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Herajärvi J, Juvonen T. Preparing the spinal cord - priming or preconditioning? A systematic review of experimental studies. Scand Cardiovasc J Suppl 2023; 57:2166100. [PMID: 36660818 DOI: 10.1080/14017431.2023.2166100] [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: 01/21/2023]
Abstract
Objectives. Paraplegia is devastating complication associated with thoracic and thoracoabdominal aortic aneurysm repair. Vast evidence has been gathered on pre-, peri- and postoperative protective adjuncts aiming to minimize spinal cord ischemia. This review focuses on the pretreatment phase of open surgical or endovascular aortic procedures and gathers the experimental data on the interventional preconditioning and priming methods that increase the spinal cord ischemic tolerance. Design. By the start of March 2021, a systematic review was performed in PubMed, Scopus and Web of Science core collection to identify the articles that reported (i) either an ischemic preconditioning, remote ischemic preconditioning or priming method prior to (ii) experimental spinal cord ischemia performed in endovascular or open surgical fashion mimicking either thoracic, abdominal or thoracoabdominal aortic aneurysm procedures. (iii) The outcomes were reported via neurological, motor-evoked potential, somatosensory-evoked potential, histopathological, immunohistochemical, physiological analysis, or in different combinations of these measurements. Results. The search yielded 7802 articles, and 57 articles were included in the systematic review. The articles were assessed by the evaluated species, the utilized pretreatment, the measured protective effects, and the suggested underlying mechanisms. Conclusions. The reviewed articles showed several possible mechanisms in ischemic and remote ischemic preconditioning for prevention of spinal cord ischemia. The main suggested method for priming was arteriogenetic stimulus. Future studies should confirm these hints of arteriogenetic stimulus with more precise quantification of the protective recruitment process.
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Affiliation(s)
- Johanna Herajärvi
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Research Unit of Surgery, Anesthesia and Critical Care, University of Oulu, Oulu, Finland
| | - Tatu Juvonen
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Research Unit of Surgery, Anesthesia and Critical Care, University of Oulu, Oulu, Finland
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Honkanen HP, Mustonen C, Herajärvi J, Tuominen H, Starck T, Kallio M, Kiviluoma K, Anttila V, Juvonen T. Priming protects the spinal cord in an experimental aortic occlusion model. J Thorac Cardiovasc Surg 2022; 164:801-809.e2. [PMID: 33220965 DOI: 10.1016/j.jtcvs.2020.09.137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 09/23/2020] [Accepted: 09/28/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Paraplegia is a devastating complication in aortic aneurysm surgery. Modifying the spinal cord vasculature is a promising method in spinal cord protection. The aim of this study was to assess whether the spinal cord can be primed by occluding thoracic segmental arteries before simulated aneurysm repair in a porcine model. METHODS Twelve piglets were randomly assigned to the priming group (6) and the control group (6). Eight uppermost thoracic segmental arteries were occluded at 5-minute intervals in the priming group before a 25-minute aortic crossclamp. In the control group, the aorta was crossclamped for 25 minutes. During the first 5 minutes, 8 segmental arteries were occluded. After the aortic crossclamping, piglets were observed under anesthesia for 5 hours and followed up 5 days postoperatively. Near-infrared spectroscopy, motor-evoked potentials, blood samples, neurology with the modified Tarlov score, and histopathology of the spinal cord were assessed. RESULTS The median Tarlov score during the first postoperative day was higher in the priming group than in the control group (P = .001). At the end, 50% of the control animals had paraplegia compared with 0% of paraplegia in the priming group. The mean regional histopathologic score differed between the priming group and the control group (P = .02). The priming group had higher motor-evoked potentials during the operation at separate time points. The lactate levels were lower in the priming group compared with the control group (Pg = .001, Pg×t = .18). CONCLUSIONS Acute priming protects the spinal cord from ischemic injury in an experimental aortic crossclamp model.
