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Hejrati N, Srikandarajah N, Alvi MA, Quddusi A, Tetreault LA, Guest JD, Marco RAW, Kirshblum S, Martin AR, Strantzas S, Arnold PM, Basu S, Evaniew N, Kwon BK, Skelly AC, Fehlings MG. The Management of Intraoperative Spinal Cord Injury - A Scoping Review. Global Spine J 2024; 14:150S-165S. [PMID: 38526924 DOI: 10.1177/21925682231196505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
STUDY DESIGN Scoping Review. OBJECTIVE To review the literature and summarize information on checklists and algorithms for responding to intraoperative neuromonitoring (IONM) alerts and management of intraoperative spinal cord injuries (ISCIs). METHODS MEDLINE® was searched from inception through January 26, 2022 as were sources of grey literature. We attempted to obtain guidelines and/or consensus statements from the following sources: American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), American Academy of Neurology (AAN), American Clinical Neurophysiology Society, NASS (North American Spine Society), and other spine surgery organizations. RESULTS Of 16 studies reporting on management strategies for ISCIs, two were publications of consensus meetings which were conducted according to the Delphi method and eight were retrospective cohort studies. The remaining six studies were narrative reviews that proposed intraoperative checklists and management strategies for IONM alerts. Of note, 56% of included studies focused only on patients undergoing spinal deformity surgery. Intraoperative considerations and measures taken in the event of an ISCI are divided and reported in three categories of i) Anesthesiologic, ii) Neurophysiological/Technical, and iii) Surgical management strategies. CONCLUSION There is a paucity of literature on comparative effectiveness and harms of management strategies in response to an IONM alert and possible ISCI. There is a pressing need to develop a standardized checklist and care pathway to avoid and minimize the risk of postoperative neurologic sequelae.
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Affiliation(s)
- Nader Hejrati
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Department of Neurosurgery & Spine Center of Eastern Switzerland, Cantonal Hospital St.Gallen, St.Gallen, Switzerland
| | - Nisaharan Srikandarajah
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Ayesha Quddusi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | | | - James D Guest
- Department of Neurosurgery and The Miami Project to Cure Paralysis, The Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Rex A W Marco
- Department of Orthopedic Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Allan R Martin
- Department of Neurological Surgery, University of California Davis, Davis, CA, USA
| | - Samuel Strantzas
- Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Paul M Arnold
- Department of Neurosurgery, University of Illinois Champaign-Urbana, Urbana, IL, USA
| | | | - Nathan Evaniew
- McCaig Institute for Bone and Joint Health, Department of Surgery, Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | | | - Michael G Fehlings
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
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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: 14] [Impact Index Per Article: 14.0] [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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3
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Naganuma M, Saiki Y, Kanda K, Akiyama M, Adachi O, Horii A, Saiki Y. Nanobubble technology to treat spinal cord ischemic injury. JTCVS OPEN 2020; 3:1-11. [PMID: 36003872 PMCID: PMC9390594 DOI: 10.1016/j.xjon.2020.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 07/09/2020] [Accepted: 07/20/2020] [Indexed: 11/29/2022]
Abstract
Background Spinal cord ischemic injury is a severe complication of aortic surgery. We hypothesized that cerebrospinal fluid (CSF) oxygenation with nanobubbles after reperfusion could ameliorate spinal cord ischemic injury. Methods Twenty white Japanese rabbits were categorized into 4 groups of 5 rabbits each: sham group, with balloon catheter insertion into the aorta; ischemia group, with spinal cord ischemic injury by abdominal aortic occlusion; nonoxygenated group, with nonoxygenated artificial CSF irrigation after spinal cord ischemic injury; and oxygenated group, with oxygenated artificial CSF irrigation after spinal cord ischemic injury. At 48 hours after spinal cord ischemic injury, the modified Tarlov score to reflect hind limb movement was evaluated. The spinal cord was histopathologically examined by counting anterior horn cells, and microarray and quantitative reverse-transcription polymerase chain reaction (qRT-PCR) analyses were performed. Results The oxygenated group showed improved neurologic function compared with the ischemia and nonoxygenated groups (P < .01 and P = .019, respectively). Anterior horn neuron prevention in the sham, nonoxygenated, and oxygenated groups was confirmed (mean modified Tarlov score: sham, 9.2 ± 1.9; nonoxygenated, 10.2 ± 2.2; oxygenated, 10.4 ± 2.2; ischemia, 2.7 ± 2.7). Microarray analysis identified 644 genes with twofold or greater increased signals between the ischemia and sham groups. Thirty-three genes related to inflammatory response were enriched among genes differentially expressed between the oxygenated and ischemia groups. Interleukin (IL)-6 and tumor necrosis factor (TNF) expression levels were significantly lower in the oxygenated group compared with the ischemia group, while qRT-PCR showed lower IL-6 and TNF expression levels in the oxygenated group compared with the ischemia group (P < .05). Conclusions CSF oxygenation with nanobubbles after reperfusion can ameliorate spinal cord ischemic injury and suppress inflammatory responses in the spinal cord.
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Romagnoli AN, Dubose JJ. Unmet needs in the management of traumatic aortic injury. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.23736/s1824-4777.20.01429-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Romagnoli AN, Dubose J. Is endovascular repair the first choice for all blunt aortic injury? A real-world assessment. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:289-297. [PMID: 30855117 DOI: 10.23736/s0021-9509.19.10909-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Blunt thoracic aortic injury (BTAI) represents an infrequently encountered but lethal traumatic injury. Minimal aortic injuries are appropriately treated by medical management, while more severe injuries require endovascular or open repair. Rapidly evolving endovascular technology has largely supplanted open repair as first line operative intervention, however, the complexity of the severely injured blunt trauma patient can complicate management decisions. The development and implementation of an optimal consensus grading system and treatment algorithm for the management of BTAI is necessary and will require multi-institutional study.
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Affiliation(s)
| | - Joseph Dubose
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Carino D, Erben Y, Zafar MA, Singh M, Brownstein AJ, Tranquilli M, Rizzo J, Ziganshin BA, Elefteriades JA. Open Replacement of the Thoracoabdominal Aorta: Short- and Long-term Outcomes at a Single Institution. Int J Angiol 2018; 27:114-120. [PMID: 29896044 PMCID: PMC5995682 DOI: 10.1055/s-0038-1649517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
Background Despite much progress in the surgical and endovascular treatment of thoracoabdominal aortic diseases (TAADs), there is no consensus regarding the optimal approach to minimize operative mortality and end-organ dysfunction. We report our experience in the past 16 years treating TAAD by open surgery. Methods A retrospective review of all TAAD patients who underwent an open repair since January 2000 was performed. The primary endpoints included early morbidity and mortality, and the secondary endpoints were overall death and rate of aortic reintervention. Results There were 112 patients treated by open surgery for TAAD. Mean age was 66 ± 10 years and 61 (54%) were male. Seventy-seven (69%) patients had aneurysmal degeneration without aortic dissection and the remaining 35 (31%) had a concomitant aortic dissection. There were 12 deaths (10.7%) and they were equally distributed between the aneurysm and dissection groups ( p = 0.8). The mortality for elective surgery was 3.2% (2/61). The rate of permanent paraplegia and stroke were each 2.6% (3/112). The rate of cerebrovascular accident was significantly higher in the dissection group (8.5% vs. 1.2%, p = 0.05). The survival at 1, 5, and 10 years was 80.6, 56.1, and 32.7%, respectively. Conclusion Our data confirm that open replacement of the thoracoabdominal aorta can be performed in expert centers quite safely. Different aortic pathologies (degenerative aneurysm vs. dissection) do not influence the short- and long-term outcomes. Open surgery should still be considered the standard in the management of TAAD.
