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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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Kuru Bektaşoğlu P, Arıkök AT, Ergüder Bİ, Sargon MF, Altun SA, Ünlüler C, Börekci A, Kertmen H, Çelikoğlu E, Gürer B. Cinnamaldehyde has ameliorative effects on rabbit spinal cord ischemia and reperfusion injury. World Neurosurg X 2024; 21:100254. [PMID: 38148767 PMCID: PMC10750183 DOI: 10.1016/j.wnsx.2023.100254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 06/14/2023] [Accepted: 11/28/2023] [Indexed: 12/28/2023] Open
Affiliation(s)
- Pınar Kuru Bektaşoğlu
- Department of Neurosurgery, University of Health Sciences, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Ata Türker Arıkök
- 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
| | - Mustafa Fevzi Sargon
- Department of Anatomy, Lokman Hekim University School of Medicine, Ankara, Turkey
| | - Seda Akyıldız Altun
- Department of Neurosurgery, University of Health Sciences, Dışkapı Education and Research Hospital, Ankara, Turkey
| | - Caner Ünlüler
- Department of Neurosurgery, University of Health Sciences, Dışkapı Education and Research Hospital, Ankara, Turkey
| | - Ali Börekci
- Istinye University Faculty of Medicine, Department of Neurosurgery, Istanbul, Turkey
| | - Hayri Kertmen
- Department of Neurosurgery, University of Health Sciences, Dışkapı Education and Research Hospital, Ankara, Turkey
| | - Erhan Çelikoğlu
- Istinye University Faculty of Medicine, Department of Neurosurgery, Istanbul, Turkey
| | - Bora Gürer
- Istinye University Faculty of Medicine, Department of Neurosurgery, Istanbul, Turkey
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3
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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: 8] [Impact Index Per Article: 8.0] [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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Lam MSH, Luoma AMV, Reddy U. Acute perioperative neurological emergencies. Int Anesthesiol Clin 2023; 61:53-63. [PMID: 37249171 DOI: 10.1097/aia.0000000000000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Michelle S H Lam
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Astri M V Luoma
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
| | - Ugan Reddy
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
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5
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El-Hajj VG, Stenimahitis V, Gharios M, Mahdi OA, Elmi-Terander A, Edström E. Spontaneous spinal cord infarctions: a systematic review and pooled analysis protocol. BMJ Open 2023; 13:e071044. [PMID: 37344113 PMCID: PMC10314618 DOI: 10.1136/bmjopen-2022-071044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 06/09/2023] [Indexed: 06/23/2023] Open
Abstract
INTRODUCTION Spinal cord infarction (SCInf) is a rare ischaemic event that manifests with acute neurological deficits. It is typically classified as either spontaneous, defined as SCInf without any inciting event, or periprocedural, which typically occur in conjunction with vascular surgery with aortic manipulations. While periprocedural SCInf has recently been the subject of intensified research, especially focusing on the primary prevention of this complication, spontaneous SCInf remains less studied. METHODS AND ANALYSIS Electronic databases, including PubMed, Web of Science and Embase, will be searched using the keywords "spinal cord", "infarction", "ischemia" and "spontaneous". The search will be set to provide only English studies published from database inception. Editorials, letters and reviews will also be excluded. Reference lists of relevant records will also be searched. Identified studies will be screened for inclusion, by one reviewer in the first step and then three in the next step to decrease the risk of bias. The synthesis will address several topics of interest including epidemiology, presentation, diagnostics, treatment strategies, outcomes and predictors. The review aims to gather the body of evidence to summarise the current knowledge on SCInf. This will lead to a better understanding of the condition, its risk factors, diagnosis and management. Moreover, the review will also provide an understanding of the prognosis of patients with SCInf with respect to neurological function, quality of life and mortality. Finally, this overview of the literature will allow the identification of knowledge gaps to help guide future research efforts. ETHICS AND DISSEMINATION Ethics approval was not required for our review as it is based on existing publications. The final manuscript will be submitted to a peer-reviewed journal.
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Affiliation(s)
- Victor Gabriel El-Hajj
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Vasilios Stenimahitis
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Gharios
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Omar Ali Mahdi
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Adrian Elmi-Terander
- Stockholm Spine Center, Löwenströmska Hospital, Upplands-Väsby, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Erik Edström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Spine Center, Löwenströmska Hospital, Upplands-Väsby, Sweden
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6
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Nisi F, Carenzo L, Ruggieri N, Reda A, Pascucci MG, Pignataro A, Civilini E, Piccioni F, Giustiniano E. The anesthesiologist's perspective on emergency aortic surgery: Preoperative optimization, intraoperative management, and postoperative surveillance. Semin Vasc Surg 2023; 36:363-379. [PMID: 37330248 DOI: 10.1053/j.semvascsurg.2023.04.017] [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: 02/26/2023] [Revised: 04/23/2023] [Accepted: 04/25/2023] [Indexed: 06/19/2023]
Abstract
The management of emergencies related to the aorta requires a multidisciplinary approach involving various health care professionals. Despite technological advancements in treatment methods, the risks and mortality rates associated with surgery remain high. In the emergency department, definitive diagnosis is usually obtained through computed tomography angiography, and management focuses on controlling blood pressure and treating symptoms to prevent further deterioration. Preoperative resuscitation is the main focus, followed by intraoperative management aimed at stabilizing the patient's hemodynamics, controlling bleeding, and protecting vital organs. After the operation, factors such as organ protection, transfusion management, pain control, and overall patient care must be taken into account. Endovascular techniques are becoming more common in surgical treatment, but they also present new challenges in terms of complications and outcomes. It is recommended that patients with suspected ruptured abdominal aortic aneurysms be transferred to facilities with both open and endovascular treatment options and a track record of successful outcomes to ensure the best patient care and long-term results. To achieve optimal patient outcomes, close collaboration and regular case discussions between health care professionals are necessary, as well as participation in educational programs to promote a culture of teamwork and continuous improvement.
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Affiliation(s)
- Fulvio Nisi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Luca Carenzo
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Nadia Ruggieri
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Antonio Reda
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | | | - Arianna Pignataro
- Vascular Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan Italy
| | - Efrem Civilini
- Vascular Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan Italy
| | - Federico Piccioni
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Enrico Giustiniano
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
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7
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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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Singh S, Pupovac SS, Assi R, Vallabhajosyula P. Comprehensive review of hybrid aortic arch repair with focus on zone 0 TEVAR and our institutional experience. Front Cardiovasc Med 2022; 9:991824. [PMID: 36187018 PMCID: PMC9520124 DOI: 10.3389/fcvm.2022.991824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/25/2022] [Indexed: 11/24/2022] Open
Abstract
Even with increasing operator experience and a better understanding of the disease and the operation, intervention for aortic arch pathologies continues to struggle with relatively higher mortality, reintervention, and neurologic complications. The hybrid aortic arch repair was introduced to simplify the procedure and improve the outcome. With recent industry-driven advances, hybrid repairs are not only offered to poor surgical candidates but have become mainstream. This review discusses the evolution of hybrid repair, terminology pertinent to this technique, and results. In addition, we aim to provide a pervasive review of hybrid aortic arch repairs with reference to relevant literature for a detailed understanding. We have also discussed our institutional experience with hybrid repairs.