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Affiliation(s)
- Hannu-Pekka Honkanen
- Research Unit of Surgery, Anesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland.
| | - Caius Mustonen
- Research Unit of Surgery, Anesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Johanna Herajärvi
- Research Unit of Surgery, Anesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland; University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Hannu Tuominen
- Department of Pathology, Oulu University Hospital, Oulu, Finland
| | - Tuomo Starck
- Research Unit of Medical Imaging, Physics and Technology, Medical Research Center Oulu University of Oulu, Oulu, Finland; Department of Clinical Neurophysiology, Oulu University Hospital, Oulu, Finland
| | - Mika Kallio
- Research Unit of Medical Imaging, Physics and Technology, Medical Research Center Oulu University of Oulu, Oulu, Finland; Department of Clinical Neurophysiology, Oulu University Hospital, Oulu, Finland
| | - Kai Kiviluoma
- Research Unit of Surgery, Anesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Vesa Anttila
- Heart Center, University of Turku and Turku University Hospital, Turku, Finland
| | - Tatu Juvonen
- Research Unit of Surgery, Anesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland; Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland
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King RW, Dias AP, MukherJee RD, Genovese EA, Veeraswamy RK, Wooster MD. Staging Endovascular Thoracic and Thoracoabdominal Aortic Aneurysm Repairs and the Risk of Post-operative Spinal Cord Ischemia. Ann Vasc Surg 2022; 85:299-304. [PMID: 35257921 DOI: 10.1016/j.avsg.2022.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 02/06/2022] [Accepted: 02/07/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Staged aortic aneurysm repair is one method used to decrease the risk of spinal cord ischemia (SCI) following endovascular aortic intervention. Sequential sacrifice of arteries perfusing the spine may allow for improved spinal perfusion through the development of collateral networks over time. To evaluate the impact of staging endovascular aortic aneurysm repairs on SCI, we conducted a conservative analysis of Vascular Quality Initiative (VQI) data. METHODS De-identified VQI data were queried for cases of endovascular thoracic and thoracoabdominal aneurysm repairs from year 2014 to 2019. Cases were selected based on inclusion criteria: aneurysmal disease, no ruptures, no prior aortic surgeries, no retreatments, and only cases with complete data on aortic zones and SCI. Chi-square, Student's t-tests, and Mann-Whitney U tests were used for univariable analyses, as appropriate. Logistic regression analyses were used to identify independent predictors of outcome. RESULTS There were 116 staged aortic repairs (SARs) (8.2%) performed out of a total of 1421 endovascular aortic repairs that fit study criteria. The overall rate of SCI within the study cohort was 3.4% (n = 48). The distribution of SARs and SCI events according to aortic zone coverage are displayed in Table 1. Patients who underwent staged endovascular aortic repairs had higher rates of SCI, pre-op spinal drain placement, non-African-American race, COPD, smoking history, positive stress tests, aspirin and statin use, increased estimated blood loss, physician-modified endografts, number of aortic zones covered, lower pre-op hemoglobin levels, larger aneurysm sac size, fusiform aneurysms, and longer total procedure times, Table 2. After adjusting for factors associated with SCI, a priori, and factors with a P < 0.1 univariable analysis, SAR was not associated with SCI (odds ratio [OR] = 1.86, 95% confidence interval [CI] = 0.77-4.50, P = 0.17). Of the six factors associated with SCI on univariable analysis, only procedure time ≥6 hours (OR = 2.49, 95% CI = 1.09-5.70, P = 0.031) and the number of aortic zones covered (OR = 1.15, 95% CI = 1.00-1.32, P = 0.047) were predictive of SCI. Staged repairs had a lower proportion of permanent SCI (38%, 3 of 8 cases) compared with repairs that were not staged (68%, 27 of 40 cases), with a relative risk reduction of 44% for those who developed SCI, P = 0.21. CONCLUSIONS In a large national data set, SARs were performed for patients with more extensive aortic disease. SARs were only performed in about 8% of cases and the rate of SCI remained low. After adjusting for baseline comorbidities, extent of aortic disease, and other factors that may potentiate SCI, staged aortic aneurysm repair had a similar risk of SCI compared with non-staged repairs. However, there was a trend toward decreased permanent SCI risk in the SAR group.
