdominal aorta. We report our experience with cardiopulmonary bypass and hypothermic circulatory arrest as the primary modality for organ protection, focusing on the early outcomes. METHODS During a 30-year interval, 285 patients underwent thoracoabdominal aortic aneurysm repair with the use of cardiopulmonary bypass with an interval of circulatory arrest (72 Crawford extent I, 107 extent II, 104 extent III, and 2 extent IV). Degenerative aneurysms were present in 72.6% and aortic dissections in 26.4% of patients. Emergent operations for rupture or acute dissection were required in 6.7% of the patients. RESULTS Thirty-day mortality was 7.4% and was highest for the Crawford extent II and extent III patients (10.3% and 6.7%, respectively). Permanent paralysis or paraplegia occurred in 15 patients (5.3%). The rates were highest for the extent II and extent III patients (6.5% and 6.7%, respectively). Cerebrospinal fluid drainage had no impact on the development of spinal cord injury, and implantation of intercostal/lumbar arteries had a protective effect only in patients with extent II repair. Stroke occurred in 4.2% of patients and renal failure that required dialysis occurred in 6.2%. One-year actual survival was 90.4%. CONCLUSIONS Our extended experience with this technique confirms its safety and effectiveness when used on a routine basis. The rates of spinal cord injury and permanent renal failure are among the lowest reported in the literature. Particularly favorable outcomes were observed in younger patients and patients undergoing elective operations.
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Affiliation(s)
- Nicholas T Kouchoukos
- Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, BJC Healthcare, St Louis, Missouri.
| | - Alexander Kulik
- Division of Cardiothoracic Surgery, Lynn Heart and Vascular Institute, Boca Raton Regional Hospital, Boca Raton, Florida
| | - Marc Haynes
- Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, BJC Healthcare, St Louis, Missouri
| | - Catherine F Castner
- Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, BJC Healthcare, St Louis, Missouri
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10
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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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Joo HC, Youn YN, Kim JH, Lee SH, Lee S, Yoo KJ. Surgical Repair of Distal Aortic Arch Aneurysm With Distal Extension: Sternotomy Versus Thoracotomy. Ann Thorac Surg 2018; 107:1139-1145. [PMID: 30448483 DOI: 10.1016/j.athoracsur.2018.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 08/26/2018] [Accepted: 10/01/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND There is no consensus as to whether a median approach or a lateral approach is better for distal aortic arch aneurysms with distal extensions. The aim of this study was to compare clinical outcomes of these two approaches for distal aortic arch aneurysms with distal extensions. METHODS From January 2001 to December 2017, 212 consecutive patients with distal aortic arch aneurysms with distal extensions underwent surgery using different approaches: hemiarch and descending thoracic aneurysm replacement through thoracotomy (group 1, n = 91); and total arch and descending thoracic aneurysm replacement through sternotomy (group 2, n = 121). Early and late outcomes were compared using scores and inverse probability of treatment adjustments to reduce treatment selection bias. RESULTS The in-hospital mortality was 9.89% (9 of 91) in the thoracotomy group and 2.48% (3 of 121) in the sternotomy group (p = 0.02). The sternotomy group had a lower incidence of permanent stroke (2.48%, 3 of 121) compared with the thoracotomy group (10.99%, 10 of 91, p = 0.01). After adjustment, patients who underwent thoracotomy were at a greater risk of hospital mortality (odds ratio 5.0, p = 0.01), permanent stroke (odds ratio 6.83, p < 0.01), and pneumonia (odds ratio 2.99, p = 0.04), compared with patients who underwent sternotomy. The overall survival at 10 years was 69.8% ± 7.0% for the thoracotomy group and 83.0% ± 5.0% for the sternotomy group (unadjusted p = 0.049, adjusted p = 0.034). CONCLUSIONS The sternotomy approach showed better outcomes in terms of operative mortality, stroke, and pneumonia, as well as long-term survival compared with the thoracotomy approach. These results suggested that the sternotomy approach was more appropriate for patients with distal aortic arch aneurysms with distal extensions.