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Affiliation(s)
- Davide Carino
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Young Erben
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
- Department of Vascular Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Mohammad A. Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Mrinal Singh
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Adam J. Brownstein
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Maryann Tranquilli
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - John Rizzo
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
- Department of Economics and Preventive Medicine, Stony Brook University, Stony Brook, New York
| | - Bulat A. Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
- Department of Surgical Diseases #2, Kazan State Medical University, Kazan, Russia
| | - John A. Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
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7
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Mirhosseini SM, Meghdadi S, Moghaddam AS. Anterior Spinal Artery Syndrome Following Coronary Artery Bypass Grafting: a Case Report. Braz J Cardiovasc Surg 2017; 32:136-137. [PMID: 28492795 PMCID: PMC5409248 DOI: 10.21470/1678-9741-2016-0039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 11/21/2016] [Indexed: 11/14/2022] Open
Abstract
We present a patient with unstable angina candidate for coronary artery bypass
grafting. Saphenous vein graft was used in obtuse marginal and left internal
mammary artery to left anterior descending artery properly. After surgery, the
patient experienced flaccid paralysis of lower limb and impaired sensation of
touch and warmth of knee and below. A computed tomography angiogram of lower
limbs and thoracolumbar magnetic resonance imaging showed no abnormality. Based
on the symptom, clinical diagnosis of anterior spinal artery syndrome was
considered. The artery of Adamkiewicz is an important supplier to the anterior
spinal artery. Internal thoracic mammary artery, used in coronary artery bypass
grafting, is suspected as a collateral supplier of the artery of Adamkiewicz and
has been accused for cause of spinal infarction.
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8
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Xia X, Qu B, Li YM, Yang LB, Fan KX, Zheng H, Huang HD, Gu JW, Kuang YQ, Ma Y. NFAT5 protects astrocytes against oxygen-glucose-serum deprivation/restoration damage via the SIRT1/Nrf2 pathway. J Mol Neurosci 2016; 61:96-104. [PMID: 27838821 DOI: 10.1007/s12031-016-0849-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 09/22/2016] [Indexed: 01/05/2023]
Abstract
Nuclear factor of activated T cells (NFAT) is a multifunctional cytokine family. NFAT5 was recently reported to be involved in many neuronal functions, but its specific function remains unclear. In this study, our aim is to investigate whether NFAT5 overexpression can protect astrocytes against oxygen-glucose-serum deprivation/restoration (OGSD/R) damage. In vivo, rats were subjected to ischemia-reperfusion injury, resulting in increased water content, infarct volume, and expression of NFAT5 protein in rat spinal cord. After primary culture for spinal cord astrocytes, the in vitro OGSD/R model was established. The results of the CCK8 assay and flow cytometry showed that, in the OGSD/R group, astrocyte cell viability was downregulated, but astrocyte apoptosis increased. Caspase 3 activity increased as well. Levels of NFAT5, as detected by real-time quantitative PCR and western blot, decreased under OGSD/R, as did SIRT1. Commercial kits for activity assays were used to show that OGSD/R inhibited SIRT1 activation but accelerated SOD activation after OGSD/R. Next, pcDNA-NFAT5 or NFAT5 siRNA was transfected into astrocytes. Overexpression of NFAT5 not only promoted the survival of the astrocytes and SIRT1 activation under OGSD/R but also inhibited cell apoptosis and SOD activation. Moreover, overexpression of NFAT5 apparently diminished histone acetylation and promoted the nuclear transport of Nrf2. Our results show that NFAT5 protects spinal astrocytes in a manner that depends on activation of the SIRT1/Nrf2 pathway. These findings present a novel potential molecular mechanism for NFAT5 therapy in the context of spinal cord injury.
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Affiliation(s)
- Xun Xia
- Department of Neurological Surgery, Chengdu Military General Hospital, Chengdu, 610083, China
| | - Bo Qu
- Department of Orthopaedics, Chengdu Military General Hospital, Chengdu, 610083, China
| | - Yun-Ming Li
- Department of Neurological Surgery, Chengdu Military General Hospital, Chengdu, 610083, China
| | - Li-Bin Yang
- Department of Neurological Surgery, Chengdu Military General Hospital, Chengdu, 610083, China
| | - Ke-Xia Fan
- Department of Neurological Surgery, Chengdu Military General Hospital, Chengdu, 610083, China
| | - Hui Zheng
- Department of Neurological Surgery, Chengdu Military General Hospital, Chengdu, 610083, China
| | - Hai-Dong Huang
- Department of Neurological Surgery, Chengdu Military General Hospital, Chengdu, 610083, China
| | - Jian-Wen Gu
- Department of Neurological Surgery, The 306th Hospital of PLA, No. 9 Anxiangbeili, Chaoyang District, Beijing, 100101, China.
| | - Yong-Qin Kuang
- Department of Neurological Surgery, Chengdu Military General Hospital, Chengdu, 610083, China.
| | - Yuan Ma
- Department of Neurological Surgery, Chengdu Military General Hospital, Chengdu, 610083, China.
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Fu S, Lv R, Wang L, Hou H, Liu H, Shao S. Resveratrol, an antioxidant, protects spinal cord injury in rats by suppressing MAPK pathway. Saudi J Biol Sci 2016; 25:259-266. [PMID: 29472775 PMCID: PMC5815991 DOI: 10.1016/j.sjbs.2016.10.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 10/22/2016] [Accepted: 10/26/2016] [Indexed: 01/25/2023] Open
Abstract
Resveratrol, a polyphenol found in various plants, including grapes, plums and peanuts has shown various medIRInal properties, including antioxidant, protection of cardiovascular disease and cancer risk. However, the effects of resveratrol on spinal cord reperfusion injury have not been investigated. Hence, the present study was designed to evaluate the effect of resveratrol on nitric oxide synthase (iNOS)/p38MAPK signaling pathway and to elucidate its regulating effect on the protection of spinal cord injury. Spinal cord ischemia–reperfusion injury (IRI) was performed by the infrarenal abdominal aorta with mini aneurysm clip model. The expressions of iNOS and p38MAPK and the levels of biochemical parameters, including nitrite/nitrate, malondialdehyde (MDA), advanced oxidation products (AOPP), reduced glutathione (GSH), superoxide dismutase (SOD) and catalase (CAT) were measured in control and experimental groups. IRI-induced rats treated with 10 mg/kg resveratrol protected spinal cord from ischemia injury as supported by improved biological parameters measured in spinal cord tissue homogenates. The resveratrol treatment significantly decreased the levels of plasma nitrite/nitrate, iNOS mRNA and protein expressions and phosphorylation of p38MAPK in IRI-induced rats. Further, IRI-produced free radicals were reduced by resveratrol treatment by increasing enzymatic and non-enzymatic antioxidant levels such as GSH, SOD and CAT. Taken together, administration of resveratrol protects the damage caused by spinal cord ischemia with potential mechanism of suppressing the activation of iNOS/p38MAPK pathway and subsequent reduction of oxidative stress due to IRI.