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Affiliation(s)
- Ryan W King
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC.
| | - Agenor P Dias
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Rupak D MukherJee
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Elizabeth A Genovese
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC; Ralph H. Johnson Department of Veteran Affairs Medical Center, Charleston, SC
| | - Ravi K Veeraswamy
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Mathew D Wooster
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
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Shiiya N, Tsuda K, Yamanaka K, Takahashi D, Washiyama N, Yamashita K, Kando Y, Ohashi Y. Clinical feasibility and safety of transoesophageal motor-evoked potential monitoring. Eur J Cardiothorac Surg 2021; 57:1076-1082. [PMID: 32011686 DOI: 10.1093/ejcts/ezaa002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 12/08/2019] [Accepted: 12/11/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Canine experiments have shown that transoesophageal motor-evoked potential monitoring is feasible, safe and stable, with a quicker response to ischaemia and a better prognostic value than transcranial motor-evoked potentials. We aimed to elucidate whether or not these findings were clinically reproducible. METHODS A bipolar oesophageal electrode mounted on a large-diameter silicon tube and a train of 5 biphasic wave stimuli were used for transoesophageal stimulation. Results of 18 patients (median age 74.5 years, 13 males) were analysed. RESULTS There were no mortalities, spinal cord injuries or complications related with transoesophageal stimulation. Transcranial motor-evoked potential could not be monitored up to the end of surgery in 3 patients for unknown reasons, 2 of whom from the beginning. Transoesophageal motor-evoked potential became non-evocable after manipulation of a transoesophageal echo probe in 2 patients. Strenuous movement of the upper limbs during transoesophageal stimulation was observed in 3 patients. In 14 patients who successfully completed both monitoring methods up to the end of surgery (11 thoraco-abdominal and 3 descending aortic repair), the final results were judged as false positives in 6 by transcranial stimulation and in 1 by transoesophageal stimulation. The stimulation intensity was significantly lower and the upper limb amplitude was significantly higher by transoesophageal stimulation, while the lower limb amplitude was comparable. CONCLUSIONS Transoesophageal motor-evoked potential monitoring is clinically feasible and safe with a low false positive rate. A better electrode design is required to avoid its migration by transoesophageal echo manipulation. Further studies may be warranted. CLINICAL REGISTRATION NUMBER UMIN000022320.
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Affiliation(s)
- Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Kazumasa Tsuda
- First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Ken Yamanaka
- First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Daisuke Takahashi
- First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Naoki Washiyama
- First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Katsushi Yamashita
- First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yumi Kando
- First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yuko Ohashi
- First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
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5
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Heber UM, Mayrhofer M, Gottardi R, Kari FA, Heber S, Windisch A, Weninger WJ, Hirtler L, Scheumann J, Rylski B, Beyersdorf F, Czerny M. The intraspinal arterial collateral network: a new anatomical basis for understanding and preventing paraplegia during aortic repair. Eur J Cardiothorac Surg 2021; 59:137-144. [PMID: 32710104 DOI: 10.1093/ejcts/ezaa227] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 05/11/2020] [Accepted: 05/18/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The anatomical distribution pattern of epidural intraspinal arteries is not entirely understood but is likely to substantially impact maintaining perfusion during segmental artery sacrifice when treating acute and chronic thoraco-abdominal aortic diseases. We investigated the anatomical distribution pattern of intraspinal arteries. METHODS Twenty fresh, non-embalmed cadaveric human bodies were studied. Anatomical dissection and investigation of the epidural arterial network were performed according to a standardized protocol. We used a generalized mixed linear model to test whether the presence probability for certain vessels differed between vertebrae/segments. RESULTS There was craniocaudal continuity of all ipsilateral longitudinal connections from T1 to L5 by the anterior radicular artery. The mean [±standard deviation (SD)] number of transverse anastomoses was 9.7 ± 2.1. The presence probability of transverse anastomoses along the spine was different between vertebrae (P < 0.0001). There were 2 distribution peaks along the spine: 1 peak around T4-T6 and 1 around T11. The mean (±SD) number of thoracic and lumbar anterior radiculomedullary arteries (ARMAs) was 3.0 ± 1.1. The probability of the presence of ARMAs along the spine was different for each vertebral segment (P < 0.0001). Between ARMAs there were gaps of up to a maximum of 9 vertebrae. All Adamkiewicz arteries were located caudally to T7. The median segment of the Adamkiewicz presence was T10/11. CONCLUSIONS The epidural collateral network shows craniocaudal continuity. The number of transverse anastomoses is high. The number of ARMAs is low, and there is considerable variation in their distribution and offspring, which is highly likely to impact perfusion during segmental artery sacrifice when treating thoraco-abdominal aortic disease.