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Affiliation(s)
- Hyun-Chel Joo
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea.
| | - Young-Nam Youn
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Jung-Hwan Kim
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Seung Hyun Lee
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Sak Lee
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Kyung-Jong Yoo
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
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Manetta F, Mullan CW, Catalano MA. Neuroprotective Strategies in Repair and Replacement of the Aortic Arch. Int J Angiol 2018; 27:98-109. [PMID: 29896042 PMCID: PMC5995688 DOI: 10.1055/s-0038-1649512] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Aortic arch surgery is a technical challenge, and cerebral protection during distal anastomosis is a continued topic of controversy and discussion. The physiologic effects of hypothermic arrest and adjunctive cerebral perfusion have yet to be fully defined, and the optimal strategies are still undetermined. This review highlights the historical context, physiological rationale, and clinical efficacy of various neuroprotective strategies during arch operations.
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Affiliation(s)
- Frank Manetta
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Clancy W. Mullan
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Michael A. Catalano
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
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13
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Kouchoukos NT, Kulik A, Castner C. Branch graft patency after open repair of thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg 2017; 153:S14-S19. [DOI: 10.1016/j.jtcvs.2016.07.063] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 06/22/2016] [Accepted: 07/02/2016] [Indexed: 10/21/2022]
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14
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Suehiro K, Funao T, Fujimoto Y, Mukai A, Nakamura M, Nishikawa K. Transcutaneous near-infrared spectroscopy for monitoring spinal cord ischemia: an experimental study in swine. J Clin Monit Comput 2016; 31:975-979. [DOI: 10.1007/s10877-016-9931-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 08/24/2016] [Indexed: 11/30/2022]
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15
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Intercostal Artery Reconstruction: The Simple and Effective Technique on Spinal Cord Protection during Thoracoabdominal Aortic Replacement. Ann Vasc Surg 2016; 34:62-7. [DOI: 10.1016/j.avsg.2015.12.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 11/28/2015] [Accepted: 12/08/2015] [Indexed: 11/20/2022]
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16
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Maitusong B, Sun HP, Xielifu D, Mahemuti M, Ma X, Liu F, Xie X, Azhati A, Zhou XR, Ma YT. Sex-Related Differences Between Patients With Symptomatic Acute Aortic Dissection. Medicine (Baltimore) 2016; 95:e3100. [PMID: 26986151 PMCID: PMC4839932 DOI: 10.1097/md.0000000000003100] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We designed a retrospective cohort study to assess sex-related differences in clinical manifestations, incidence, and outcomes of patients with symptomatic acute aortic dissection (AAD). We collected clinical data from 2010 to 2015 of 400 patients with AAD. Patients' clinical characteristics, treatment, and outcomes were analyzed as a function of sex. Among 400 patients with AAD, the ratio of men to women was 3.18:1; the incidence of atherosclerosis was higher in women (P = 0.02). Dysphoria (P = 0.01), focal neurological deficits (P = 0.04), and pulse deficits (P = 0.03) were more frequent in men. Imaging findings revealed that pleural effusion (P < 0.01), celiac trunk involvement (P < 0.01), and superior mesenteric artery involvement (P = 0.02) were more frequent in men. Dissection-related pneumonia (P = 0.02), pulmonary atelectasis (P = 0.01), aortic intramural hematoma (P < 0.01), ischemic electrocardiographic changes (P = 0.03), and in-hospital complications such as myocardial ischemia (P = 0.03), hypoxemia (P < 0.01), cardiac tamponade (P = 0.01) occurred more frequently in women. Women with type A dissection had higher in-hospital mortality than men (P < 0.01). The presentation of AAD varies with a patient's sex. Women with AAD had clinical features different from men as follows: higher age of onset, more frequent inpatient complications, and higher in-hospital mortality. These findings may lead to a better understanding of aortic dissection in women that will improve their outcomes.