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Affiliation(s)
- Song Fu
- Department of Spinal, The Wendeng Osteopathic Hospital, Weihai City, Shandong Province 264400, China
| | - Renhua Lv
- Department of Orthopaedics, Wendeng Central Hospital, Weihai City, Shandong Province 264400, China
| | - Longqiang Wang
- Department of Spinal, The Wendeng Osteopathic Hospital, Weihai City, Shandong Province 264400, China
| | - Haitao Hou
- Department of Spinal, The Wendeng Osteopathic Hospital, Weihai City, Shandong Province 264400, China
| | - Haijun Liu
- Department of Spinal, The Wendeng Osteopathic Hospital, Weihai City, Shandong Province 264400, China
| | - Shize Shao
- Department of Spinal, The Wendeng Osteopathic Hospital, Weihai City, Shandong Province 264400, China
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Morrissey NJ, Kantonen I, Liu H, Sidiqui M, Marin ML, Hollier LH. Effect of Mesenteric Ischemia/Reperfusion on Spinal Cord Injury following Transient Aortic Occlusion in Rabbits. J Endovasc Ther 2016. [DOI: 10.1177/15266028020090s208] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To investigate in a rabbit model if prolonged periods of mesenteric ischemia followed by reperfusion may affect the rate of neurological complications. Methods: An infrarenal aortic snare, which consisted of a Silastic vessel loop whose ends were passed through plastic tubing, was placed in 50 male New Zealand white rabbits. In 40 of these animals, a similar but smaller device was placed around the superior mesenteric artery (SMA); all devices were exteriorized to allow vessel occlusion in the awake animal. The aorta was occluded for 12 minutes in the 10 control and 40 experimental animals, but the experimental rabbits also had occlusion of the SMA for varying intervals: 10 minutes (group 1), 12 minutes (group 2), and 18 minutes (group 3). To assess the hemodynamic effects of aortic and aortic/SMA occlusion, select control and test animals had blood pressure and heart rate monitoring via indwelling carotid catheters during the occlusion periods. The animals were euthanized, and spinal cords from paralyzed and normal rabbits were examined histologically Results: Neurological deficit occurred in 20% of controls and in 70%, 80%, and 100% in the experimental groups, respectively. There were no significant differences in systemic blood pressure at any time point during occlusion and reperfusion in the monitored control or test animals. There was no evidence of thrombosis of spinal arteries on histological analysis, nor was there evidence of bowel infarction at the time of sacrifice in animals undergoing combined aortic/SMA occlusion. Conclusions: Mesenteric ischemia/reperfusion worsens the neurological outcome in animals undergoing transient aortic occlusion. This observation is independent of hemodynamic influences and not the result of spinal artery thrombosis.
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Affiliation(s)
- Nicholas J. Morrissey
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai School of Medicine, New York, New York, USA
| | - Ilkka Kantonen
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai School of Medicine, New York, New York, USA
| | - Harry Liu
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai School of Medicine, New York, New York, USA
| | - Mohamed Sidiqui
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai School of Medicine, New York, New York, USA
| | - Michael L. Marin
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai School of Medicine, New York, New York, USA
| | - Larry H. Hollier
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai School of Medicine, New York, New York, USA
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Ramirez D, Zargar H, Caputo P, Kaouk JH. Robotic-assisted laparoscopic prostatectomy: An update on functional and oncologic outcomes, techniques, and advancements in technology. J Surg Oncol 2015; 112:746-52. [PMID: 26369794 DOI: 10.1002/jso.24040] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 08/26/2015] [Indexed: 11/11/2022]
Abstract
The robotic platform has revolutionized the management of prostate cancer over the last 15 years. Several techniques have been developed to improve functional and oncologic outcomes, including meticulous apical and posterior dissection, nerve sparing techniques, bladder neck and urethral length sparing, and anastomotic reconstruction. Future developments involving novel single-site, robotic technology will undoubtedly further the field of minimally invasive urology. These topics are reviewed within this article.
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Affiliation(s)
- Daniel Ramirez
- Glickman Institute of Urology and Nephrology, Cleveland Clinic, Cleveland, Ohio
| | - Homayoun Zargar
- Glickman Institute of Urology and Nephrology, Cleveland Clinic, Cleveland, Ohio
| | - Peter Caputo
- Glickman Institute of Urology and Nephrology, Cleveland Clinic, Cleveland, Ohio
| | - Jihad H Kaouk
- Glickman Institute of Urology and Nephrology, Cleveland Clinic, Cleveland, Ohio
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Abstract
Spinal cord injury (SCI) is a major health problem and is associated with a diversity of neurological symptoms. Pathophysiologically, dysfunction after SCI results from the culmination of tissue damage produced both by the primary insult and a range of secondary injury mechanisms. The application of hypothermia has been demonstrated to be neuroprotective after SCI in both experimental and human studies. The myriad of protective mechanisms of hypothermia include the slowing down of metabolism, decreasing free radical generation, inhibiting excitotoxicity and apoptosis, ameliorating inflammation, preserving the blood spinal cord barrier, inhibiting astrogliosis, promoting angiogenesis, as well as decreasing axonal damage and encouraging neurogenesis. Hypothermia has also been combined with other interventions, such as antioxidants, anesthetics, alkalinization and cell transplantation for additional benefit. Although a large body of work has reported on the effectiveness of hypothermia as a neuroprotective approach after SCI and its application has been translated to the clinic, a number of questions still remain regarding its use, including the identification of hypothermia's therapeutic window, optimal duration and the most appropriate rewarming rate. In addition, it is necessary to investigate the neuroprotective effect of combining therapeutic hypothermia with other treatment strategies for putative synergies, particularly those involving neurorepair.
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Affiliation(s)
- Jiaqiong Wang
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, the Lois Pope Life Center, Locator code (R-48), PO BOX 016960, Miami, FL 33136, USA.
| | - Damien D Pearse
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, the Lois Pope Life Center, Locator code (R-48), PO BOX 016960, Miami, FL 33136, USA.
- The Department of Neurological Surgery, University of Miami Miller School of Medicine, the Lois Pope Life Center, Locator code (R-48), PO BOX 016960, Miami, FL 33136, USA.
- The Neuroscience Program, University of Miami Miller School of Medicine, the Lois Pope Life Center, Locator code (R-48), PO BOX 016960, Miami, FL 33136, USA.
- The Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, the Lois Pope Life Center, Locator code (R-48), PO BOX 016960, Miami, FL 33136, USA.
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Cohort comparison of thoracic endovascular aortic repair with open thoracic aortic repair using modern end-organ preservation strategies. Ann Vasc Surg 2015; 29:882-90. [PMID: 25757992 DOI: 10.1016/j.avsg.2015.01.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 12/31/2014] [Accepted: 01/01/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pivotal trials showed that thoracic endovascular aortic repair (TEVAR) has improved outcomes compared with open surgery for treating descending thoracic aortic aneurysms. However, those trials included historical open controls in which modern end-organ preservation strategies were not routinely employed. To create a more level assessment, we compared our outcomes of elective TEVAR with modern open thoracic aortic repair (OTAR) controls. METHODS A retrospective review of thoracic aortic aneurysm patients undergoing TEVAR was compared with a contemporaneous cohort of OTAR patients. Partial bypass or hypothermic circulatory arrest was used in all OTAR patients. Cerebrospinal fluid drain placement was attempted in all patients. Preoperative characteristics, operative variables, and outcomes were recorded, and the Kaplan-Meier method was used for survival estimates. RESULTS The main outcome was mortality. Secondary outcomes included postoperative spinal cord ischemia (SCI) or stroke, and any persistent neurologic deficit 30 days following the operation. During the study period, 62 patients underwent TEVAR and 56 underwent OTAR with median follow-up of 23.7 months and 36.4 months, respectively. No difference existed between the TEVAR and OTAR with respect to overall neurologic complications (8.1% vs. 12.5%, P = 0.55) as well as any residual neurologic deficit at 30 days (0% vs. 5.4%, P = 0.10). TEVAR patients had fewer complications including pneumonia (P = 0.02), rebleeding (P = 0.02), and acute kidney injury (P = 0.001). There was no difference in 30-day mortality (1.6% vs. 8.9%, P = 0.10), 1-year mortality (12.2% vs. 14%, P = 0.80), or 5-year mortality (53.9% vs. 44%, P = 0.48) between TEVAR and OTAR, respectively. CONCLUSIONS TEVAR continues to show improved perioperative outcomes with a trend toward decreased 30-day mortality and fewer major adverse events compared with OTAR. However, with the routine use of end-organ preservation strategies during OTAR, neurologic deficits, particularly SCI, can be safely reduced to comparable levels with those of TEVAR and 1-year all-cause mortality rates are similar between the groups. These OTAR results may serve as a benchmark as TEVAR is increasingly applied for other aortic pathologies, such as chronic dissection, wherein long-term efficacy is not proven.