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Affiliation(s)
- Ulrike M Heber
- Center for Anatomy and Cell Biology, Division of Anatomy, MIC und CMI, Medical University of Vienna, Vienna, Austria.,Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Marcel Mayrhofer
- Center for Anatomy and Cell Biology, Division of Anatomy, MIC und CMI, Medical University of Vienna, Vienna, Austria
| | - Roman Gottardi
- Department of Cardiovascular and Endovascular Surgery, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Fabian A Kari
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany.,Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Stefan Heber
- Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Alfred Windisch
- Center for Anatomy and Cell Biology, Division of Anatomy, MIC und CMI, Medical University of Vienna, Vienna, Austria
| | - Wolfgang J Weninger
- Center for Anatomy and Cell Biology, Division of Anatomy, MIC und CMI, Medical University of Vienna, Vienna, Austria
| | - Lena Hirtler
- Center for Anatomy and Cell Biology, Division of Anatomy, MIC und CMI, Medical University of Vienna, Vienna, Austria
| | - Johannes Scheumann
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany.,Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany.,Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany.,Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany.,Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
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Garcia-Ballestas E, Murlimanju BV, Durango-Espinosa YA, Joaquim AF, Vasquez HE, Moscote-Salazar LR, Agrawal A. Collateral Circulation in Spinal Cord Injury: A Comprehensive Review. INDIAN JOURNAL OF NEUROTRAUMA 2020. [DOI: 10.1055/s-0040-1713724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractSurgery is the most common cause of spinal cord ischemia; it is also caused by hemodynamic changes, which disrupt the blood flow. Direct ligation of the spinal arteries, especially the Adamkiewicz artery is involved as well. Other causes of spinal cord ischemia include arteriography procedures, thoracic surgery, epidural and rachianesthesia, foraminal infiltration, arterial dissection, systemic hypotension, emboligenic heart disease, thoracic disc herniation, and compression. Understanding the vascular anatomy of the spinal cord is essential to develop optimal strategies for preventing ischemic injuries to the spinal cord. During ischemia, a rich network of intra and paraspinal collaterals allow enough blood flow to compensate the intensity of spinal cord ischemia. In case of interruption of flow of a main artery, the collateral artery increases its flow to maintain perfusion to the tissues. Avoiding spinal cord ischemia by using collateral circulation is necessary to prevent the establishment of hypovolemia, hyperthermia and elevations in venous pressures. The objective of this narrative review is to present the current concepts of spinal collateral circulation and its role in the setting of ischemic events, affecting the vascular supply of the spinal cord.
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Affiliation(s)
- Ezequiel Garcia-Ballestas
- Faculty of Medicine, Center for Biomedical Research (CIB), University of Cartagena, Cartagena, Colombia
| | - B. V. Murlimanju
- Department of Anatomy, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | | | - Andrei F. Joaquim
- Neurosurgery Division, Cartagena de Indias, Bolivar Department of Neurology, State University of Campinas, Campinas-Sao Paulo, Brazil
| | - Harold E. Vasquez
- Universidad del Sinu, Cartagena de Indias, Consejo Latinoamericano de Neurointensivismo (CLaNi), Cartagena de Indias, Colombia
| | - Luis Rafael Moscote-Salazar
- Neurosurgeon-Critical Care, Center for Biomedical Research (CIB), Cartagena Neurotrauma Research Group, Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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von Aspern K, Haunschild J, Borger MA, Etz CD. Anatomical description of the intraspinal collateral network: bringing the concept full circle—is the devil in the details? Eur J Cardiothorac Surg 2020; 59:144-146. [DOI: 10.1093/ejcts/ezaa341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Josephina Haunschild
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Michael A Borger
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Christian D Etz
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
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King RW, Wooster MD, Ruddy JM, Genovese EA, Anderson JM, Brothers TE, Veeraswamy RK. Previous thoracic aortic repair is not associated with adverse outcomes after thoracic endovascular aortic repair. J Vasc Surg 2020; 71:1097-1108. [PMID: 31619351 PMCID: PMC7189752 DOI: 10.1016/j.jvs.2019.07.