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Affiliation(s)
- Buamina Maitusong
- From the Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, People's Republic of China (BM, Y-TM, MM, H-PS, XM, XX, AA, X-RZ, DX); Xinjiang Key Laboratory of Cardiovascular Disease Research, Urumqi 830054, People's Republic of China (Y-TM, FL)
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Etz CD, Weigang E, Hartert M, Lonn L, Mestres CA, Di Bartolomeo R, Bachet JE, Carrel TP, Grabenwöger M, Schepens MA, Czerny M. Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery†. Eur J Cardiothorac Surg 2015; 47:943-57. [DOI: 10.1093/ejcts/ezv142] [Citation(s) in RCA: 173] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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18
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Tanaka H, Minatoya K, Sasaki H, Seike Y, Itonaga T, Oda T, Kobayashi J. Recent thoraco-abdominal aortic repair outcomes using moderate-to-deep hypothermia combined with targeted reconstruction of the Adamkiewicz artery. Interact Cardiovasc Thorac Surg 2015; 20:605-10; discussion 610. [DOI: 10.1093/icvts/ivv013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Accepted: 12/19/2014] [Indexed: 11/12/2022] Open
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Panthee N, Ono M. Spinal cord injury following thoracic and thoracoabdominal aortic repairs. Asian Cardiovasc Thorac Ann 2015; 23:235-246. [DOI: 10.1177/0218492314548901] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Objective To discuss the currently available approaches to prevent spinal cord injury during thoracic and thoracoabdominal aortic repairs. Methods We carried out a PubMed search up to 2013 using the Medical Subject Headings: “aortic aneurysm/surgery” and “spinal cord ischemia”; “aortic aneurysm, thoracic/surgery” and “spinal cord ischemia”; “aneurysm/surgery” and “spinal cord ischemia/cerebrospinal fluid”; “aortic aneurysm/surgery” and “paraplegia”. All 190 original articles satisfying our inclusion criteria were analyzed for incidence, predictors, and other pertinent variables related to spinal cord injury, and we compared the results in recent publications with those in earlier reports. Results The mean age of the 38,491 patients was 65.3 ± 4.9 years. The overall incidence of paraplegia and/or paraparesis was 7.1% ± 6.1% (range 0%–32%). The incidence of spinal cord injury before 2000, from 2001 to 2007, and 2008–2013 was 9.0% ± 6.7%, 7.0% ± 6.1%, and 5.9% ± 5.2%, respectively ( p = 0.019). Various predictors of spinal cord injury were identified, extent of disease being the most common. Modification of surgical techniques, use of adjuncts, and better understanding of spinal cord perfusion physiology were attributed to the decrease in postoperative spinal cord injury in recent years. Conclusions Spinal cord injury after thoracic and thoracoabdominal aortic repair poses a real challenge to cardiovascular surgeons. However, with evolving surgical strategies, identification of predictors, and use of various adjuncts over the years, the incidence of spinal cord injury after thoracic/thoracoabdominal aortic repair has declined. Embracing a multimodality approach offers a good insight into combating this grave complication.
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Affiliation(s)
- Nirmal Panthee
- Department of Cardiac Surgery, University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, University of Tokyo, Tokyo, Japan
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Miles LF, Hu R, Jones RM, Carson S, McCall PR. Inferior Vena Cava Resection and Hemihepatectomy for Leiomyosarcoma, Utilizing Cardiopulmonary Bypass, in Situ Hepatic Perfusion, and Distal Hypothermic Circulatory Arrest. J Cardiothorac Vasc Anesth 2015; 30:169-75. [PMID: 26002188 DOI: 10.1053/j.jvca.2015.01.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | - Scott Carson
- Department of Cardiac Surgery, Austin Health, Melbourne, Australia
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Lee WY, Yoo JS, Kim JB, Jung SH, Choo SJ, Chung CH, Lee JW. Outcomes of open surgical repair of descending thoracic aortic disease. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2014; 47:255-61. [PMID: 25207223 PMCID: PMC4157476 DOI: 10.5090/kjtcs.2014.47.3.255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 10/14/2013] [Accepted: 10/25/2013] [Indexed: 11/16/2022]
Abstract
Background To determine the predictors of clinical outcomes following surgical descending thoracic aortic (DTA) repair. Methods We identified 103 patients (23 females; mean age, 64.1±12.3 years) who underwent DTA replacement from 1999 to 2011 using either deep hypothermic circulatory arrest (44%) or partial cardiopulmonary bypass (CPB, 56%). Results The early mortality rate was 4.9% (n=5). Early major complications occurred in 21 patients (20.3%), which included newly required hemodialysis (9.7%), low cardiac output syndrome (6.8%), pneumonia (7.8%), stroke (6.8%), and multi-organ failure (3.9%). None experienced paraplegia. During a median follow-up of 56.3 months (inter-quartile range, 23.1 to 85.1 months), there were 17 late deaths and one aortic reoperation. Overall survival at 5 and 10 years was 80.9%±4.3% and 71.7%±5.9%, respectively. Reoperation-free survival at 5 and 10 years was 77.3%±4.8% and 70.2%±5.8%. Multivariable analysis revealed that age (hazard ratio [HR], 1.10; 95% confidence interval [CI], 1.05 to 1.15; p<0.001) and left ventricle (LV) function (HR, 0.88; 95% CI, 0.82 to 0.96; p<0.003) were significant and independent predictors of long-term mortality. CPB strategy, however, was not significantly related to mortality (p=0.49). Conclusion Surgical DTA repair was practicable in terms of acceptable perioperative mortality/morbidity as well as favorable long-term survival. Age and LV function were risk factors for long-term mortality, irrespective of the CPB strategy.
