Reversal of Spinal Cord Ischemia Following Endovascular Thoracic Aortic Aneurysm Repair With Hyperbaric Oxygen and Therapeutic Hypothermia

BACKGROUND

Neurological adverse events with spinal cord ischemia (SCI) remain one of the most feared complications in patients undergoing thoracic endovascular aortic repair (TEVAR). These patients can develop irreversible paraplegia with lifelong consequences with physical and psychological agony.

CASE PRESENTATION

We herein present a patient who developed SCI with bilateral lower leg paraplegia on the third postoperative day following TEVAR. Spinal catheter was inserted for spinal fluid drainage. A hyperbaric oxygen therapy was initiated for 90 minutes for 2 days, which was followed by therapeutic hypothermia for 24 hours with a target temperature of 33°C. The patient exhibited significant neurological recovery following these treatments, and he ultimately regained full neurological function without spinal deficit.

DISCUSSION

This represents the first reported case of full neurological recovery of a patient who developed complete SCI following TEVAR procedure. The neurological recovery was due in part to immediate therapeutic hypothermia and hyperbaric oxygen therapy which reversed the spinal ischemia.

Functional Assessment and Evaluation of Outcome After Endovascular Therapy With Coverage of the Left Subclavian Artery in Case of Blunt Thoracic Aortic Injury

BACKGROUND

Patients suffering blunt thoracic aortic injury (BTAI) can be treated by use of thoracic endovascular aortic repair (TEVAR). In this setting, the coverage of the left subclavian artery (LSA) is frequently necessary. Nevertheless, the functionality of the upper left extremity after TEVAR had been rarely analyzed. Thus, this study intends to underline the safety of TEVAR as well as to determine the functionality of the left arm after coverage of the LSA.

METHODS

All patients suffering from BTAI treated by endovascular means in 3 centers (Aachen [Germany], Maastricht [Netherlands], and Innsbruck [Austria]) between 1996 and 2009 were retrospectively analyzed. The safety of the procedure had been assessed by the morbidity and mortality rate. The mid-term functional status of the upper left extremity was evaluated by using the DASH score (disabilities of the arm shoulder and hand).

RESULTS

Forty-six patients (40 male, 6 female), mean age 39.4 ± 16.9 years suffered from BTAI caused by traffic accident (n = 31 [67.39%]), by skiing injury (n = 8 [17.39%]), and by fall (n = 7 [15.21%]). All patients underwent TEVAR, the technical success rate was 100%; 1 carotid-carotid subclavian bypass implantation was necessary. LSA coverage was performed in 76% (35/46) of the cases. Total complication rate was 17.3% (8/46); the endoleak rate was 8.6% (4/46) (2 × Ib, 1 × IIa, 1 × IV). Further complications were bypass and endograft occlusion. The postoperative mortality rate was 6% (3/46), the DASH score was completed in 65% (30/46). The study population reached a mean value of 17 ± 20, which is comparable to a nonharmed reference group (10.10 ± 14.68). A significant correlation between the DASH score and patients age could be demonstrated (2-sided P value: 0.0213).

CONCLUSIONS

Endovascular therapy of BTAI revealed a good primary success rate. An adequate mid-term functional status of the upper left extremity could be assessed in comparison to a nonharmed reference group.

Iliac leg and abdominal aortic cuff stent-graft for blunt thoracic aortic injury in young patient

Thoracic endovascular aortic repair for blunt thoracic aortic injury in young adults with small aortic diameter often encounters high difficulty. We report, to our knowledge, the first case of successful treatment using combination of iliac leg and abdominal aortic cuff stent-graft.

Aberrant right subclavian artery in blunt aortic injury: implication for treatment and review of the literature

Blunt aortic injury (BAI) involving an aberrant right subclavian artery (ARSA) is uncommon. The presence of an ARSA entails several treatment issues, in particular regarding the risk of perioperative posterior cerebral stroke. We report the case of a man with an ARSA who suffered from BAI. An initial conservative treatment with delayed open repair was chosen. A review of the published literature with discussion of the case is presented. The presence of an ARSA in patients with BAI can be considered a poor anatomy for endovascular repair, and suitable patients may benefit from delayed open repair.

Early outcomes of deliberate nonoperative management for blunt thoracic aortic injury in trauma

OBJECTIVE

Traumatic blunt aortic injury has traditionally been viewed as a surgical emergency, whereas nonoperative therapy has been reserved for nonsurgical candidates. This study reviews our experience with deliberate, nonoperative management for blunt thoracic aortic injury.

METHODS

A retrospective chart review with selective longitudinal follow-up was conducted for patients with blunt aortic injury. Surveillance imaging with computed tomography angiography was performed. Nonoperative patients were then reviewed and analyzed for survival, evolution of aortic injury, and treatment failures.

RESULTS

During the study period, 53 patients with an average age of 45 years (range, 18-80 years) were identified, with 28% presenting to the Stanford University School of Medicine emergency department and 72% transferred from outside hospitals. Of the 53 patients, 29 underwent planned, nonoperative management. Of the 29 nonoperative patients, in-hospital survival was 93% with no aortic deaths in the remaining patients. Survival was 97% at a median of 1.8 years (range, 0.9-7.2 years). One patient failed nonoperative management and underwent open repair. Serial imaging was performed in all patients (average = 107 days; median, 31 days), with 21 patients having stable aortic injuries without progression and 5 patients having resolved aortic injuries.

CONCLUSIONS

This experience suggests that deliberate, nonoperative management of carefully selected patients with traumatic blunt aortic injury may be a reasonable alternative in the polytrauma patient; however, serial imaging and long-term follow-up are necessary.