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MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissection. J Thorac Cardiovasc Surg 2022; 163:1231-1249. [PMID: 35090765 DOI: 10.1016/j.jtcvs.2021.11.091] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 01/16/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Md
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
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10
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MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery Clinical Practice Guidelines on the Management of Type B Aortic Dissection. Ann Thorac Surg 2022; 113:1073-1092. [PMID: 35090687 DOI: 10.1016/j.athoracsur.2021.11.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Texas
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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11
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Steffner KR, Cheung AT. Preservation of Spinal Cord Function. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00023-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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12
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Oftadeh M, Ural N, LeVan P, Prabhu V, Haske M. The Evolution and Future of Spinal Drain for Thoracic Aortic Aneurysm Repair: A Review. J Cardiothorac Vasc Anesth 2021; 35:3362-3373. [PMID: 34154920 DOI: 10.1053/j.jvca.2021.04.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 11/11/2022]
Abstract
For decades, spinal drains for cerebrospinal fluid (CSF) pressure monitoring and drainage have been used as adjuncts to protect against spinal cord injury resulting from thoracic aortic aneurysm repair. There are many different approaches to placement and management of CSF drains, with no true consensus on best practice. Furthermore, the incidence of complications resulting from spinal drains largely has been stagnant. This review describes the history and rationale behind placement of CSF drains, explore various considerations, techniques, and equipment, and discuss potential considerations for developing more comprehensive protocols.
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Affiliation(s)
- Mina Oftadeh
- Department of Anesthesiology, Loyola University Medical Center, Maywood, IL.
| | - Nil Ural
- Department of Anesthesiology, Loyola University Medical Center, Maywood, IL
| | - Pierre LeVan
- Department of Anesthesiology, Franciscan Health Olympia Fields, Olympia Fields, IL
| | - Vikram Prabhu
- Department of Anesthesiology, Loyola University Medical Center, Maywood, IL
| | - Michael Haske
- Department of Anesthesiology, Loyola University Medical Center, Maywood, IL
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13
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Preventing spinal cord injury following thoracoabdominal aortic aneurysm repair: The battle to eliminate paraplegia. JTCVS Tech 2021; 8:11-15. [PMID: 34401794 PMCID: PMC8350759 DOI: 10.1016/j.xjtc.2021.01.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 11/22/2022] Open
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14
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Kahveci R, Kahveci FO, Gokce EC, Gokce A, Kısa Ü, Sargon MF, Fesli R, Gürer B. Effects of Ganoderma lucidum Polysaccharides on Different Pathways Involved in the Development of Spinal Cord Ischemia Reperfusion Injury: Biochemical, Histopathologic, and Ultrastructural Analysis in a Rat Model. World Neurosurg 2021; 150:e287-e297. [PMID: 33689849 DOI: 10.1016/j.wneu.2021.02.129] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 02/28/2021] [Accepted: 02/28/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Inflammation and oxidative stress are 2 important factors in the emergence of paraplegia associated with spinal cord ischemia-reperfusion injury (SCIRI) after thoracoabdominal aortic surgery. Here it is aimed to investigate the effects of Ganoderma lucidum polysaccharide (GLPS) on SCIRI. METHODS Rats were randomly selected into 4 groups of 8 animals each: sham, ischemia, methylprednisolone, and GLPS. To research the impacts of various pathways that are efficacious in formation of SCIRI, tumor necrosis factor α, interleukin 1β, nitric oxide, superoxide dismutase levels, and catalase, glutathione peroxidase activities, malondialdehyde levels, and caspase-3 activity were measured in tissues taken from the spinal cord of rats in all groups killed 24 hours after ischemia reperfusion injury. The Basso, Beattie, and Bresnahan locomotor scale and inclined plane test were used for neurologic assessment before and after SCIRI. In addition, histologic and ultrastructural analyses of tissue samples in all groups were performed. RESULTS SCIRI also caused marked increase in tissue tumor necrosis factor α, interleukin 1β, nitric oxide, malondialdehyde levels, and caspase-3 activity, because of inflammation, increased free radical generation, lipid peroxidation, and apoptosis, respectively. On the other hand, SCIRI caused significant reduction in tissue superoxide dismutase, glutathione peroxidase, and catalase activities. Pretreatment with GLPS likewise diminished the level of the spinal cord edema, inflammation, and tissue injury shown by pathologic and ultrastructural examination. Pretreatment with GLPS reversed all these biochemical changes and improved the altered neurologic status. CONCLUSIONS These outcomes propose that pretreatment with GLPS prevents progression of SCIRI by alleviating inflammation, oxidation, and apoptosis.
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Affiliation(s)
- Ramazan Kahveci
- Department of Neurosurgery, Balıkesir University, Faculty of Medicine, Balıkesir, Turkey
| | - Fatih Ozan Kahveci
- Department of Emergency Medicine, Balıkesir Atatürk City Hospital, Balıkesir, Turkey
| | - Emre Cemal Gokce
- Department of Neurosurgery, Abdurrahman Yurtaslan Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Aysun Gokce
- Department of Pathology, Ministry of Health, Diskapi Yildirim Beyazit Education and Research Hospital, Ankara, Turkey
| | - Üçler Kısa
- Department of Biochemistry, Kirikkale University, Faculty of Medicine, Kirikkale, Turkey
| | - Mustafa Fevzi Sargon
- Department of Anatomy, Lokman Hekim University, Faculty of Medicine, Ankara, Turkey
| | - Ramazan Fesli
- Department of Neurosurgery, Tarsus Medical Park Hospital, Mersin, Turkey
| | - Bora Gürer
- Department of Neurosurgery, University of Health Sciences, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey.
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15
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Perioperative care after thoracoabdominal aortic aneurysm repair: The Baylor College of Medicine experience. Part 2: Postoperative management. J Thorac Cardiovasc Surg 2021; 161:699-705. [DOI: 10.1016/j.jtcvs.2019.11.143] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/01/2019] [Accepted: 11/21/2019] [Indexed: 01/16/2023]
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16
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Neth BJ, Hewitt AL, Edlund WS, Guerin JB, Patterson MC, Keating GF. Rapidly Progressive Paraplegia in an 11-Year-Old Girl: A Case of Spinal Cord Infarction and Expected Imaging Findings. Child Neurol Open 2021; 7:2329048X20981295. [PMID: 33426143 PMCID: PMC7758642 DOI: 10.1177/2329048x20981295] [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: 11/29/2022] Open
Abstract
Rapidly progressive non-traumatic paraplegia in a child is uncommonly encountered in clinical practice, but is an important presentation to consider given the potential for significant morbidity. We present the case of an 11-year-old girl who was found to have hyperacute paraplegia due to spinal cord infarction. We discuss the appropriate workup, differential diagnosis in children and how this relates to adults; and describe the prognosis and current state of management options for spinal cord infarction.