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Affiliation(s)
- Won-Young Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Jae Suk Yoo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Cheol Hyun Chung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
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22
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Yoo JS, Kim JB, Jung SH, Choo SJ, Chung CH, Lee JW. Surgical repair of descending thoracic and thoracoabdominal aortic aneurysm involving the distal arch: open proximal anastomosis under deep hypothermia versus arch clamping technique. J Thorac Cardiovasc Surg 2014; 148:2101-7. [PMID: 25131174 DOI: 10.1016/j.jtcvs.2014.06.068] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 05/30/2014] [Accepted: 06/05/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND Surgical repair of a descending thoracic and thoracoabdominal aortic aneurysm (DTA/TAAA) involving the distal arch is challenging and requires either deep hypothermic circulatory arrest (DHCA) or crossclamping of the distal arch. The aim of this study was to compare these 2 techniques in the treatment of DTA/TAAA involving the distal arch. METHODS From 1994 to 2012, 298 patients underwent open repair of DTA/TAAA through a left thoracotomy. One hundred seventy-four patients with distal arch involvement who were suitable for either DHCA (n=81) or arch clamping (AC; n=93), were analyzed. In-hospital outcomes were compared using propensity scores and inverse-probability-of-treatment weighting adjustment to reduce treatment selection bias. RESULTS Early mortality was 11.1% in the DHCA group and 8.6% in the AC group (P=.58). Major adverse outcomes included stroke in 16 patients (9.2%), low cardiac output syndrome in 15 (8.6%), paraplegia in 10 (5.7%), and multiorgan failure in 10 (5.7%). After adjustment, patients who underwent DHCA were at similar risk of death (odds ratio [OR], 1.14; P=.80) and permanent neurologic injury (OR, 0.95; P=.92) to those who underwent AC. Although prolonged ventilator support (>24 hours) was more frequent with DHCA than with AC (OR, 2.60; P=.003), DHCA showed a tendency to lower the risk of paraplegia (OR, 0.15; P=.057). CONCLUSIONS Compared with AC, DHCA did not increase postoperative mortality and morbidity, except for prolonged ventilator support. However, DHCA may offer superior spinal cord protection to AC during repair of DTA/TAAA involving the distal arch.