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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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Jeong W, Sood A, Ghani KR, Pucheril D, Sammon JD, Gupta NS, Menon M, Peabody JO. Bimanual examination of the retrieved specimen and regional hypothermia during robot-assisted radical prostatectomy: a novel technique for reducing positive surgical margin and achieving pelvic cooling. BJU Int 2014; 114:955-7. [DOI: 10.1111/bju.12573] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | | | | | - Nilesh S. Gupta
- Department of Pathology; Henry Ford Health System; Detroit MI USA
| | - Mani Menon
- Vattikuti Urology Institute; Detroit MI USA
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Surgery for thoracic aortic disease in Japan: evolving strategies toward the growing enemies. Gen Thorac Cardiovasc Surg 2014; 63:185-96. [DOI: 10.1007/s11748-014-0476-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Indexed: 01/15/2023]
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Sood A, Jeong W, Peabody JO, Hemal AK, Menon M. Robot-assisted radical prostatectomy: inching toward gold standard. Urol Clin North Am 2014; 41:473-84. [PMID: 25306159 DOI: 10.1016/j.ucl.2014.07.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Robot-assisted radical prostatectomy (RARP) offers excellent and lasting oncologic control. Technical refinements in apical dissection, such as the retroapical approach of synchronous urethral transection, and adoption of real-time frozen section analysis of the excised prostate during RARP have substantially reduced positive surgical margin rates, particularly in high-risk disease patients. Furthermore, precision offered by the robotic platform and technical evolution of radical prostatectomy, including enhanced nerve sparing (veil), have led to improved potency and continence outcomes as well as better safety profile in patients undergoing surgical therapy for prostate cancer.
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Affiliation(s)
- Akshay Sood
- Vattikuti Urology Institute, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA.
| | - Wooju Jeong
- Vattikuti Urology Institute, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA
| | - James O Peabody
- Vattikuti Urology Institute, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA
| | - Ashok K Hemal
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, Medical Center Boulevard, NC 27157-1090, USA
| | - Mani Menon
- Vattikuti Urology Institute, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA
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Kilic A, Shah AS, Black JH, Whitman GJ, Yuh DD, Cameron DE, Conte JV. Trends in repair of intact and ruptured descending thoracic aortic aneurysms in the United States: A population-based analysis. J Thorac Cardiovasc Surg 2014; 147:1855-60. [DOI: 10.1016/j.jtcvs.2013.06.032] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 05/02/2013] [Accepted: 06/27/2013] [Indexed: 11/15/2022]
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Wu Y, Satkunendrarajah K, Fehlings M. Riluzole improves outcome following ischemia–reperfusion injury to the spinal cord by preventing delayed paraplegia. Neuroscience 2014; 265:302-12. [DOI: 10.1016/j.neuroscience.2014.01.059] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 01/17/2014] [Accepted: 01/28/2014] [Indexed: 12/15/2022]
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Tian F, Xu LH, Zhao W, Tian LJ, Ji XL. The neuroprotective mechanism of puerarin treatment of acute spinal cord injury in rats. Neurosci Lett 2013; 543:64-8. [DOI: 10.1016/j.neulet.2013.03.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 03/16/2013] [Accepted: 03/18/2013] [Indexed: 10/27/2022]
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Salido EM, Dorfman D, Bordone M, Chianelli M, González Fleitas MF, Rosenstein RE. Global and ocular hypothermic preconditioning protect the rat retina from ischemic damage. PLoS One 2013; 8:e61656. [PMID: 23626711 PMCID: PMC3633982 DOI: 10.1371/journal.pone.0061656] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 03/12/2013] [Indexed: 11/18/2022] Open
Abstract
Retinal ischemia could provoke blindness. At present, there is no effective treatment against retinal ischemic damage. Strong evidence supports that glutamate is implicated in retinal ischemic damage. We investigated whether a brief period of global or ocular hypothermia applied 24 h before ischemia (i.e. hypothermic preconditioning, HPC) protects the retina from ischemia/reperfusion damage, and the involvement of glutamate in the retinal protection induced by HPC. For this purpose, ischemia was induced by increasing intraocular pressure to 120 mm Hg for 40 min. One day before ischemia, animals were submitted to global or ocular hypothermia (33°C and 32°C for 20 min, respectively) and fourteen days after ischemia, animals were subjected to electroretinography and histological analysis. Global or ocular HPC afforded significant functional (electroretinographic) protection in eyes exposed to ischemia/reperfusion injury. A marked alteration of the retinal structure and a decrease in retinal ganglion cell number were observed in ischemic retinas, whereas global or ocular HPC significantly preserved retinal structure and ganglion cell count. Three days after ischemia, a significant decrease in retinal glutamate uptake and glutamine synthetase activity was observed, whereas ocular HPC prevented the effect of ischemia on these parameters. The intravitreal injection of supraphysiological levels of glutamate induced alterations in retinal function and histology which were significantly prevented by ocular HPC. These results support that global or ocular HPC significantly protected retinal function and histology from ischemia/reperfusion injury, probably through a glutamate-dependent mechanism.
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Affiliation(s)
- Ezequiel M Salido
- Laboratory of Retinal Neurochemistry and Experimental Ophthalmology, Department of Human Biochemistry, School of Medicine, University of Buenos Aires/CEFyBO, CONICET, Buenos Aires, Argentina
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Complications arising after thoracic aortic surgery: A case report on an unusual spinal cord infarction. Physiopathological and clinical considerations. Ann Phys Rehabil Med 2013; 56:51-62. [DOI: 10.1016/j.rehab.2013.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 12/28/2012] [Accepted: 01/06/2013] [Indexed: 11/24/2022]
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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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Kobayashi S, Yoshizawa H, Shimada S, Guerrero AR, Miyachi M. Changes of blood flow, oxygen tension, action potential and vascular permeability induced by arterial ischemia or venous congestion on the spinal cord in canine model. J Orthop Res 2013; 31:139-46. [PMID: 22912247 DOI: 10.1002/jor.22197] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 07/06/2012] [Indexed: 02/04/2023]
Abstract
It is generally considered that the genesis of myelopathy associated with the degenerative conditions of the spine may result from both mechanical compression and circulatory disturbance. Many references about spinal cord tissue ischemic damage can be found in the literature, but not detailed studies about spinal cord microvasculature damage related to congestion or blood permeability. This study investigates the effect of ischemia and congestion on the spinal cord using an in vivo model. The aorta was clamped as an ischemia model of the spinal cord and the inferior vena cava was clamped as a congestion model at the 6th costal level for 30 min using forceps transpleurally. Measurements of blood flow, partial oxygen pressure, and conduction velocity in the spinal cord were repeated over a period of 1 h after release of clamping. Finally, we examined the status of blood-spinal cord barrier under fluorescence and transmission electron microscope. Immediately after clamping of the inferior vena cava, the central venous pressure increased by about four times. Blood flow, oxygen tension and action potential were more severely affected by the aorta clamping; but this ischemic model did not show any changes of blood permeability in the spinal cord. The intramedullar edema was more easily produced by venous congestion than by arterial ischemia. In conclusions, venous congestion may be a preceding and essential factor of circulatory disturbance in the compressed spinal cord inducing myelopathy.