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Affiliation(s)
- Bryan J Neth
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Angela L Hewitt
- Department of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | - Wendy S Edlund
- Department of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | - Julie B Guerin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Marc C Patterson
- Department of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | - Gesina F Keating
- Department of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
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17
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Ashton C, Banham N, Needham M. Acute spontaneous spinal cord infarction: Utilisation of hyperbaric oxygen treatment, cerebrospinal fluid drainage and pentoxifylline. Diving Hyperb Med 2020; 50:325-331. [PMID: 33325011 DOI: 10.28920/dhm50.4.325-331] [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: 05/15/2020] [Accepted: 08/09/2020] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Spinal cord infarction (SCI) is a potentially devastating disorder presenting with an acute anterior spinal artery syndrome, accounting for an estimated 1% of stroke presentations. Aetiologies include aortic surgical complications, systemic hypotension, fibrocartilaginous embolism and vascular malformations. Diagnosis is clinical combined with restriction on diffusion-weighted magnetic resonance imaging (MRI). There are no treatment guidelines for non-perioperative cases although there is limited literature regarding potential therapies, including hyperbaric oxygen treatment (HBOT) and cerebrospinal fluid (CSF) drainage. We describe 13 cases of acute SCI, five receiving HBOT, and three also receiving pentoxifylline and drainage of lumbar CSF. METHODS Data for all patients with MRI-proven SCI at Fiona Stanley Hospital from 2014-2019 were reviewed. RESULTS Thirteen patients, median age 57 years (31-74), 54% female, were identified. Aetiologies: two fibrocartilaginous emboli; seven likely atherosclerotic; two thromboembolic; two cryptogenic. All presented with flaccid paraplegia except one with Brown-Sequard syndrome. Levels ranged from C4 to T11. Five patients received HBOT within a median time of 40 hours from symptom onset, with an average 15 treatments (10-20). Three of these received triple therapy (HBOT, pentoxifylline, CSF drainage) and had median Medical Research Council manual muscle testing power of 5, median modified Rankin Score (mRS) of 1 and American Spinal Injury Association (ASIA) score of D on discharge, compared with 2 power, mRS 3.5 and ASIA B in those who did not. CONCLUSIONS SCI can be severely disabling. Triple therapy with pentoxifylline, CSF drainage and HBOT may reduce disability and further prospective trials are required.
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Affiliation(s)
- Catherine Ashton
- Neurology Department, Fiona Stanley Hospital, Murdoch, Australia.,Corresponding author: Dr Catherine Ashton, Neurology Department, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA 6150, Australia,
| | - Neil Banham
- Department of Hyperbaric Medicine, Fiona Stanley Hospital, Murdoch, Australia
| | - Merrilee Needham
- Neurology Department, Fiona Stanley Hospital, Murdoch, Australia.,Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia.,Perron Institute for Neurological and Translational Science, Nedlands, Australia.,University of Notre Dame, Fremantle, Australia
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18
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Chatterjee S, Preventza O, Orozco-Sevilla V, Coselli JS. Critical care management after open thoracoabdominal aortic aneurysm repair. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 62:220-229. [PMID: 33307646 DOI: 10.23736/s0021-9509.20.11712-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Thoracoabdominal aortic aneurysm repair is technically demanding for the surgeon and physiologically demanding on the patient. As such, it requires diligent multidisciplinary perioperative care to maximize the likelihood of a successful outcome. In this article, we discuss key principles for managing patients after open thoracoabdominal aortic aneurysm repair, which we have learned over the course of performing more than 3500 of such procedures. These principles address patient handoff between the operating room and Intensive Care Unit, resuscitation, prevention and management of spinal cord deficits, and important neurological, respiratory, cardiovascular, renal, gastrointestinal, and hematological considerations. Understanding the expected postoperative course allows for earlier recognition of deviations from that course and increases the likelihood of successful rescue of patients from adverse outcomes. Achieving positive outcomes after thoracoabdominal aortic aneurysm repair requires attention to detail across the perioperative, intraoperative, and postoperative phases of care.
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Affiliation(s)
- Subhasis Chatterjee
- Division of General Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA - .,Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA -
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA.,Department of Cardiovascular Surgery, CHI St Luke's Health - Baylor St Luke's Medical Center, Houston, TX, USA
| | - Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA.,Department of Cardiovascular Surgery, CHI St Luke's Health - Baylor St Luke's Medical Center, Houston, TX, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA.,Department of Cardiovascular Surgery, CHI St Luke's Health - Baylor St Luke's Medical Center, Houston, TX, USA
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19
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Currie LA. Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management. Crit Care Nurse 2020; 40:75-80. [PMID: 33257969 DOI: 10.4037/ccn2020684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Linda Ann Currie
- Linda Ann Currie is a clinical nurse specialist in the cardiac surgery intensive care unit at the Virginia Commonwealth University Health System, Richmond, Virginia
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20
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Lumbar drain complications in patients undergoing fenestrated or branched endovascular aortic aneurysm repair: Development of an institutional protocol for lumbar drain management. J Vasc Surg 2020; 72:1576-1583. [DOI: 10.1016/j.jvs.2020.02.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/03/2020] [Indexed: 11/23/2022]
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21
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Zhou L, Song Z, Zhou L, Qiu Y, Hu N, Hu Y, Hu X. Protective role of astragalus injection in spinal cord ischemia-reperfusion injury in rats. ACTA ACUST UNITED AC 2019; 23:116-121. [PMID: 29664452 PMCID: PMC8015442 DOI: 10.17712/nsj.2018.4.20170391] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objectives: To investigate the neuroprotective effect of Astragalus injection in a spinal cord ischemia-reperfusion (I/R) injury model. Methods: A total of 27 Sprague Dawley rats were randomly divided into 3 groups: control group (n=3), I/R group (n=12), and Astragalus injection group (Ast group, n=12). Spinal cord ischemia was induced by occlusion of the abdominal aorta above the right renal artery for 32 min. Animals in the Ast group were administered Astragalus injection (6.42 mL/kg) at 30 min before the induction of ischemia. After reperfusion for 8, 12, 24, or 48 hours, the serum neuron-specific enolase (NSE) concentration was measured by enzyme-linked immunosorbent assay (ELISA) and the aquaporin-4 (AQP4) protein level was detected by western blotting. Results: The pathological changes, as assessed by hematoxylin and eosin (HE) staining, were milder in the spinal cords of the Ast group compared to the I/R group. Enzyme-linked immunosorbent assay demonstrated that the NSE concentration of the Ast group was significantly lower than that of the I/R group (p<0.05). However, the NSE concentrations of the I/R and Ast groups were significantly higher than that of the control group (p=0.05). Additionally, the expression of AQP4 in the Ast group was lower than that of the I/R group at each time point. Conclusion: These findings indicate that Astragalus injection has a neuroprotective effect in spinal cord I/R injury by decreasing the AQP4 expression.