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/18/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND As many as 20% of patients who have undergone previous thoracic aortic repair will require reintervention, which could entail thoracic endovascular aortic repair (TEVAR). A paucity of data is available on mortality and the incidence of spinal cord ischemia (SCI) and other postoperative complications associated with TEVAR after previous aortic repairs exclusive to the thoracic aorta. The aim of the present study was to assess the effect of previous thoracic aortic repair on the 30-day mortality and SCI outcomes for patients after TEVAR. METHODS The Society for Vascular Surgery Vascular Quality Initiative database was queried for all cases of TEVAR from 2012 to 2018. Patients were excluded if they had undergone previous abdominal aortic repair, the TEVAR had extended beyond aortic zone 5, or SCI data were missing. The 3 cohorts compared were TEVAR with previous ascending aortic or aortic arch repair (group 1), TEVAR with previous descending thoracic aortic repair (group 2), and TEVAR without previous repair (group 3). The primary outcomes of interest were 30-day mortality and SCI. The secondary outcomes included stroke, myocardial infarction, cardiac complications, respiratory complications, postoperative length of stay, and reintervention. The patient variables were compared using χ2 tests, analysis of variance, or Kruskal-Wallis tests, as appropriate. Logistic regression analysis was performed to identify the predictors of 30-day mortality and SCI. RESULTS A total of 4010 patients met the inclusion criteria, with 470 in group 1, 132 in group 2, and 3408 in group 3. The 30-day mortality was 4% (19 of 470) in group 1, 6% (8 of 132) in group 2, and 6% (213 of 3408) in group 3 (P = .17). The incidence of SCI was 3% (14 of 470) in group 1, 3% (4 of 132) in group 2, and 3.8% (128 of 3408) in group 3 (P = .65). Stroke, reintervention, myocardial infarction, and cardiac complications were not significantly different among the 3 groups. The incidence of respiratory complications was greatest for group 3 (11%; 360 of 3408) compared with groups 1 (9%; 44 of 470) and 2 (4%; 5 of 132; P = .034). Similarly, the postoperative length of stay was longest for group 3 (9.6 ± 19.4 days vs 8.2 ± 18.3 days for group 1 and 5.9 ± 8.6 days for group 2; P = .038). The independent predictors of 30-day mortality for all TEVAR patients included units of packed red blood cells transfused intraoperatively, urgent or emergent repairs, older age, increasing serum creatinine level, inability to perform self-care, total procedure time, occlusion of the left subclavian artery intraoperatively, distal endograft landing zone 5, and diabetes. The predictors of SCI included the total procedure time, urgent and emergent repairs, and increasing serum creatinine level. CONCLUSIONS TEVAR after previous thoracic aortic repair was not associated with an increased risk of SCI or 30-day mortality compared with TEVAR without previous aortic repair.
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Affiliation(s)
- Ryan W King
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC.
| | - Mathew D Wooster
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Jean M Ruddy
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC; Ralph H. Johnson Department of Veteran Affairs Medical Center, Charleston, SC
| | - Elizabeth A Genovese
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC; Ralph H. Johnson Department of Veteran Affairs Medical Center, Charleston, SC
| | - Joseph M Anderson
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Thomas E Brothers
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC; Ralph H. Johnson Department of Veteran Affairs Medical Center, Charleston, SC
| | - Ravi K Veeraswamy
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
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Saravi B, Wittmann K, Krause S, Puttfarcken L, Siepe M, Göbel U, Beyersdorf F, Kari FA. Analysis of spinal cord blood supply combining vascular corrosion casting and fluorescence microsphere technique: A feasibility study in an aortic surgical large animal model. Clin Anat 2020; 34:527-535. [PMID: 32115761 DOI: 10.1002/ca.23586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/17/2020] [Accepted: 02/19/2020] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Spinal cord ischemia after cardiovascular interventions continues to be a devastating problem in modern surgery. The role of intraspinal vascular networks and anterior radiculomedullary arteries (ARMA) in preventing spinal cord ischemia is poorly understood. MATERIALS AND METHODS Landrace pigs (n = 30, 35.1 ± 3.9 kg) underwent a lateral thoracotomy. Fluorescent microspheres were injected into the left atrium and a reference sample was aspirated from the descending aorta. Repeated measurements of spinal cord and renal cortical blood flow from the left and right kidneys with three different microsphere colors in five pigs were taken to validate reproducibility. Spinal cord blood flow to the upper thoracic (T1-T4), mid-thoracic (T5-T8), lower thoracic (T9-T13), and lumbar (L1-L3) levels were determined. After euthanasia, we carried out selective vascular corrosion cast and counted the left and right ARMAs from levels T1-T13. RESULTS Blood flow analysis of the left and right kidneys revealed a strong correlation (r = .94, p < .001). We detected more left than right ARMAs, with the highest prevalence at T4 (p < .05). The mean number of ARMAs was 8 ± 2. Their number in the upper thoracic region ranged from 2 to 7 (mean of 5 ± 1), while in the lower thoracic region they ranged from 0 to 5 (mean of 3 ± 1 [p < .001]). CONCLUSIONS This study shows that combining fluorescence microsphere technique and vascular corrosion cast is well suited for assessing the blood flow and visualizing the arteries at the same time.