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Affiliation(s)
- Jae Suk Yoo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Cheol Hyun Chung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Sadek M, Abjigitova D, Pellet Y, Rachakonda A, Panagopoulos G, Plestis K. Operative Outcomes After Open Repair of Descending Thoracic Aortic Aneurysms in the Era of Endovascular Surgery. Ann Thorac Surg 2014; 97:1562-7. [DOI: 10.1016/j.athoracsur.2014.01.046] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 01/07/2014] [Accepted: 01/17/2014] [Indexed: 11/27/2022]
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Vallabhajosyula P, Szeto WY, Pulsipher A, Desai N, Menon R, Moeller P, Musthaq S, Pochettino A, Bavaria JE. Antegrade thoracic stent grafting during repair of acute Debakey type I dissection promotes distal aortic remodeling and reduces late open distal reoperation rate. J Thorac Cardiovasc Surg 2014; 147:942-8. [DOI: 10.1016/j.jtcvs.2013.10.047] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 10/31/2013] [Indexed: 11/16/2022]
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25
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Yoo JS, Kim JB, Joo Y, Lee WY, Jung SH, Choo SJ, Chung CH, Lee JW. Deep hypothermic circulatory arrest versus non-deep hypothermic beating heart strategy in descending thoracic or thoracoabdominal aortic surgery. Eur J Cardiothorac Surg 2014; 46:678-84. [DOI: 10.1093/ejcts/ezu053] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Demir A, Erdemli Ö, Ünal U, Taşoğlu İ. Near-Infrared Spectroscopy Monitoring of the Spinal Cord During Type B Aortic Dissection Surgery. J Card Surg 2013; 28:291-4. [DOI: 10.1111/jocs.12082] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Aslı Demir
- Anesthesia Clinic; Türkiye Yüksek İhtisas Education and Research Hospital; Ankara Turkey
| | - Özcan Erdemli
- Cardiovasculary Clinic; Acıbadem University Medical Faculty Ankara Acıbadem Hospital; Ankara Turkey
| | - Utku Ünal
- Cardiovasculary Clinic; Türkiye Yüksek İhtisas Education and Research Hospital; Ankara Turkey
| | - İrfan Taşoğlu
- Cardiovasculary Clinic; Türkiye Yüksek İhtisas Education and Research Hospital; Ankara Turkey
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Outcomes after thoracoabdominal aortic aneurysm repair using hypothermic circulatory arrest. J Thorac Cardiovasc Surg 2013; 145:S139-41. [DOI: 10.1016/j.jtcvs.2012.11.077] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 08/15/2012] [Accepted: 11/28/2012] [Indexed: 11/19/2022]
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Awad H, Elgharably H, Popovich PG. Role of induced hypothermia in thoracoabdominal aortic aneurysm surgery. Ther Hypothermia Temp Manag 2012; 2:119-37. [PMID: 24716449 DOI: 10.1089/ther.2012.0009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
For more than 50 years, hypothermia has been used in aortic surgery as a tool for neuroprotection. Hypothermia has been introduced into thoracoabdominal aortic aneurysm (TAAA) surgery by many cardiovascular centers to protect the body's organs, including the spinal cord. Numerous publications have shown that hypothermia can prevent immediate and delayed motor dysfunction after aortic cross-clamping. Here, we reviewed the historical application of hypothermia in aortic surgery, role of hypothermia in preclinical studies, cellular and molecular mechanisms by which hypothermia confers neuroprotection, and the role of systemic and regional hypothermia in clinical protocols to reduce and/or eliminate the devastating consequences of ischemic spinal cord injury after TAAA repair.
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Affiliation(s)
- Hamdy Awad
- 1 Department of Anesthesiology, Wexner Medical Center at The Ohio State University , Columbus, Ohio
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Aortic arch occlusion technique using a balloon during open proximal anastomosis. Gen Thorac Cardiovasc Surg 2012; 60:247-8. [PMID: 22451151 DOI: 10.1007/s11748-011-0828-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 04/26/2011] [Indexed: 10/28/2022]
Abstract
We report a new aortic arch occlusion technique with a balloon for distal aortic arch repair via left thoracotomy using an open proximal method. Distal aortic arch repair via left thoracotomy sometimes causes brain infarction and perioperative myocardial infarction. That is because air or debris enters into coronary arteries and cervical branches and the left ventricle. Occlusion of the aortic arch using a balloon can prevent such perioperative complications.