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Affiliation(s)
- Liya Zhou
- Department of Orthopedics, Xiangyang Hospital of Traditional Chinese Medicine, Xiangyang,China
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22
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Rocha RV, Friedrich JO, Elbatarny M, Yanagawa B, Al-Omran M, Forbes TL, Lindsay TF, Ouzounian M. A systematic review and meta-analysis of early outcomes after endovascular versus open repair of thoracoabdominal aortic aneurysms. J Vasc Surg 2019; 68:1936-1945.e5. [PMID: 30470373 DOI: 10.1016/j.jvs.2018.08.147] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 08/05/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The objective of this study was to compare the early results of endovascular vs open thoracoabdominal aortic aneurysm (TAAA) repair. METHODS MEDLINE and Embase were searched for studies from January 2006 to March 2018 that compared endovascular vs open repair of TAAA using branched or fenestrated endografts. Data were subjected to a meta-analysis using a random-effects model. The outcomes of interest included early mortality, spinal cord injury, renal failure requiring dialysis, stroke, and hospital length of stay. RESULTS Eight comparative studies met inclusion criteria. There were two retrospective propensity-matched studies, two unadjusted single-center retrospective studies, and four unadjusted national population-based studies. Mortality in the matched studies was equivalent in both groups. Pooled analysis of all unmatched observational studies revealed a survival benefit for endovascular over open repair (relative risk [RR], 0.63; 95% confidence interval [CI],0.45-0.87); P < .01, I2 = 47%). Endovascular repair was also associated with lower incidence of spinal cord injury (RR, 0.65; 95% CI, 0.42-1.01; P = .05; I2 = 28%). For unmatched studies, pooled RR of renal failure requiring dialysis significantly favored endovascular repair (RR, 0.44; 95% CI, 0.23-0.85; P = .01; I2 = 0%), although in the adjusted cohort, risk of dialysis was not different (RR, 1.00; 95% CI, 0.06-15.65; P = 1.00). Postoperative stroke rate was reported in three unadjusted studies and was not different between groups (RR, 0.81; 95% CI, 0.28-2.40; P = .71; I2 = 77%). Hospital length of stay was reported in four studies and was shorter in the endovascular group (mean difference, -4.4 days; 95% CI, -6.6 to -1.7; P < .01; I2 = 73%). CONCLUSIONS There are few reports comparing endovascular vs open repair of TAAAs. Short-term outcomes may be improved in patients undergoing endovascular treatment of TAAA on the basis of a limited number of studies with high risk of bias. These findings highlight the need for larger comparative studies with standardization of reporting.
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Affiliation(s)
- Rodolfo V Rocha
- Division of Cardiac Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jan O Friedrich
- Department of Critical Care Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Bobby Yanagawa
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Al-Omran
- Division of Vascular Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada.
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23
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Yoshitani K, Masui K, Kawaguchi M, Kawamata M, Kakinohana M, Kato S, Hasuwa K, Yamakage M, Yoshikawa Y, Nishiwaki K, Aoyama T, Inagaki Y, Yamasaki K, Matsumoto M, Ishida K, Yamashita A, Seo K, Kakumoto S, Hayashi H, Tanaka Y, Tanaka S, Ishida T, Uchino H, Kakinuma T, Yamada Y, Mori Y, Izumi S, Nishimura K, Nakai M, Ohnishi Y. Clinical Utility of Intraoperative Motor-Evoked Potential Monitoring to Prevent Postoperative Spinal Cord Injury in Thoracic and Thoracoabdominal Aneurysm Repair: An Audit of the Japanese Association of Spinal Cord Protection in Aortic Surgery Database. Anesth Analg 2018; 126:763-768. [PMID: 29283918 DOI: 10.1213/ane.0000000000002749] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Spinal cord ischemic injury is the most devastating sequela of descending and thoracoabdominal aortic surgery. Motor-evoked potentials (MEPs) have been used to intraoperatively assess motor tract function, but it remains unclear whether MEP monitoring can decrease the incidence of postoperative motor deficits. Therefore, we reviewed multicenter medical records of patients who had undergone descending and thoracoabdominal aortic repair (both open surgery and endovascular repair) to assess the association of MEP monitoring with postoperative motor deficits. METHODS Patients included in the study underwent descending or thoracoabdominal aortic repair at 12 hospitals belonging to the Japanese Association of Spinal Cord Protection in Aortic Surgery between 2000 and 2013. Using multivariable mixed-effects logistic regression analysis, we investigated whether intraoperative MEP monitoring was associated with postoperative motor deficits at discharge after open and endovascular aortic repair. RESULTS We reviewed data from 1214 patients (open surgery, 601 [49.5%]; endovascular repair, 613 [50.5%]). MEP monitoring was performed in 631 patients and not performed in the remaining 583 patients. Postoperative motor deficits were observed in 75 (6.2%) patients at discharge. Multivariable logistic regression analysis revealed that postoperative motor deficits at discharge did not have a significant association with MEP monitoring (adjusted odds ratio [OR], 1.13; 95% confidence interval [CI], 0.69-1.88; P = .624), but with other factors: history of neural deficits (adjusted OR, 6.08; 95% CI, 3.10-11.91; P < .001), spinal drainage (adjusted OR, 2.14; 95% CI, 1.32-3.47; P = .002), and endovascular procedure (adjusted OR, 0.45; 95% CI, 0.27-0.76; P = .003). The sensitivity and specificity of MEP <25% of control value for motor deficits at discharge were 37.8% (95% CI, 26.5%-49.5%) and 95.5% (95% CI, 94.7%-96.4%), respectively. CONCLUSIONS MEP monitoring was not significantly associated with motor deficits at discharge.