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Affiliation(s)
- Shigeru Kobayashi
- Faculty of Medical Sciences, Department of Orthopaedics and Rehabilitation Medicine, The University of Fukui, Shimoaizuki 23, Matsuoka, Fukui 910-1193, Japan.
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Abstract
BACKGROUND During aortic aneurysm surgery, cross-clamping can lead to inadequate blood supply to the spinal cord resulting in neurological deficit. Cerebrospinal fluid drainage (CSFD) may increase the perfusion pressure to the spinal cord and hence reduce the risk of ischaemic spinal cord injury. OBJECTIVES To determine the effect of CSFD during thoracic and thoracoabdominal aortic aneurysm (TAAA) surgery on the risk of developing spinal cord injury. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched May 31 2012) and CENTRAL (2012, Issue 5) for publications describing randomised controlled trials of cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery. Reference lists of relevant articles were checked. SELECTION CRITERIA Randomised trials involving CSFD during thoracic and TAAA surgery. DATA COLLECTION AND ANALYSIS Both authors assessed the quality of trials independently. SNK extracted data and GS verified the data. MAIN RESULTS Three trials with a total of 287 participants operated on for Type I or II TAAA were included.In the first trial of 98 participants, neurological deficits in the lower extremities occurred in 14 (30%) of CSFD group and 17 (33%) controls. The deficit was observed within 24 hours of the operation in 21 (68%), and from three to 22 days in 10 (32%) participants. CSFD did not have a significant benefit in preventing ischaemic injury to the spinal cord.The second trial of 33 participants used a combination of CSFD and intrathecal papaverine. It showed a statistically significant reduction in the rate of postoperative neurological deficit (P = 0.039), compared to controls. Analysis was undertaken after only one third of the estimated sample size had entered the trial.In the third trial TAAA repair was performed on 145 participants. CSFD was initiated during the operation and continued for 48 hours after surgery. Paraplegia or paraparesis occurred in 9 of 74 participants (12.2%) in the control group versus 2 of 82 participants (2.7%) receiving CSFD (P = 0.03). Overall, CSFD resulted in an 80% reduction in the relative risk of postoperative deficits. Meta-analysis showed an odds ratio (OR) of 0.48 (95 % confidence interval (CI) 0.25 to 0.92). For CSFD-only trials, OR was 0.57 (95% CI 0.28 to 1.17) and for intention-to-treat analysis in CSFD-only studies, the OR remained unchanged. AUTHORS' CONCLUSIONS There are limited data supporting the role of CSFD in thoracic and thoracoabdominal aneurysm surgery for prevention of neurological injury. Further clinical and experimental studies are indicated.
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Herlambang B, Orihashi K, Mizukami T, Takahashi S, Uchida N, Hiyama E, Sueda T. New method for absolute spinal cord ischemia protection in rabbits. J Vasc Surg 2011; 54:1109-16. [PMID: 21890303 DOI: 10.1016/j.jvs.2011.04.043] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Revised: 04/20/2011] [Accepted: 04/20/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study aims to establish a superior procedure to prevent spinal cord damage after severe spinal cord ischemia during aortic surgery. We examined the synergistic effect of topical hypothermia of the spinal cord combined with radical scavenger infusion into the clamped segment of the aorta to prevent spinal cord damage in an animal model. METHODS Spinal cord ischemia was induced in rabbits by clamping the aorta between the renal artery and aortic bifurcation for 30 minutes. Rabbits were divided into four groups of 16 each: group I, sham-operated; group II, edaravone (6 mL, 4°C, 1 mg/kg); group III, saline (6 mL, 4°C) with transvertebral cooling pads; group IV, edaravone (6 mL, 4°C, 1 mg/kg) and transvertebral cooling pads. Solutions were injected into the clamped segment of the aorta. Postoperative assessments included the Tarlov score, spinal cord histopathology, and measurement of malondialdehyde levels in the spinal cord tissue. RESULTS At 48 hours after reperfusion, the mean Tarlov scores in groups I, II, III, and IV were 4.0, 1.5, 1.9, and 4.0, respectively. The mean number of normal motor neurons was significantly higher in groups I (54.1) and IV (53.7) than in groups II (32.8) and III (36.3; P < .001). The mean malondialdehyde level in groups I (19.8 nmol/mL) and IV (22.6 nmol/mL) was significantly lower than in groups II (64.8 nmol/mL) and III (60.9 nmol/mL; P < .001). At 168 hours after reperfusion, the mean Tarlov scores in groups I, II, III, and IV were 4.0, 1.1, 1.3, and 4.0, respectively. The mean number of normal motor neurons was significantly higher in groups I (52.9) and IV (50.8) than in groups II (22.4) and III (25.9; P < .001). The mean malondialdehyde level in groups I (20.7 nmol/mL) and IV (23.4 nmol/mL) was significantly lower than in groups II (68.9 nmol/mL) and III (61.6 nmol/mL; P < .001). CONCLUSION In a rabbit model with aortic clamping up to 30 minutes, which consistently produces complete paraplegia in rabbits, spinal cord damage was partially reduced by topical cooling with transvertebral cooling pads or the injection of edaravone into the clamped segment of aorta, but was more effectively protected by a combined use of these two strategies.
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Affiliation(s)
- Bagus Herlambang
- Department of Cardiovascular Surgery, Division of Clinical Medical Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan.
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Urdziková L, Likavčanová-Mašínová K, Vaněček V, Růžička J, Sedý J, Syková E, Jendelová P. Flt3 ligand synergizes with granulocyte-colony-stimulating factor in bone marrow mobilization to improve functional outcome after spinal cord injury in the rat. Cytotherapy 2011; 13:1090-104. [PMID: 21539498 DOI: 10.3109/14653249.2011.575355] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND AIMS The effect of granulocyte-colony-stimulating factor (G-CSF) and/or the cytokine fms-like thyrosin kinase 3 (Flt3) ligand on functional outcome and tissue regeneration was studied in a rat model of spinal cord injury (SCI). METHODS Rats with a balloon-induced compression lesion were injected with G-CSF and/or Flt3 ligand to mobilize bone marrow cells. Behavioral tests (Basso-Beattie-Bresnahan and plantar test), blood counts, morphometric evaluation of the white and gray matter, and histology were performed 5 weeks after SCI. RESULTS The mobilization of bone marrow cells by G-CSF, Flt3 ligand and their combination improved the motor and sensory performance of rats with SCI, reduced glial scarring, increased axonal sprouting and spared white and gray matter in the lesion. The best results were obtained with a combination of G-CSF and Flt3. G-CSF alone or in combination with Flt3 ligand significantly increased the number of white blood cells, but not red blood cells or hemoglobin content, during and after the time-course of bone marrow stimulation. The combination of factors led to infiltration of the lesion by CD11b(+) cells. CONCLUSIONS The observed improvement in behavioral and morphologic parameters and tissue regeneration in animals with SCI treated with a combination of both factors could be associated with a prolonged time-course of mobilization of bone marrow cells. The intravenous administration of G-CSF and/or Flt3 ligand represents a safe and effective treatment modality for SCI.