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Affiliation(s)
| | - Karin Wittmann
- Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sonja Krause
- Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Luisa Puttfarcken
- Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Göbel
- Anesthesiology and Intensive Care, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Fabian A Kari
- Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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10
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Arteriogenesis of the Spinal Cord-The Network Challenge. Cells 2020; 9:cells9020501. [PMID: 32098337 PMCID: PMC7072838 DOI: 10.3390/cells9020501] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 12/27/2022] Open
Abstract
Spinal cord ischemia (SCI) is a clinical complication following aortic repair that significantly impairs the quality and expectancy of life. Despite some strategies, like cerebrospinal fluid drainage, the occurrence of neurological symptoms, such as paraplegia and paraparesis, remains unpredictable. Beside the major blood supply through conduit arteries, a huge collateral network protects the central nervous system from ischemia—the paraspinous and the intraspinal compartment. The intraspinal arcades maintain perfusion pressure following a sudden inflow interruption, whereas the paraspinal system first needs to undergo arteriogenesis to ensure sufficient blood supply after an acute ischemic insult. The so-called steal phenomenon can even worsen the postoperative situation by causing the hypoperfusion of the spine when, shortly after thoracoabdominal aortic aneurysm (TAAA) surgery, muscles connected with the network divert blood and cause additional stress. Vessels are a conglomeration of different cell types involved in adapting to stress, like endothelial cells, smooth muscle cells, and pericytes. This adaption to stress is subdivided in three phases—initiation, growth, and the maturation phase. In fields of endovascular aortic aneurysm repair, pre-operative selective segmental artery occlusion may enable the development of a sufficient collateral network by stimulating collateral vessel growth, which, again, may prevent spinal cord ischemia. Among others, the major signaling pathways include the phosphoinositide 3 kinase (PI3K) pathway/the antiapoptotic kinase (AKT) pathway/the endothelial nitric oxide synthase (eNOS) pathway, the Erk1, the delta-like ligand (DII), the jagged (Jag)/NOTCH pathway, and the midkine regulatory cytokine signaling pathways.