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Affiliation(s)
- Kenji Yoshitani
- From the Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenichi Masui
- Department of Anesthesiology, National Defense Medical College, Tokorozawa, Japan.,Department of Anesthesiology, Showa University School of Medicine, Tokyo, Japan
| | | | - Mikito Kawamata
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Manabu Kakinohana
- Department of Anesthesiology, University of Ryukyu, Faculty of Medicine, Nishihara, Japan
| | - Shinya Kato
- From the Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kyoko Hasuwa
- From the Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michiaki Yamakage
- Department of Anesthesiology, Sapporo Medical University, School of Medicine, Sapporo, Japan
| | - Yusuke Yoshikawa
- Department of Anesthesiology, Sapporo Medical University, School of Medicine, Sapporo, Japan
| | - Kimitoshi Nishiwaki
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Chikusa-ku, Nagoya
| | - Tadashi Aoyama
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Chikusa-ku, Nagoya
| | - Yoshimi Inagaki
- Department of Anesthesiology and Critical Care and Medicine, Tottori University, Faculty of Medicine, Tottori, Japan
| | - Kazumasa Yamasaki
- Department of Anesthesiology and Critical Care and Medicine, Tottori University, Faculty of Medicine, Tottori, Japan
| | - Mishiya Matsumoto
- Department of Anesthesiology, Yamaguchi University, Graduate School of Medicine, Ube, Japan
| | - Kazuyoshi Ishida
- Department of Anesthesiology, Yamaguchi University, Graduate School of Medicine, Ube, Japan
| | - Atsuo Yamashita
- Department of Anesthesiology, Yamaguchi University, Graduate School of Medicine, Ube, Japan
| | - Katsuhiro Seo
- Department of Anesthesiology and Intensive Care Medicine, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Shinichi Kakumoto
- Department of Anesthesiology and Intensive Care Medicine, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Hironobu Hayashi
- Department of Anesthesiology, Nara Medical University, Kashihara, Japan
| | - Yuu Tanaka
- Department of Anesthesiology, Nara Medical University, Kashihara, Japan
| | - Satoshi Tanaka
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takashi Ishida
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hiroyuki Uchino
- Department of Anesthesiology, Tokyo Medical University, Tokyo, Japan
| | - Takayasu Kakinuma
- Department of Anesthesiology, Tokyo Medical University, Tokyo, Japan
| | - Yoshitsugu Yamada
- Department of Anesthesiology, Faculty of Vital Care Medicine, The Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshiteru Mori
- Department of Anesthesiology, Faculty of Vital Care Medicine, The Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shunsuke Izumi
- Department of Anesthesiology, University of Ryukyu, Faculty of Medicine, Nishihara, Japan
| | - Kunihiro Nishimura
- Department of Statistics and Data Analysis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michikazu Nakai
- Department of Statistics and Data Analysis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshihiko Ohnishi
- From the Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Japan
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Strohm TA, John S, Hussain MS. Cerebrospinal fluid drainage and blood pressure elevation to treat acute spinal cord infarct. Surg Neurol Int 2018; 9:195. [PMID: 30294499 PMCID: PMC6169349 DOI: 10.4103/sni.sni_2_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 02/02/2018] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Current management of acute spinal cord infarction (SCI) is limited. Lumbar cerebrospinal fluid drainage (CSFD) with blood pressure augmentation is utilized in the thoracic/thoracoabdominal aortic repair and thoracic endovascular aortic repair (TEVAR) populations to increase spinal perfusion pressure. CASE DESCRIPTION We identified 3 patients who sustained acute SCI and underwent CSFD and maintenance of elevated mean arterial pressure (MAP) within 24 hours of injury. The first patient exhibited delayed-onset ischemia after a TEVAR. The second patient presented with an acute type B aortic intramural hematoma. The third patient developed spinal cord ischemia following bronchial artery embolization. There was significant improvement in the motor examination (e.g., ASIA impairment scale grade B or C) to grade D utilizing both blood pressure augmentation and CSFD. CONCLUSIONS Lumbar CSFD with MAP elevation benefited 3 patients with acute SCI of varying etiologies.
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Affiliation(s)
- Tamara A. Strohm
- Department of Neurology, Cleveland Clinic, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Seby John
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Muhammad S. Hussain
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
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25
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Khayat M, Cooper KJ, Khaja MS, Gandhi R, Bryce YC, Williams DM. Endovascular management of acute aortic dissection. Cardiovasc Diagn Ther 2018; 8:S97-S107. [PMID: 29850422 DOI: 10.21037/cdt.2017.10.07] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Acute dissection of the thoracic aorta is a potentially life-threatening condition which requires collaborative treatment from multiple specialties for optimal patient outcomes. Dissections involving the ascending aorta and aortic arch have traditionally been managed entirely by surgery, while dissections beyond the arch vessels have most commonly been relegated to medical management. This algorithm has been undergoing a paradigm shift over the past two decades due to improvements in stent graft technology, better understanding of the hemodynamic interactions of the true and false lumen and their influence on organ and limb perfusion, and improvements in medical management and long term surveillance for dissection-related complications. This manuscript includes a brief discussion of the pathogenesis and etiology of dissection, followed by an in-depth review of the medical and endovascular techniques utilized to treat patients afflicted by this condition.
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Affiliation(s)
- Mamdouh Khayat
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health Systems, Ann Arbor, MI, USA
| | - Kyle J Cooper
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health Systems, Ann Arbor, MI, USA
| | - Minhaj S Khaja
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health Systems, Ann Arbor, MI, USA
| | - Ripal Gandhi
- Department of Radiology, Division of Vascular and Interventional Radiology, Miami Cardiac and Vascular Institute, Miami, FL, USA
| | - Yolanda C Bryce
- Department of Radiology, Division of Vascular and Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David M Williams
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health Systems, Ann Arbor, MI, USA
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26
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DeAngelis MC, Green MS. Anesthesia for Aortic Surgery. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Awad H, Ramadan ME, El Sayed HF, Tolpin DA, Tili E, Collard CD. Spinal cord injury after thoracic endovascular aortic aneurysm repair. Can J Anaesth 2017; 64:1218-1235. [PMID: 29019146 DOI: 10.1007/s12630-017-0974-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 08/04/2017] [Accepted: 09/13/2017] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Thoracic endovascular aortic aneurysm repair (TEVAR) has become a mainstay of therapy for aneurysms and other disorders of the thoracic aorta. The purpose of this narrative review article is to summarize the current literature on the risk factors for and pathophysiology of spinal cord injury (SCI) following TEVAR, and to discuss various intraoperative monitoring and treatment strategies. SOURCE The articles considered in this review were identified through PubMed using the following search terms: thoracic aortic aneurysm, TEVAR, paralysis+TEVAR, risk factors+TEVAR, spinal cord ischemia+TEVAR, neuromonitoring+thoracic aortic aneurysm, spinal drain, cerebrospinal fluid drainage, treatment of spinal cord ischemia. PRINCIPAL FINDINGS Spinal cord injury continues to be a challenging complication after TEVAR. Its incidence after TEVAR is not significantly reduced when compared with open thoracoabdominal aortic aneurysm repair. Nevertheless, compared with open procedures, delayed paralysis/paresis is the predominant presentation of SCI after TEVAR. The pathophysiology of SCI is complex and not fully understood, though the evolving concept of the importance of the spinal cord's collateral blood supply network and its imbalance after TEVAR is emerging as a leading factor in the development of SCI. Cerebrospinal fluid drainage, optimal blood pressure management, and newer surgical techniques are important components of the most up-to-date strategies for spinal cord protection. CONCLUSION Further experimental and clinical research is needed to aid in the discovery of novel neuroprotective strategies for the protection and treatment of SCI following TEVAR.