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Affiliation(s)
- Lucia Urdziková
- Institute of Experimental Medicine, Academy of Sciences of the Czech Republic, Prague, Czech Republic
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David N, Roux N, Clavier E, Godier S, Brossard F, Bessou JP, Plissonnier D. Open repair of extensive thoracoabdominal and thoracic aneurysm: a preliminary single-center experience with femorofemoral distal aortic perfusion with oxygenator and without cerebrospinal fluid drainage. Ann Vasc Surg 2011; 25:583-9. [PMID: 21420828 DOI: 10.1016/j.avsg.2010.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Revised: 12/23/2010] [Accepted: 12/27/2010] [Indexed: 11/29/2022]
Abstract
Thoracoabdominal aortic aneurysms (TAAA) and extensive thoracic descending aortic aneurysms (TDA) are not accessible through standard endovascular treatment. Fenestrated and branched endograft technology was developed rapidly without widespread application. The aim of this study was to review our open repair (OR) experience of TAAA and TDA. A total of 28 patients who underwent elective OR of TAAA or TDA between January 2001 and January 2009 were analyzed retrospectively. The mean age of the patients was 65.5 years (three women). The anatomic locations of the aneurysms were as follows: six in thoracic descending aorta and 22 in thoracoabdominal aorta (14 TAAA I, two TAAA II, six TAAA III). TDA (40 patients) available for ordinary endovascular treatment and TAAA IV (35 patients) were excluded from this study. To focus on spinal cord vascularization, 25 patients were submitted for angiography. Three patients suffering from back pain required quick treatment and were excluded from angiographic investigations. Angiography procedures were contributive in 23 patients (92%). Surgical repairs were driven through left thoraco-phreno-laparotomy, with the adjunct of distal aortic perfusion (femorofemoral bypass) including the use of an oxygenator and sequential aortic cross-clamping. Cerebrospinal fluid drainage was not used in this experience. The 30-day mortality rate was 14.3% (four of 28 patients): one multiorgan failure and three pulmonary sepsis. An immediate postoperative paraplegia occurred, affecting a patient with TDA who was previously submitted for infrarenal aorta replacement, despite angiographic identification and revascularization of intercostal artery destined to spinal artery. The 1-year survival rate was 82.1% (23 of 28 patients). In the preliminary experience of this study, OR of extensive TAAA and TDA with distal aortic perfusion and an oxygenator without use of cerebrospinal fluid drainage was associated with a significant perioperative mortality rate (14.2%), a reasonable rate of paraplegia (3%), and 1-year survival rate of 82.1%.
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Affiliation(s)
- Nathalie David
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France.
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Okita Y. Fighting spinal cord complication during surgery for thoracoabdominal aortic disease. Gen Thorac Cardiovasc Surg 2011; 59:79-90. [DOI: 10.1007/s11748-010-0668-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Indexed: 10/18/2022]
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Carmona P, Mateo E, Otero M, Marqués JI, Peña JJ, Llagunes J, Aguar F, De Andrés J. [Spinal cord protection during open and endovascular surgery in thoracic and thoracoabdominal aorta diseases]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2011; 58:110-118. [PMID: 21427827 DOI: 10.1016/s0034-9356(11)70009-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
In recent decades great advances have been made in surgical procedures for treating thoracic and thoracoabdominal aorta defects. Associated mortality and morbidity rates have dropped considerably, mainly in major reference centers, but nonetheless continue to be significant. The need for new strategies to reduce mortality and morbidity has made endovascular approaches an attractive alternative for high-risk surgical patients. The most feared complications of these procedures include paraparesis and paraplegia, which have devastating consequences on patients' quality of life. We provide an updated review of the pathophysiology of spinal cord ischemia in open and endovascular surgery, as well as perioperative measures designed to protect the spinal cord in both types of procedure.
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Affiliation(s)
- P Carmona
- Consorcio Hospital General Universitario de Valencia.
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Conrad MF, Chung TK, Cambria MR, Paruchuri V, Brady TJ, Cambria RP. Effect of chronic dissection on early and late outcomes after descending thoracic and thoracoabdominal aneurysm repair. J Vasc Surg 2010; 53:600-7; discussion 607. [PMID: 21112177 DOI: 10.1016/j.jvs.2010.09.053] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 09/14/2010] [Accepted: 09/15/2010] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Although chronic aortic dissection (CD) has traditionally been considered a predictor of perioperative morbidity and mortality after descending thoracic/thoracoabdominal aneurysm repair (thoracoabdominal aortic aneurysm [TAA]), recent reports have rejected this assertion. Still, few contemporary studies document late outcomes after TAA for CD, which is the goal of this study. METHODS From August 1987 to December 2005, 480 patients underwent TAA; 73 (15%) CD and 407 (85%) degenerative aneurysms (DA). Operative management consisted of a clamp-and-sew technique with adjuncts in 53 (78%) CD and 355 (93%) DA patients (P < .001). Epidural cooling was used to prevent spinal cord injury (SCI) in 51 (70%) CD and 214 (53%) DA patients (P = .007). Study end points included perioperative SCI/mortality, freedom from reintervention, and long-term survival. RESULTS CD patients were younger (mean age 64.5 years CD vs 72.5 years DA, P < .001) and more frequently had a family history of aneurysmal disease (23% CD vs 6% DA, P < .001). Forty-three (59%) CD patients had elective TAA (vs 322 (79%) DA, P = .001). Eleven (15%) CD patients had Marfan's syndrome (vs 0% DA, P < .001), and 17 (23%) CD patients had a prior arch or ascending aortic repair (vs 16 [4%] DA, P < .001). CD patients were more likely to have Crawford type I & II thoracoabdominal aneurysms (44 [60%] vs 120 [29%] DA, P < .001), while only two (3%) CD patients had type IV aneurysms (vs 99 [24%] DA). There was no difference in perioperative mortality between the two groups (11% CD vs 8.6% DA, P = .52), nor was there a difference in flaccid paralysis, which occurred in five (7%) CD and 22 (5%) DA patients (P = .92). At 5 years, 70% of CD patients were free from reintervention versus 74% of DA (P = .36). The actuarial survival was 53% and 32% at 5 and 10 years for CD versus 47% and 17% for DA (P = .07). CONCLUSIONS Despite increased operative complexity, CD does not appear to increase perioperative SCI or mortality after TAA when compared with DA. Long-term freedom from aneurysm-related reintervention is similar for both groups as is survival, despite patients with CD being of younger age at presentation.
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Affiliation(s)
- Mark F Conrad
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass 02114, USA.
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Turkkan A, Alkan T, Goren B, Kocaeli H, Akar E, Korfali E. Citicoline and postconditioning provides neuroprotection in a rat model of ischemic spinal cord injury. Acta Neurochir (Wien) 2010; 152:1033-42. [PMID: 20112033 DOI: 10.1007/s00701-010-0598-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Accepted: 01/05/2010] [Indexed: 12/14/2022]
Abstract
BACKGROUND Ischemic spinal cord injury is a chain of events caused by the reduction and/or cessation of spinal cord blood flow, which results in neuronal degeneration and loss. Ischemic postconditioning is defined as a series of intermittent interruptions of blood flow in the early phase of reperfusion and has been shown to reduce the infarct size in cerebral ischemia. Our study aimed to characterize the relationship between the neuronal injury-decreasing effects of citicoline and ischemic postconditioning, which were proven to be effective against the apoptotic process. METHOD Spinal cord ischemia was produced in rats using an intrathoracic approach to implement the synchronous arcus aorta and subclavian artery clipping method. In our study, 42 male Sprague-Dawley rats (309 +/- 27 g) were used. Animals were divided into sham operated, spinal ischemia, citicoline, postconditioning, and postconditioning citicoline groups. Postconditioning was generated by six cycles of 1 min occlusion/5 min reperfusion. A 600 mmol/kg dose of citicoline was given intraperitoneally before ischemia in the citicoline and postconditioning citicoline groups. All rats were sacrificed 96 h after reperfusion. For immunohistochemical analysis, bcl-2, caspase 3, caspase 9, and bax immune staining were performed. Caspase 3, caspase 9, bax, and bcl-2 were used as apoptotic and antiapoptotic markers, respectively. FINDINGS The blood pressure values obtained at the onset of reperfusion were significantly lower than the preischemic values. A difference in immunohistochemical scoring was detected between the caspase 3, caspase 9, bax, and bcl-2 groups. When comparisons between the ischemia (groups 2, 3, 4, and 5) and sham groups (group 1) were performed, a significant increase in caspase 3, caspase 9, bax, and bcl-2 was detected. When comparing the subgroups, the average score of caspase 9 was found to be significantly higher in ischemia group 2. The average score of bcl-2 was also found to be significantly higher in postconditioning and citicoline group 5. CONCLUSIONS It is thus thought that combining citicoline with postconditioning provides protection by inhibiting the caspase pathway and by increasing the antiapoptotic proteins.