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Kari FA, Saravi B, Krause S, Puttfarcken L, Wittmann K, Förster K, Rylski B, Maier S, Göbel U, Siepe M, Czerny M, Beyersdorf F. Spinal ischaemia after thoracic endovascular aortic repair with left subclavian artery sacrifice: is there a critical stent graft length? Eur J Cardiothorac Surg 2019; 53:385-391. [PMID: 28958025 DOI: 10.1093/ejcts/ezx285] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 06/20/2017] [Accepted: 07/05/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Thoracic endovascular aortic repair (TEVAR) is used for treatment of thoracic aortic pathologies, but the covered stent graft can induce spinal ischaemia depending on the length used. The left subclavian artery contributes to spinal cord collateralization and is frequently occluded by the stent graft. Our objective was to investigate the impact of covered stent graft length on the risk of spinal ischaemia in the setting of left subclavian artery sacrifice. METHODS Twenty-six pigs (German country race, mean body weight 36 ± 4 kg) underwent simulated descending aortic TEVAR via left lateral thoracotomy, with left subclavian artery and thoracic segmental artery occlusion in normothermia. Animals were assigned to treatment groups according to simulated stent graft length: TEVAR to T8 (n = 4), TEVAR to T9 (n = 4), TEVAR to T10 (n = 4), TEVAR to T11 (n = 7) and TEVAR to T12 (n = 1) and a sham group (n = 6). End points included spinal cord perfusion pressure, cerebrospinal fluid pressure and spinal cord blood flow using fluorescent microspheres. RESULTS There were no group differences in spinal cord perfusion pressure drop or in spinal cord perfusion pressure regeneration potential at 3 h after the procedure: from a baseline average of 75 mmHg (95% confidence interval 71-83 mmHg) to 73 mmHg (67-75 mmHg) at 3 h in Group T10 versus from a baseline average of 67 mmHg (95% CI 50-81 mmHg) to 65 mmHg (95% confidence interval 48-81 mmHg) in Group T8. There were no differences in the spinal cord blood flow courses over time in the different groups nor was there any difference in cerebrospinal fluid pressure levels and cerebrospinal fluid pressure dynamics between groups. However, we did observe local blood flow distribution to the spinal cord that was inhomogeneous depending on the distance between the simulated stent graft end and the first thoracic anterior radiculomedullary artery. CONCLUSIONS The risk of spinal ischaemia after serial segmental artery occlusion does not depend on the distal extent of the aortic repair alone. Future attempts to allow patient risk stratification for spinal ischaemia need to focus on anterior radiculomedullary artery anatomy together with the extent of planned aortic repair.
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Affiliation(s)
- Fabian A Kari
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Babak Saravi
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sonja Krause
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Luisa Puttfarcken
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karin Wittmann
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katharina Förster
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Göbel
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Anesthesiology and Critical Care, University Medical Center Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
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12
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Kari FA, Saravi B, Krause S, Puttfarcken L, Scheumann J, Förster K, Rylski B, Maier S, Göbel U, Siepe M, Czerny M, Beyersdorf F. New insights into spinal cord ischaemia after thoracic aortic procedures: the importance of the number of anterior radiculomedullary arteries for surgical outcome. Eur J Cardiothorac Surg 2019; 54:149-156. [PMID: 29917121 DOI: 10.1093/ejcts/ezy058] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/30/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Anterior radiculomedullary arteries (ARMAs) link dorsal segmental arteries and the intraspinal compartment of the spinal collateral network. The number of thoracic ARMA is highly variable from one person to another. The impact of the number of ARMAs on spinal cord perfusion during thoracic aortic procedures is unknown. We investigated the influence of the number of thoracic ARMAs on spinal cord perfusion in an aortic surgical large animal model. METHODS Twenty-six pigs were included (20 treatment animals, 6 sham animals, weight 34 ± 3 kg). The animals underwent ligation of the left subclavian artery and the thoracic segmental arteries via a left lateral thoracotomy with normothermia. After sacrifice, complete body perfusion with coloured cast resin was performed and the number of thoracic ARMAs was documented at autopsy. End points were spinal cord perfusion pressure, cerebrospinal fluid pressure, spinal cord blood flow (microspheres) and neurological outcome. Observation time was 3 h post-ligation. RESULTS The numbers of thoracic ARMAs ranged between 3 (n = 1) and 13 (n = 1). The mean number was 8. Animals were grouped according to number of thoracic ARMA: 6-7 (5 animals), 8-10 (8 animals) and 11-13 (5 animals). A large number of thoracic ARMAs was linked to (i) a lower drop in spinal cord blood flow from baseline to post-clamp, (ii) the presence and increased magnitude of hyperaemia evident 3 h post-clamp (P < 0.001) and (iii) the presence of early hyperaemia starting immediately post-clamp in animals with 11 or more ARMA (P < 0.001). CONCLUSIONS We showed that a large number of thoracic ARMA protects against spinal cord injury during descending aortic surgical procedures.1.