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Affiliation(s)
- Hamdy Awad
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Doan Hall 534, 410 West 10th Avenue, Columbus, OH, 43210, USA.
| | - Mohamed Ehab Ramadan
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Doan Hall 534, 410 West 10th Avenue, Columbus, OH, 43210, USA.,Department of Anesthesiology, Theodor Bilharz Research Institute, Giza, Egypt
| | - Hosam F El Sayed
- Division of Vascular Diseases & Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Daniel A Tolpin
- Division of Cardiovascular Anesthesiology, The Texas Heart Institute, Baylor St. Luke's Medical Center, Houston, TX, USA
| | - Esmerina Tili
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Doan Hall 534, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Charles D Collard
- Division of Cardiovascular Anesthesiology, The Texas Heart Institute, Baylor St. Luke's Medical Center, Houston, TX, USA
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Sheth KN, Nourollahzadeh E. Neurologic complications of cardiac and vascular surgery. HANDBOOK OF CLINICAL NEUROLOGY 2017; 141:573-592. [PMID: 28190436 DOI: 10.1016/b978-0-444-63599-0.00031-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This chapter will provide an overview of the major neurologic complications of common cardiac and vascular surgeries, such as coronary artery bypass grafting and carotid endarterectomy. Neurologic complications after cardiac and vascular surgeries can cause significant morbidity and mortality, which can negate the beneficial effects of the intervention. Some of the complications to be discussed include ischemic and hemorrhagic stroke, seizures, delirium, cognitive dysfunction, cerebral hyperperfusion syndrome, cranial nerve injuries, and peripheral neuropathies. The severity of these complications can range from mild to lethal. The etiology of complications can include a variety of mechanisms, which can differ based on the type of cardiac or vascular surgery that is performed. Our knowledge about neuropathology, prevention, and management of surgical complications is growing and will be discussed in this chapter. It is imperative for clinicians to be familiar with these complications in order to narrow the differential diagnosis, start early management, anticipate the natural history, and improve outcomes.
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Affiliation(s)
- K N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale New Haven Hospital, New Haven, CT, USA.
| | - E Nourollahzadeh
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale New Haven Hospital, New Haven, CT, USA
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Cole SP. Intensive Care Management of Thoracic Aortic Surgical Patients, Including Thoracic and Infradiaphragmatic Endovascular Repair (EVAR/TEVAR). Semin Cardiothorac Vasc Anesth 2016; 19:331-41. [PMID: 26660057 DOI: 10.1177/1089253215613791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The patient with thoracic aortic disease can present for open or endovascular repair. Thoracic endovascular aortic repair (TEVAR) has emerged as a minimally invasive option for a multitude of aortic pathology, including dissections, aneurysms, traumatic injuries, and ulcers. Postoperative management of these patients depends on the extent of procedure, whether it was open or endovascular, and, finally, on the preoperative comorbidities present. While procedural success has catapulted TEVAR to popularity, midterm results have been mixed. Additionally, periprocedural complications such as paraplegia and renal failure remain a significant morbidity in these patients.
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Jones DD, Watson RE, Heaton HA. Presentation and Medical Management of Fibrocartilaginous Embolism in the Emergency Department. J Emerg Med 2016; 51:315-8. [DOI: 10.1016/j.jemermed.2016.05.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 04/13/2016] [Accepted: 05/26/2016] [Indexed: 11/25/2022]
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Lindsay H, Srinivas C, Djaiani G. Neuroprotection during aortic surgery. Best Pract Res Clin Anaesthesiol 2016; 30:283-303. [DOI: 10.1016/j.bpa.2016.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 04/21/2016] [Accepted: 05/09/2016] [Indexed: 01/16/2023]
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Hobbs RD, Ullery BW, Mentzer AR, Cheung AT. Protocol for prevention of spinal cord ischemia after thoracoabdominal aortic surgery. Vascular 2016; 24:430-4. [DOI: 10.1177/1708538115593193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective This manuscript was written to present a systemic protocol for the prevention, early detection, and treatment of spinal cord ischemia following open and endovascular thoracoabdominal aortic operations. Methods This protocol was a collaborative effort between surgeons, anesthesiologists and intensivists. It was implemented at our institution in November 2007. Nurses are trained to prevent, rapidly detect and ultimately aid in the treatment of spinal cord ischemia. Results Implementation of this protocol has aided in prevention, detection and treatment of spinal cord ischemia in patients after open and endovascular thoracoabdominal aortic operations. Conclusion Standardized care and reliance on trained nursing staff to monitor for symptoms following thoracoabdominal aortic operations are safe and aid in the rapid detection, treatment and reversal of spinal cord ischemia.
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Affiliation(s)
- Reilly D Hobbs
- Division of Cardiothoracic and Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Brant W Ullery
- Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Allison R Mentzer
- Division of Cardiothoracic and Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Albert T Cheung
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Gerstein NS, Panikkath PV, Carlson AP, Pollock DM, Tayler E, Augoustides JG. CASE 4—2016. J Cardiothorac Vasc Anesth 2016; 30:548-54. [DOI: 10.1053/j.jvca.2015.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Indexed: 01/16/2023]
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Lobenwein D, Tepeköylü C, Kozaryn R, Pechriggl EJ, Bitsche M, Graber M, Fritsch H, Semsroth S, Stefanova N, Paulus P, Czerny M, Grimm M, Holfeld J. Shock Wave Treatment Protects From Neuronal Degeneration via a Toll-Like Receptor 3 Dependent Mechanism: Implications of a First-Ever Causal Treatment for Ischemic Spinal Cord Injury. J Am Heart Assoc 2015; 4:e002440. [PMID: 26508745 PMCID: PMC4845137 DOI: 10.1161/jaha.115.002440] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Paraplegia following spinal cord ischemia represents a devastating complication of both aortic surgery and endovascular aortic repair. Shock wave treatment was shown to induce angiogenesis and regeneration in ischemic tissue by modulation of early inflammatory response via Toll‐like receptor (TLR) 3 signaling. In preclinical and clinical studies, shock wave treatment had a favorable effect on ischemic myocardium. We hypothesized that shock wave treatment also may have a beneficial effect on spinal cord ischemia. Methods and Results A spinal cord ischemia model in mice and spinal slice cultures ex vivo were performed. Treatment groups received immediate shock wave therapy, which resulted in decreased neuronal degeneration and improved motor function. In spinal slice cultures, the activation of TLR3 could be observed. Shock wave effects were abolished in spinal slice cultures from TLR3−/− mice, whereas the effect was still present in TLR4−/− mice. TLR4 protein was found to be downregulated parallel to TLR3 signaling. Shock wave–treated animals showed significantly better functional outcome and survival. The protective effect on neurons could be reproduced in human spinal slices. Conclusions Shock wave treatment protects from neuronal degeneration via TLR3 signaling and subsequent TLR4 downregulation. Consequently, it represents a promising treatment option for the devastating complication of spinal cord ischemia after aortic repair.