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Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology,American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons,and Society for Vascular Medicine. J Am Coll Cardiol 2010; 55:e27-e129. [PMID: 20359588 DOI: 10.1016/j.jacc.2010.02.015] [Citation(s) in RCA: 1002] [Impact Index Per Article: 71.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Is hypothermia a reliable adjunct for spinal cord protection in descending and thoracoabdominal aortic repair with regional or systemic cooling? Gen Thorac Cardiovasc Surg 2010; 58:220-2. [PMID: 20449711 DOI: 10.1007/s11748-009-0530-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Indexed: 10/19/2022]
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Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: Executive Summary. Circulation 2010. [DOI: 10.1161/cir.0b013e3181d47d48] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: Executive Summary. J Am Coll Cardiol 2010. [DOI: 10.1016/j.jacc.2010.02.010] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010; 121:e266-369. [PMID: 20233780 DOI: 10.1161/cir.0b013e3181d4739e] [Citation(s) in RCA: 1179] [Impact Index Per Article: 84.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Yu Q, Zhou Q, Huang H, Wang Y, Tian S, Duan D. Protective Effect of Etomidate on Spinal Cord Ischemia–Reperfusion Injury Induced by Aortic Occlusion in Rabbits. Ann Vasc Surg 2010; 24:225-32. [DOI: 10.1016/j.avsg.2009.06.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Revised: 05/18/2009] [Accepted: 06/09/2009] [Indexed: 12/22/2022]
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Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM, Jacobs AK, Smith SC, Anderson JL, Adams CD, Buller CE, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Stevenson WG, Tarkington LG, Yancy CW. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: Executive Summary. Catheter Cardiovasc Interv 2010; 76:E43-86. [DOI: 10.1002/ccd.22537] [Citation(s) in RCA: 225] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Preventza O, Wheatley GH, Williams J, Ramaiah V, Rodriguez-Lopez J, Diethrich EB. Identifying Paraplegia Risk Associated with Thoracic Endografting. Asian Cardiovasc Thorac Ann 2009; 17:568-72. [DOI: 10.1177/0218492309349813] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Endografting, like open surgical repair of the thoracic aorta, can be complicated by paraplegia. We reviewed our thoracic endografting experience regarding the incidence and treatment of spinal cord neurologic events. Between February 2000 and July 2008, 346 patients underwent endoluminal grafting of the descending thoracic aorta. Indications for intervention included atherosclerotic aneurysms (45.9%), acute and chronic dissections (31.5%), miscellaneous lesions (13.6%), and penetrating aortic ulcers (8.9%). Ten women and 4 men (4.0%), with a mean age of 71.3 years, developed either paraparesis (1.7%) or paraplegia (2.3%). Nine (64.3%) of these patients had an aneurysm, 4 (28.6%) had acute or chronic type B aortic dissection, and 1 (7.1%) had a penetrating aortic ulcer; 3 (21.4%) of them had previously undergone open abdominal aortic aneurysm repair, and 13 (92.9%) required coverage of more than 20 cm of the aorta. Cerebrospinal fluid drainage was instituted in 7/8 paraplegic patients. Eight (57.1%) of the 14 patients recovered fully, 2 (14.3%) experienced partial recovery, and 4 (28.6%) had significant neurological deficits. Paraplegia following thoracic endografting appears to be associated with female sex, longsegment coverage of the thoracic aorta, and aneurysmal disease.
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Affiliation(s)
- Ourania Preventza
- Department of Cardiovascular and Endovascular Surgery Arizona Heart Institute Phoenix, AZ, USA
| | - Grayson H Wheatley
- Department of Cardiovascular and Endovascular Surgery Arizona Heart Institute Phoenix, AZ, USA
| | - James Williams
- Department of Cardiovascular and Endovascular Surgery Arizona Heart Institute Phoenix, AZ, USA
| | - Venkatesh Ramaiah
- Department of Cardiovascular and Endovascular Surgery Arizona Heart Institute Phoenix, AZ, USA
| | - Julio Rodriguez-Lopez
- Department of Cardiovascular and Endovascular Surgery Arizona Heart Institute Phoenix, AZ, USA
| | - Edward B Diethrich
- Department of Cardiovascular and Endovascular Surgery Arizona Heart Institute Phoenix, AZ, USA
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Mell MW, Wynn MM, Reeder SB, Tefera G, Hoch JR, Acher CW. A New Intercostal Artery Management Strategy for Thoracoabdominal Aortic Aneurysm Repair. J Surg Res 2009; 154:99-104. [DOI: 10.1016/j.jss.2008.05.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2008] [Revised: 05/12/2008] [Accepted: 05/19/2008] [Indexed: 11/29/2022]
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Finley DS, Osann K, Skarecky D, Ahlering TE. Hypothermic Nerve-sparing Radical Prostatectomy: Rationale, Feasibility, and Effect on Early Continence. Urology 2009; 73:691-6. [DOI: 10.1016/j.urology.2008.09.085] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Revised: 09/16/2008] [Accepted: 09/20/2008] [Indexed: 10/21/2022]
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Fansa I, Altug ME, Melek I, Ucar E, Kontas T, Akcora B, Atik E, Duman T. The Neuroprotective and Anti-inflammatory Effects of Diltiazem in Spinal Cord Ischaemia–Reperfusion Injury. J Int Med Res 2009; 37:520-33. [DOI: 10.1177/147323000903700228] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The protective effects of diltiazem were examined in a rabbit model of spinal cord ischaemia–reperfusion induced by infrarenal aortic occlusion for 30 min. In the diltiazem group ( n = 6), an intravenous infusion (2 μg/kg per min) was started 10 min before ischaemia induction; normal saline solution was infused in the control group ( n = 6). Neurological function was assessed using modified Tarlov criteria 24 h after surgery. Plasma samples were analysed for interleukin (IL)-6 and IL-10. Spinal tissue was analysed for malondialdehyde, nitric oxide and reduced glutathione activities. Tarlov scores of the diltiazem-treated rabbits indicated significantly improved hind-limb motor function compared with the control group. The diltiazem group also had better quantitative and qualitative histopathological findings. Diltiazem infusion significantly reduced IL-6 levels 3 and 24 h after reperfusion compared with the control group. The mean IL-10 level in the diltiazem group was significantly higher than in the control group 24 h after reperfusion. It is concluded that diltiazem has cytoprotective and anti-inflammatory properties, leading to reduced spinal cord injury.