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A propensity score–matched comparison of deep versus mild hypothermia during thoracoabdominal aortic surgery. J Thorac Cardiovasc Surg 2012; 143:186-93. [DOI: 10.1016/j.jtcvs.2011.07.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2010] [Revised: 06/14/2011] [Accepted: 07/14/2011] [Indexed: 12/31/2022]
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Conrad MF, Ergul EA, Patel VI, Cambria MR, LaMuraglia GM, Simon M, Cambria RP. Evolution of operative strategies in open thoracoabdominal aneurysm repair. J Vasc Surg 2011; 53:1195-1201.e1. [DOI: 10.1016/j.jvs.2010.11.055] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Revised: 10/28/2010] [Accepted: 11/06/2010] [Indexed: 10/18/2022]
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Kulik A, Castner CF, Kouchoukos NT. Outcomes after thoracoabdominal aortic aneurysm repair with hypothermic circulatory arrest. J Thorac Cardiovasc Surg 2011; 141:953-60. [DOI: 10.1016/j.jtcvs.2010.06.010] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2009] [Revised: 03/30/2010] [Accepted: 06/06/2010] [Indexed: 11/17/2022]
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Taniguchi S, Shibata R, Onohara D. Ruptured thoracic descending aortic aneurysm coexisting with DeBakey type IIIb aortic dissection. Gen Thorac Cardiovasc Surg 2011; 59:34-7. [PMID: 21225398 DOI: 10.1007/s11748-010-0612-0] [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: 09/14/2009] [Accepted: 03/08/2010] [Indexed: 11/27/2022]
Abstract
We have encountered a rare case of ruptured true thoracic aortic aneurysm coexisting with DeBakey type IIIb aortic dissection. The patient was a 67-year-old woman who had a past history of hypertension and cerebral infarction. She experienced DeBakey type IIIb acute aortic dissection, and initially conservative medical treatment was carried out. However, the patient suddenly went into shock, and emergency contrast-enhanced computed tomography revealed the presence of a ruptured true thoracic aortic aneurysm coexisting with the type IIIb dissection. Replacement of the descending aorta was performed through a left thoracotomy using circulatory arrest and deep hypothermia. The rupture site and intimal tear were located in the middle of the aneurysm. Open proximal and distal anastomoses were carried out using a 22 × 10 mm gelatin-covered Dacron graft. The patient was discharged from our hospital uneventfully on the 33rd postoperative day.
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Affiliation(s)
- Shinichiro Taniguchi
- Department of Cardiovascular Surgery, Graduate School of Medicine, Nagasaki University, 1-7-1 Sakamoto-machi, Nagasaki 852-8501, Japan.
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Fehrenbacher JW, Siderys H, Terry C, Kuhn J, Corvera JS. Early and late results of descending thoracic and thoracoabdominal aortic aneurysm open repair with deep hypothermia and circulatory arrest. J Thorac Cardiovasc Surg 2010; 140:S154-60; discussion S185-S190. [DOI: 10.1016/j.jtcvs.2010.08.054] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Revised: 08/10/2010] [Accepted: 08/23/2010] [Indexed: 10/18/2022]
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Turkkan A, Alkan T, Goren B, Kocaeli H, Akar E, Korfali E. Citicoline and postconditioning provides neuroprotection in a rat model of ischemic spinal cord injury. Acta Neurochir (Wien) 2010; 152:1033-42. [PMID: 20112033 DOI: 10.1007/s00701-010-0598-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Accepted: 01/05/2010] [Indexed: 12/14/2022]
Abstract
BACKGROUND Ischemic spinal cord injury is a chain of events caused by the reduction and/or cessation of spinal cord blood flow, which results in neuronal degeneration and loss. Ischemic postconditioning is defined as a series of intermittent interruptions of blood flow in the early phase of reperfusion and has been shown to reduce the infarct size in cerebral ischemia. Our study aimed to characterize the relationship between the neuronal injury-decreasing effects of citicoline and ischemic postconditioning, which were proven to be effective against the apoptotic process. METHOD Spinal cord ischemia was produced in rats using an intrathoracic approach to implement the synchronous arcus aorta and subclavian artery clipping method. In our study, 42 male Sprague-Dawley rats (309 +/- 27 g) were used. Animals were divided into sham operated, spinal ischemia, citicoline, postconditioning, and postconditioning citicoline groups. Postconditioning was generated by six cycles of 1 min occlusion/5 min reperfusion. A 600 mmol/kg dose of citicoline was given intraperitoneally before ischemia in the citicoline and postconditioning citicoline groups. All rats were sacrificed 96 h after reperfusion. For immunohistochemical analysis, bcl-2, caspase 3, caspase 9, and bax immune staining were performed. Caspase 3, caspase 9, bax, and bcl-2 were used as apoptotic and antiapoptotic markers, respectively. FINDINGS The blood pressure values obtained at the onset of reperfusion were significantly lower than the preischemic values. A difference in immunohistochemical scoring was detected between the caspase 3, caspase 9, bax, and bcl-2 groups. When comparisons between the ischemia (groups 2, 3, 4, and 5) and sham groups (group 1) were performed, a significant increase in caspase 3, caspase 9, bax, and bcl-2 was detected. When comparing the subgroups, the average score of caspase 9 was found to be significantly higher in ischemia group 2. The average score of bcl-2 was also found to be significantly higher in postconditioning and citicoline group 5. CONCLUSIONS It is thus thought that combining citicoline with postconditioning provides protection by inhibiting the caspase pathway and by increasing the antiapoptotic proteins.