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Affiliation(s)
- Fabian A Kari
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Babak Saravi
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sonja Krause
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Luisa Puttfarcken
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Scheumann
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katharina Förster
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Göbel
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Anesthesiology and Critical Care, University Medical Center Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
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13
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Somatosensory and transcranial motor evoked potential monitoring in a porcine model for experimental procedures. PLoS One 2018; 13:e0205410. [PMID: 30296297 PMCID: PMC6175523 DOI: 10.1371/journal.pone.0205410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 09/25/2018] [Indexed: 11/19/2022] Open
Abstract
Evoked potential monitoring has evolved as an essential tool not only for elaborate neurological diagnostics, but also for general clinical practice. Moreover, it is increasingly used to guide surgical procedures and prognosticate neurological outcome in the critical care unit, e.g. after cardiac arrest. Experimental animal models aim to simulate a human-like scenario to deduct relevant clinical information for patient treatment and to test novel therapeutic opportunities. Porcine models are particularly ideal due to a comparable cardiovascular system and size. However, certain anatomic disparities have to be taken into consideration when evoked potential monitoring is used in animal models. We describe a non-invasive and reproducible set-up useful for different modalities in porcine models. We further illustrate hints to overcome multi-faceted problems commonly occurring while using this sophisticated technique. Our descriptions can be used to answer a plethora of experimental questions, and help to further facilitate experimental therapeutic innovation.
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14
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Kari FA, Wittmann K, Krause S, Saravi B, Puttfarcken L, Förster K, Rylski B, Maier S, Göbel U, Siepe M, Czerny M, Beyersdorf F. Spinal Ischemia in Thoracic Aortic Procedures: Impact of Radiculomedullary Artery Distribution. Ann Thorac Surg 2017; 104:1953-1959. [PMID: 28935349 DOI: 10.1016/j.athoracsur.2017.05.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 04/17/2017] [Accepted: 05/11/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND The aim of this study was to assess the influence of thoracic anterior radiculomedullary artery (tARMA) distribution on spinal cord perfusion in a thoracic aortic surgical model. METHODS Twenty-six pigs (34 ± 3 kg; study group, n = 20; sham group, n = 6) underwent ligation of the left subclavian artery and thoracic segmental arteries. End points were spinal cord perfusion pressure (SCPP), regional spinal cord blood flow (SCBF), and neurologic outcome with an observation time of 3 hours. tARMA distribution patterns tested for an effect on end points included (1) maximum distance between any 2 tARMAs within the treated aortic segment (0 or 1 segment = small-distance group; >1 segment = large-distance group) and (2) distance between the end of the treated aortic segment and the first distal tARMA (at the level of the distal simulated stent-graft end = group 0; gap of 1 or more segments = group ≥1). RESULTS The number of tARMA ranged from 3 to 13 (mean, 8). In the large-distance group, SCBF dropped from 0.48 ± 0.16 mL/g/min to 0.3 ± 0.08 mL/g/min (p < 0.001). We observed no detectable SCBF drop in the small-distance group: 0.2 ± 0.05 mL/g/min at baseline to 0.23 ± 0.05 mL/g/min immediately after clamping (p = 0.147). SCBF increased from 0.201 ± 0.055 mL/g/min at baseline to 0.443 ± 0.051 mL/g/min at 3 hours postoperatively (p < 0.001) only in the small-distance group. CONCLUSIONS We demonstrate experimental data showing that distribution patterns of tARMAs correlate with the degree of SCBF drop and insufficient reactive parenchymal hyperemia in aortic procedures. Individual ARMA distribution patterns along the treated aortic segment could help us predict the individual risk of spinal ischemia.
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Affiliation(s)
- Fabian A Kari
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Medical Faculty of the University of Freiburg, Freiburg, Germany.
| | - Karin Wittmann
- Department of Anesthesiology and Critical Care, University Medical Center Freiburg, Faculty of Medicine of the University of Freiburg, Freiburg, Germany
| | - Sonja Krause
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Babak Saravi
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Luisa Puttfarcken
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Katharina Förster
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Ulrich Göbel
- Department of Anesthesiology and Critical Care, University Medical Center Freiburg, Faculty of Medicine of the University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Medical Faculty of the University of Freiburg, Freiburg, Germany
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15
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DeAnda A, Roughneen PT. Spinal Cord Collateral Pathways-The Road Not Taken. Semin Thorac Cardiovasc Surg 2017; 28:388-389. [PMID: 28043448 DOI: 10.1053/j.semtcvs.2016.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Abe DeAnda
- Division of Cardiothoracic Surgery, University of Texas Medical Branch, Galveston, Texas.
| | - Patrick T Roughneen
- Division of Cardiothoracic Surgery, University of Texas Medical Branch, Galveston, Texas
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