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Affiliation(s)
- Daniela Lobenwein
- University Hospital for Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria (D.L., C.T., R.K., E.J.P., M.G., S.S., M.G., J.H.)
| | - Can Tepeköylü
- University Hospital for Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria (D.L., C.T., R.K., E.J.P., M.G., S.S., M.G., J.H.)
| | - Radoslaw Kozaryn
- University Hospital for Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria (D.L., C.T., R.K., E.J.P., M.G., S.S., M.G., J.H.)
| | - Elisabeth J Pechriggl
- University Hospital for Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria (D.L., C.T., R.K., E.J.P., M.G., S.S., M.G., J.H.) Division of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Innsbruck Medical University, Innsbruck, Austria (E.J.P., M.B., H.F.)
| | - Mario Bitsche
- Division of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Innsbruck Medical University, Innsbruck, Austria (E.J.P., M.B., H.F.)
| | - Michael Graber
- University Hospital for Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria (D.L., C.T., R.K., E.J.P., M.G., S.S., M.G., J.H.)
| | - Helga Fritsch
- Division of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Innsbruck Medical University, Innsbruck, Austria (E.J.P., M.B., H.F.)
| | - Severin Semsroth
- University Hospital for Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria (D.L., C.T., R.K., E.J.P., M.G., S.S., M.G., J.H.)
| | - Nadia Stefanova
- Division of Neurobiology, Department of Neurology, Innsbruck Medical University, Innsbruck, Austria (N.S.)
| | - Patrick Paulus
- Department of Anesthesiology and Operative Intensive Care Medicine, Kepler University Hospital Linz, Linz, Austria (P.P.)
| | - Martin Czerny
- Department for Cardiovascular Surgery, University Hospital Freiburg, Freiburg, Germany (M.C.)
| | - Michael Grimm
- University Hospital for Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria (D.L., C.T., R.K., E.J.P., M.G., S.S., M.G., J.H.)
| | - Johannes Holfeld
- University Hospital for Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria (D.L., C.T., R.K., E.J.P., M.G., S.S., M.G., J.H.)
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Arora H, Ullery BW, Kumar PA, Cheung AT. Pro: Patients at Risk for Spinal Cord Ischemia After Thoracic Endovascular Aortic Repairs Should Receive Prophylactic Cerebrospinal Fluid Drainage. J Cardiothorac Vasc Anesth 2015; 29:1376-80. [DOI: 10.1053/j.jvca.2015.05.192] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Indexed: 11/11/2022]
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Abstract
The development of thoracic endovascular aortic repair (TEVAR) has allowed a minimally invasive approach for management of an array of thoracic aortic pathologies. Initially developed specifically for exclusion of thoracic aortic aneurysms, TEVAR is now used as an alternative to open surgery for a variety of disease pathologies due to the lower morbidity of this approach. Advances in endograft technology continue to broaden the applications of this technique.
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Affiliation(s)
- David A Nation
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
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Ramírez Mejía AR, Méndez Montero JV, Vásquez-Caicedo ML, Bustos García de Castro A, Cabeza Martínez B, Ferreirós Domínguez J. Radiological Evaluation and Endovascular Treatment of Hemoptysis. Curr Probl Diagn Radiol 2015; 45:215-24. [PMID: 26293972 DOI: 10.1067/j.cpradiol.2015.07.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 07/16/2015] [Accepted: 07/17/2015] [Indexed: 11/22/2022]
Abstract
Hemoptysis can be a life-threatening condition that warrants urgent investigation and intervention. Common causes include bronchiectasis, chronic obstructive pulmonary disease, tuberculosis, and malignancy. Computed tomography angiography is an accurate imaging modality for assessment of hemoptysis. The bronchial arteries are the source of bleeding in most cases of hemoptysis, and bronchial artery embolization is the treatment of choice. The aim of this article is to summarize the pathophysiology, causes, initial management, and diagnostic approach of hemoptysis. Endovascular treatment of hemoptysis, technique, embolic materials, outcomes, complications, and follow-up of patients are discussed.
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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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Abstract
Critical care management of vascular surgical patients poses significant challenges owing to patients' comorbidities and the magnitude of the surgical procedures. The primary goals of the anesthesiologist and intensivist are reestablishing preoperative homeostasis, optimizing hemodynamics until return of normal organ function, and managing postoperative complications promptly and effectively. Postoperative critical care management demands a detailed knowledge of the various vascular surgical procedures and the potential postoperative complications. In this review, the authors describe the postoperative complications related to the major specific vascular surgical procedures and their perioperative management.
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Affiliation(s)
- Ettore Crimi
- Department of Anesthesia and Critical Care Medicine, Shands Hospital, University of Florida, 1600 Southwest Archer Road, PO Box 100254, Gainesville, FL 32610-025, USA.
| | - Charles C Hill
- Department of Anesthesia, Pain and Perioperative Medicine, Stanford University Medical Center, Stanford University School of Medicine, 300 Pasteur Drive, H3580, MC5640, Stanford, CA 94305, USA
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Enteral albuterol decreases the need for chronotropic agents in patients with cervical spinal cord injury–induced bradycardia. J Trauma Acute Care Surg 2014; 76:297-301; discussion 301-2. [DOI: 10.1097/ta.0000000000000118] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Fabbro M, Gregory A, Gutsche JT, Ramakrishna H, Szeto WY, Augoustides JG. CASE 11--2014. Successful open repair of an extensive descending thoracic aortic aneurysm in a complex patient. J Cardiothorac Vasc Anesth 2013; 28:1397-402. [PMID: 24094566 DOI: 10.1053/j.jvca.2013.05.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Michael Fabbro
- Cardiothoracic and Vascular Section, Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Alexander Gregory
- Cardiothoracic and Vascular Section, Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Jack T Gutsche
- Cardiothoracic and Vascular Section, Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | | | - Wilson Y Szeto
- Division of Cardiac Surgery, Department of Surgery; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Cardiothoracic and Vascular Section, Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA.
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Abstract
Vascular disease affecting the spinal can cause substantial neurologic morbidity. Several vascular spinal cord ailments present as neurologic emergencies, and should thus be recognizable to the practicing neurologist. We review the epidemiology, presentation, management strategies, and prognosis of various pathologies, including infarction, dural arteriovenous fistula, arteriovenous malformation, cavernous malformation, compressive epidural hematoma, vasculitis, and genetic abnormalities.