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Patency and durability of presewn multiple branched graft for thoracoabdominal aortic aneurysm repair. J Vasc Surg 2010; 51:1367-72. [DOI: 10.1016/j.jvs.2010.01.031] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 01/13/2010] [Accepted: 01/13/2010] [Indexed: 11/17/2022]
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Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology,American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons,and Society for Vascular Medicine. J Am Coll Cardiol 2010; 55:e27-e129. [PMID: 20359588 DOI: 10.1016/j.jacc.2010.02.015] [Citation(s) in RCA: 1002] [Impact Index Per Article: 71.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Protection from postischemic spinal cord injury by perfusion cooling of the epidural space during most or all of a descending thoracic or thoracoabdominal aneurysm repair. Gen Thorac Cardiovasc Surg 2010; 58:228-34. [DOI: 10.1007/s11748-009-0495-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2009] [Accepted: 06/04/2009] [Indexed: 10/19/2022]
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Cheng L, Huang F, Chang Q, Zhu J, Yu C, Liu Y, Zhang H, Zheng J, Sun LZ. Repair of extensive thoracoabdominal aortic aneurysm with a tetrafurcate graft: midterm results of 63 cases. Heart Surg Forum 2010; 13:E1-6. [PMID: 20150031 DOI: 10.1532/hsf98.20091081] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The objective is to present a method for maintaining the spinal cord blood supply and our midterm results for using a tetrafurcate graft in extensive thoracoabdominal aortic aneurysm (TAAA) repair. METHODS From August 2003 to October 2007, we used a tetrafurcate graft to perform repairs to TAAAs of Crawford extent II in 63 consecutive patients. The mean age of this group of patients was 39.98 +/- 10.62 years, and 46 (73%) of them were male. All of the procedures were performed under profound hypothermia with a short interval of circulatory arrest. T6 to T12 intercostal arteries were reconstructed as a "neo-intercostal artery" (N-IA) and were connected to an 8-mm sidearm of the graft to maintain the spinal cord blood supply. Visceral arteries were joined into a patch and were anastomosed to the end of the main graft. The left renal artery was anastomosed to an 8-mm sidearm or joined to the patch. The other 10-mm sidearms were anastomosed to iliac arteries. RESULTS With 100% follow-up, the early-mortality rate was 7.94%. The incidence of cerebral complications was 9.52%. Temporary paraplegia was observed in 2 patients, and paraparesis occurred in 1 patient. Pulmonary complication was the most common morbidity in this group (25.40%). Two patients with Marfan syndrome had N-IA artery pseudoaneurysms during follow-up. The mean survival time of this group was 50.64 +/- 2.13 months, with survival rates of 92.06% after 1 year, 88.38% after 2 years, and 86.11% after 3 years. CONCLUSION The N-IA may play an important role in spinal cord protection, and N-IA pseudoaneurysm should be avoided in Marfan syndrome patients. The use of a tetrafurcate graft is a reliable method for TAAA repair, with satisfactory midterm results.
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Affiliation(s)
- Lijian Cheng
- Department of Cardiovascular Surgery, Cardiovascular Institute, Peking Union Medical College, Beijing, China.