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Affiliation(s)
- I Fansa
- Department of Cardiovascular Surgery, Faculty of Medicine, Mustafa Kemal University, Antakya/Hatay, Turkey
| | - ME Altug
- Department of Surgery, Faculty of Veterinary Medicine, Mustafa Kemal University, Antakya/Hatay, Turkey
| | - I Melek
- Department of Neurology, Faculty of Medicine, Mustafa Kemal University, Antakya/Hatay, Turkey
| | - E Ucar
- Department of Internal Medicine, Faculty of Medicine, Mustafa Kemal University, Antakya/Hatay, Turkey
| | - T Kontas
- Department of Biochemistry, Faculty of Veterinary Medicine, Mustafa Kemal University, Antakya/Hatay, Turkey
| | - B Akcora
- Department of Paediatric Surgery, Faculty of Medicine, Mustafa Kemal University, Antakya/Hatay, Turkey; and
| | - E Atik
- Department of Pathology, Faculty of Medicine, Mustafa Kemal University, Antakya/Hatay, Turkey
| | - T Duman
- Department of Neurology, Faculty of Medicine, Mustafa Kemal University, Antakya/Hatay, Turkey
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Abstract
Increasing evidence suggests that induction of mild hypothermia (32-35 degrees C) in the first hours after an ischaemic event can prevent or mitigate permanent injuries. This effect has been shown most clearly for postanoxic brain injury, but could also apply to other organs such as the heart and kidneys. Hypothermia has also been used as a treatment for traumatic brain injury, stroke, hepatic encephalopathy, myocardial infarction, and other indications. Hypothermia is a highly promising treatment in neurocritical care; thus, physicians caring for patients with neurological injuries, both in and outside the intensive care unit, are likely to be confronted with questions about temperature management more frequently. This Review discusses the available evidence for use of controlled hypothermia, and also deals with fever control. Besides discussing the evidence, the aim is to provide information to help guide treatments more effectively with regard to timing, depth, duration, and effective management of side-effects. In particular, the rate of rewarming seems to be an important factor in establishing successful use of hypothermia in the treatment of neurological injuries.
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Affiliation(s)
- Kees H Polderman
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, Netherlands.
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Conrad MF, Ye JY, Chung TK, Davison JK, Cambria RP. Spinal cord complications after thoracic aortic surgery: long-term survival and functional status varies with deficit severity. J Vasc Surg 2008; 48:47-53. [PMID: 18486422 DOI: 10.1016/j.jvs.2008.02.047] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Revised: 02/13/2008] [Accepted: 02/17/2008] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Paraplegia after thoracoabdominal aneurysm (TAA) repair has been associated with poor survival. Little information exists concerning the spectrum of severity that characterizes spinal cord ischemic (SCI) complications. This study stratified SCI by deficit severity to determine its impact on late survival and functional outcomes. METHODS A review of our prospectively maintained thoracic aortic database was performed from May 1987 through December 2005 to identify patients who experienced SCI of any extent after TAA repair. During this period, 576 patients underwent descending thoracic aortic repair (93 open, 105 endovascular [TEVAR]) or open TAA repair (279 extent I to III; 99 extent IV). To stratify severity of SCI, we created a spinal cord ischemia deficit (SCID) scale, which is defined as: I, flaccid paralysis; II, average neurologic muscle grade indicating <50% function; and III, average neurologic muscle grade indicating >50% function. Long-term outcomes were evaluated in relation to these groups by actuarial methods. RESULTS During the study period, 64 (11.1%) patients developed SCI of any severity (7 of 105 [6.6%] TEVAR, 57 of 471 [12%] open). These were stratified by SCID level: I, 24 (37.5%); II, 31 (48.4%); and III, 9 (14.1%). SCI was immediate in 33 (54.1%) and delayed in 28 (45.9%). Most SCI (6 of 7) associated with TEVAR was delayed. The 30-day mortality was significantly higher in the SCI group than the overall patient cohort (15 of 64 [23.4%] vs 41 of 512 [8%], P < .001) and varied by SCID level: I, 11 of 24 (45.8%); II, 4 of 31 (12.9%); and III, 0 of 9 (0%; P = .001). The 5-year actuarial survival for all SCI was lower than for non-SCI patients (25% +/- 6% vs 51% +/- 3%, P < .001) and varied linearly with SCID level but was similar between SCID II/III and the non-SCI patients (41% +/- 10% vs 51% +/- 3%, P = .281). No SCID I patients were alive at 5 years. No patients with SCID I recovered the ability to walk, but eight of 11 (73%) with SCID II and the nine (100%) with SCID III could ambulate with or without assistance at last follow-up. CONCLUSION Survival and functional outcomes correlate with SCI severity. Patients with SCID I have a poor long-term outlook. Survival of SCID II/III patients is similar to non-SCI patients; most recover the ability to ambulate.
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Affiliation(s)
- Mark F Conrad
- Division of Vascular and Endovascular Surgery of the General Surgical Services, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
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Seren M, Budak B, Turan N, Parlar A, Akar F, Ulus A. Collaborative Therapy with Nebivalol and l-NAME for Spinal Cord Ischemia/Reperfusion Injury. Ann Vasc Surg 2008; 22:425-31. [DOI: 10.1016/j.avsg.2007.12.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Revised: 12/03/2007] [Accepted: 12/04/2007] [Indexed: 11/29/2022]
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Yu QJ, Zhou QS, Huang HB, Wang YL, Tian SF, Duan DM. Protective Effect of Ketamine on Ischemic Spinal Cord Injury in Rabbits. Ann Vasc Surg 2008; 22:432-9. [DOI: 10.1016/j.avsg.2008.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2007] [Revised: 03/17/2008] [Accepted: 03/21/2008] [Indexed: 12/28/2022]
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Hypothermia suppresses excitatory synaptic transmission and neuronal death induced by experimental ischemia in spinal ventral horn neurons. Spine (Phila Pa 1976) 2007; 32:E741-7. [PMID: 18245989 DOI: 10.1097/brs.0b013e31815b654b] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Whole-cell patch-clamp recordings were performed from the ventral horn neurons obtained from the rat spinal cord slices. OBJECTIVE This study investigated the effects of hypothermia on excitatory synaptic transmission and ischemia-induced neuronal death. SUMMARY OF BACKGROUND DATA Hypothermia has long been recognized as a promising physical strategy against both ischemic and traumatic spinal cord injuries. However, the mechanism of hypothermia-mediated neuroprotective action in the spinal cord is still not fully understood at the single cell level. METHODS Whole-cell patch-clamp recordings were performed from ventral horn neurons obtained from the spinal cord slices. Ischemia was simulated by superfusing an oxygen- and glucose-deprived medium [ischemia simulating medium (ISM)]. RESULTS When the temperature of the superfusing artificial cerebrospinal fluid solution was changed from normothermia (36 degrees C) to hypothermia (32 degrees C, 28 degrees C, and 24 degrees C), the frequency of spontaneous excitatory postsynaptic currents was significantly decreased in a temperature-dependent manner. Surperfusing the ISM generated an agonal inward current which consisted of a slow and subsequent rapid inward current in all of the neurons tested. The latencies of the slow and rapid inward currents after the ISM exposures were significantly longer at hypothermia than at normothermia. Hypothermia decreased the slope of the ISM-induced slow inward current, although it did not affect the slope of the rapid inward current. Moreover, the glutamate receptor antagonists slightly prolonged the latencies of the slow and rapid inward currents that were induced by ISM and significantly decreased their slopes. CONCLUSION These results suggest that hypothermia reduces the excitatory synaptic activities and ischemic neuronal death in the spinal ventral horn. This finding may help in achieving a better understanding of the mechanisms of hypothermia-mediated neuroprotection in the spinal cord.
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