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Affiliation(s)
- Mark N Rubin
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
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Aguilar Lloret C, Sernano Hernando FJ, Baquero MC, Fernández Francos S, López-Timoneda F. [Anesthesia in the surgical repair of thoracoabdominal aneurysms: 17 years experience]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2013; 60:16-22. [PMID: 23062570 DOI: 10.1016/j.redar.2012.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 07/10/2012] [Accepted: 07/13/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To review the results after thoracoabdominal aortic aneurysms repair performed by the same team of surgeons and anesthesiologists over a 17 year period. MATERIAL AND METHODS A prospective and observational study carried out on 65 patients (97% male) who were operated on from 1995 until July 2011 for thoracoabdominal aneurysm, Crawford type i 5 (7.6%), ii 22 (33.8%), iii 17 (26.11%) and iv 21 (32.31%). RESULTS The 30-day mortality was 9.2% (6/65 patients), which was the same as the incidence of paraplegia. This complication only occurred in the Crawford types ii and iii aneurysms. Paraplegia was present in 4.5% (1/22) of patients in whom "left bypass" was used, compared with 29% (5/17) in which the intervention was performed by cross-clamping without distal aortic perfusion (P=.068). The most frequent complication was respiratory, with prolonged mechanical ventilation (>48h) in 20% (13 patients) of cases. The mean hospital stay was 28 days (7-92). DISCUSSION The average mortality in referral centers is 9.7%, ranging between 5% and 16%. In other centres the mortality at 30 days is between 19% and 31% per year. Our group had a 9.2% of mortality rate at 30 days. The incidence of paraplegia in hospitals with greater experience ranges between 2.7% and 16%. Nowadays, an incidence of less than 10% is accepted as good. We had 9.2%. The use of CSF drainage in these patients, as well as the use of left bypass and moderate hypothermia in the Crawford types i, ii and iii appear to be acceptable for prophylaxis of paraplegia.
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Affiliation(s)
- C Aguilar Lloret
- Servicio de Anestesiología y Reanimación, [corrected] Hospital Clínico San Carlos, Madrid, España.
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Predictors of Outcome in Patients with Spinal Cord Ischemia after Open Aortic Repair. Neurocrit Care 2012; 18:70-4. [DOI: 10.1007/s12028-012-9807-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bilal H, O'Neill B, Mahmood S, Waterworth P. Is cerebrospinal fluid drainage of benefit to neuroprotection in patients undergoing surgery on the descending thoracic aorta or thoracoabdominal aorta? Interact Cardiovasc Thorac Surg 2012; 15:702-8. [PMID: 22761120 DOI: 10.1093/icvts/ivs284] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Is cerebrospinal fluid (CSF) drainage of benefit in patients undergoing surgery on the descending thoracic aorta or thoracoabdominal aorta?' Altogether 1177 papers were found using the reported search, of which 17 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Ten of 13 studies demonstrate significant neurological protection from CSF drainage (± additional adjuncts), with two further papers showing no significant difference between patients who had or had not had CSF drainage and one study unable to provide any conclusions. For patients having surgery on the thoracic aorta or thoracoabdominal aorta CSF drainage, maintaining pressures <10 mmHg (P < 0.03), in conjunction with other neuroprotective strategies, minimizes the risk of neurological sequelae when compared with patients treated with similar adjuncts but without CSF drainage. The majority of studies used additional neuroprotective strategies, including cooling and reattachment of the intercostal arteries as adjuncts to CSF drainage. Logistic regression curves demonstrated that the longer the ischaemia time, the greater the benefit from CSF drainage (P < 0.04). Four papers observed complications of CSF drainage, of which the main complications were: catheter occlusion or dislodgement, headache, meningitis and subdural haematoma. Overall, CSF drainage does offer a neuroprotective benefit; preventing paraplegia if CSF pressures are maintained <10 mmHg.
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Affiliation(s)
- Haris Bilal
- Department of Cardiothoracic Surgery, University Hospital of South Manchester, Manchester, UK
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Spinal cord stroke: acute imaging and intervention. Case Rep Neurol Med 2012; 2012:706780. [PMID: 22937358 PMCID: PMC3420482 DOI: 10.1155/2012/706780] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Accepted: 04/26/2012] [Indexed: 12/04/2022] Open
Abstract
Spinal cord infarction is an uncommon disease and as such is often a diagnostic challenge for clinicians. It can vary in its onset, severity, outcome, and recovery from patient to patient. Treatment options for this relatively rare condition also remain elusive. Current consensus recommendations are antiplatelet therapy and the symptomatic management of associated complications such as paraplegia and thromboembolic disease. There are multiple studies in surgical literature of a variety of interventions and adjuncts used for reducing the risk of ischemic spinal cord neurological injury, seen most often in the setting of thoracoabdominal aortic repair operations. We report two cases of acute non-surgical-related spinal cord infarcts, where early diagnosis was made and aggressive, early treatments instituted. With often devastating outcomes, we highlight the need for early detection and that interventions, commonly used in preventing neurological injury after high-risk aneurysm repairs, may be beneficial in treating and reducing the severity of disability in acute spinal cord stroke.
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Guppy KH, Silverthorn JW, Akins PT. Subarachnoid hemorrhage due to retained lumbar drain. J Neurosurg Spine 2011; 15:641-4. [DOI: 10.3171/2011.8.spine11387] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intrathecal spinal catheters (lumbar drains) are indicated for several medical and surgical conditions. In neurosurgical procedures, they are used to reduce intracranial and intrathecal pressures by diverting CSF. They have also been placed for therapeutic access to administer drugs, and more recently, vascular surgeons have used them to improve spinal cord perfusion during the treatment of thoracic aortic aneurysms. Insertion of these lumbar drains is not without attendant complications. One complication is the shearing of the distal end of the catheter with a resultant retained fragment. The authors report the case of a 65-year-old man who presented with a subarachnoid hemorrhage due to the migration of a retained lumbar drain that sheared off during its removal. To the best of the authors' knowledge, this is the first case of rostral migration of a retained intrathecal catheter causing subarachnoid hemorrhage. The authors review the literature on retained intrathecal spinal catheters, and their findings support either early removal of easily accessible catheters or close monitoring with serial imaging.
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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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Desai ND, Pochettino A, Szeto WY, Moser GW, Moeller PJ, Sodhi N, Jackson B, Woo E, Fairman RM, Bavaria J. Thoracic endovascular aortic repair: Evolution of therapy, patterns of use, and results in a 10-year experience. J Thorac Cardiovasc Surg 2011; 142:587-94. [DOI: 10.1016/j.jtcvs.2011.02.050] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Revised: 01/03/2011] [Accepted: 02/09/2011] [Indexed: 11/30/2022]
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