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Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010; 121:e266-369. [PMID: 20233780 DOI: 10.1161/cir.0b013e3181d4739e] [Citation(s) in RCA: 1182] [Impact Index Per Article: 84.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Replacement of the descending thoracic aorta: Contemporary outcomes using hypothermic circulatory arrest. J Thorac Cardiovasc Surg 2010; 139:249-55. [DOI: 10.1016/j.jtcvs.2009.08.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Revised: 07/07/2009] [Accepted: 08/07/2009] [Indexed: 11/19/2022]
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Chronidou F, Apostolakis E, Papapostolou I, Grintzalis K, Georgiou CD, Koletsis EN, Karanikolas M, Papathanasopoulos P, Dougenis D. Beneficial effect of the oxygen free radical scavenger amifostine (WR-2721) on spinal cord ischemia/reperfusion injury in rabbits. J Cardiothorac Surg 2009; 4:50. [PMID: 19758462 PMCID: PMC2751753 DOI: 10.1186/1749-8090-4-50] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Accepted: 09/17/2009] [Indexed: 11/10/2022] Open
Abstract
Background Paraplegia is the most devastating complication of thoracic or thoraco-abdominal aortic surgery. During these operations, an ischemia-reperfusion process is inevitable and the produced radical oxygen species cause severe oxidative stress for the spinal cord. In this study we examined the influence of Amifostine, a triphosphate free oxygen scavenger, on oxidative stress of spinal cord ischemia-reperfusion in rabbits. Methods Eighteen male, New Zealand white rabbits were anesthetized and spinal cord ischemia was induced by temporary occlusion of the descending thoracic aorta by a coronary artery balloon catheter, advanced through the femoral artery. The animals were randomly divided in 3 groups. Group I functioned as control. In group II the descending aorta was occluded for 30 minutes and then reperfused for 75 min. In group III, 500 mg Amifostine was infused into the distal aorta during the second half-time of ischemia period. At the end of reperfusion all animals were sacrificed and spinal cord specimens were examined for superoxide radicals by an ultra sensitive fluorescent assay. Results Superoxide radical levels ranged, in group I between 1.52 and 1.76 (1.64 ± 0.10), in group II between 1.96 and 2.50 (2.10 ± 0.23), and in group III (amifostine) between 1.21 and 1.60 (1.40 ± 0.19) (p = 0.00), showing a decrease of 43% in the Group of Amifostine. A lipid peroxidation marker measurement ranged, in group I between 0.278 and 0.305 (0.296 ± 0.013), in group II between 0.427 and 0.497 (0.463 ± 0.025), and in group III (amifostine) between 0.343 and 0.357 (0.350 ± 0.007) (p < 0.00), showing a decrease of 38% after Amifostine administration. Conclusion By direct and indirect methods of measuring the oxidative stress of spinal cord after ischemia/reperfusion, it is suggested that intra-aortic Amifostine infusion during spinal cord ischemia phase, significantly attenuated the spinal cord oxidative injury in rabbits.
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Affiliation(s)
- Fany Chronidou
- Cardiothoracic Surgery Department, Medical School, University of Patras, Patras, Greece.
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Feezor RJ, Lee WA. Strategies for Detection and Prevention of Spinal Cord Ischemia during TEVAR. Semin Vasc Surg 2009; 22:187-92. [DOI: 10.1053/j.semvascsurg.2009.07.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Etz CD, Zoli S, Kari FA, Mueller CS, Bodian CA, Di Luozzo G, Plestis KA, Griepp RB. Redo Lateral Thoracotomy for Reoperative Descending and Thoracoabdominal Aortic Repair: A Consecutive Series of 60 Patients. Ann Thorac Surg 2009; 88:758-66; discussion 767. [DOI: 10.1016/j.athoracsur.2009.04.140] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 04/26/2009] [Accepted: 04/28/2009] [Indexed: 11/26/2022]
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Pochettino A, Brinkman WT, Moeller P, Szeto WY, Moser W, Cornelius K, Bowen FW, Woo YJ, Bavaria JE. Antegrade Thoracic Stent Grafting During Repair of Acute DeBakey I Dissection Prevents Development of Thoracoabdominal Aortic Aneurysms. Ann Thorac Surg 2009; 88:482-9; discussion 489-90. [DOI: 10.1016/j.athoracsur.2009.04.046] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Revised: 04/10/2009] [Accepted: 04/14/2009] [Indexed: 10/20/2022]
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Juvonen T, Biancari F, Rimpiläinen J, Satta J, Rainio P, Kiviluoma K. Strategies for Spinal Cord Protection during Descending Thoracic and Thoracoabdominal Aortic Surgery: Up-to-date Experimental and Clinical Results - A review. SCAND CARDIOVASC J 2009. [DOI: 10.1080/cdv.36.3.136.160] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Fischbein MP, Miller DC. Long-Term Durability of Open Thoracic and Thoracoabdominal Aneurysm Repair. Semin Vasc Surg 2009; 22:74-80. [DOI: 10.1053/j.semvascsurg.2009.04.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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