Prevention of spinal ischemia
during repair of descending
(DTA) or thoracoabdominal
aortic aneurysms (TAA)
Fabien Koskas, Julien Gaudric
CHU Pitié-Salpêtrière, Paris,
France
PROTECTION MEDULLAIRE
Clampage médullaire
Hémodynamique
Ischémie
médullaire
Hypoxie
Hyperpression LCR
PROTECTION MEDULLAIRE
Clampage médullaire
Potentiels évoqués
somesthésiques/moteur
Diminution métabolisme médullaire
Hypothermie profonde / péridurale
Perfusion aortique distale
CEC/shunts
Ischémie
médullaire
Identification et réimplantation
de l’A. d’Adamkiewicz
Identification groupes à risque
Clampage court <30mn
Pharmacologie
(papavérine intrathécale etc…)
Artifices techniques
PROTECTION MEDULLAIRE
Clampage médullaire
Hémodynamique
Contrôle tensionnel per op
-clampage proximal
-déclampage
CEC
Contrôle tensionnel post-op
Paraplégies 2aires
Ischémie
médullaire
Contrôle pertes sanguines
Cell saver, récupérateurs
PROTECTION MEDULLAIRE
Clampage médullaire
Hémodynamique
Ischémie
médullaire
Hypoxie
exclusion pulm G
Oxygénateur/CEC
PaO2 post op
PROTECTION MEDULLAIRE
Clampage médullaire
Hémodynamique
Ischémie
médullaire
Hypoxie
Hyperpression LCR
Drainage per et post opératoire
Personal experience
Open surgery of DTA-TAA
1990-2000
Dissection
Atheroma
Other
Total
1990-2000
Paraplegia
Paraparesis
Total
DTA % TAA I % TAA II % TAA III % TAA IV % Total %
33
8
12
3
34
8
64 15
19
4
41 10
47 11
5
1
19
144 34
36
8
94 22
4
12
3
0
92
22
41 10
70 16
235
55
17
11
99
23
4
70 16
1
3
82 19
426 100
DTA % TAA I % TAA II % TAA III % TAA IV % Total %
2
1
3
8
18
19
9
13
1
1
33
8
8
6
3
8
12
13
5
7
1
1
29
7
144 100
36 100
94 100
70 100
82 100
426 100
Mechanisms of postoperative
paraplegia after T(EV)AR
• Reversible intraoperative spinal ischemia
• Reperfusion injury
– Breakdown of cellular membranes : edema
– Spinal compression injury
• Irreversible spinal ischemia
– Permanent suppression of the spinal blood supply by the
aortic procedure
– Thromboembolic events within the spinal blood supply
• Poor perioperative systemic hemodynamics
Vascularisation médullaire
ASP
ASP
ADK: D8-L2=85%
ASA
Si ADK<D12: A radiculaire
thor moy entre D7-D8
Kieffer E, in Techniques modernes
en chirurgie vasculaire 2007
Lazorthes G et al. Arterial vascularization of the spinal cord. J Neurosurg 1971;35:253-62
25,0%
15,0%
Adamkiewicz
MDA
SDA
10,0%
5,0%
L3
L2
L1
T12
T11
T10
T9
T8
T7
T6
T5
T4
T3
0,0%
VA
Probability %
20,0%
480 personal cases using exhaustive spinal angiograpy
J Vasc Surg 2002;35:262-8.
AK>
AK=
AK?
AK<
Ann Vasc Surg 1989;3:34-46.
Risk of paraplegia/paresis
after open surgical repair of TAA
Type
I
II
III
IV
%
15
15-40
10
10
Class
Ak>
Ak<
Ak=
Ak?
%
<10
<10
5-50*
50
*Depending upon spinal arterial reattachment
Ann Vasc Surg 1989;3:34-46.
Spinal angiography & Results
1990-2000
Ak>
Ak<
Ak=
Ak?
Total done
1990-2000
Paraplegia
Paraparesis
Total
DTA % TAA I % TAA II % TAA III % TAA IV % Total %
4
1
2
0
0
0
12
3
23
5
41
10
26
6
3
1
0
0
0
0
0
0
29
7
63 15
28
7
75 18
45 11
17
4
228
54
1
1
0
13
5
1
31
7
99 23
34
8
88 21
45 11
329
77
6
3
6
1
63 15
DTA % TAA I % TAA II % TAA III % TAA IV % Total %
2
1
3
8
18
19
9
13
1
1
33
8
8
6
3
8
12
13
5
7
1
1
29
7
144 100
36 100
94 100
70 100
82 100
426 100
Risk of paraplegia/paresis after
endovascular repair
• Unknown
• Probably globally lesser than after open surgery
– Selection bias
– Better perioperative hemodynamics
– Conservation of collateral pathways
• Very low,
especially in the Ak> and Ak< groups
• Not null,
especially whenever Ak= or Ak?
Spinal angio versus spinal imaging
• Exhaustive spinal angio (ESA) is our gold
standard, especially for open surgery of TAAs
II
• ESA is technically demanding, time consuming,
expensive and invasive
• EVAR might require a less exhaustive
evaluation : selective spinal imaging (SSI)
• With modern CT technology, more and more
cases can benefit from SSI without the need of
another acquisition than that necessary to
document the aortic lesion*
* Kawaharada et al. Eur J Cardiothorac Surg 2002;21:970-4.
* Yoshioka K et al. Radiographics 2003;23:1215-25
Principles of selective spinal imaging
• Explore all intercostal arteries to be covered
by the stent-graft and adjacent
• With multislice CT (16 bit +), using the
same acquisition as that taken for imaging
the aortic lesion
• With sequential catheterization only in case
of a failure
• Classify according to the result
Methods of spinal protection
•
•
•
•
•
Spinal revascularization
Distal perfusion
Spinal or general hypothermia
Spinal drainage
Intrathecal or IV drugs
– Papaverin, steroïds , calcium blockers, radical
scavengers, barbiturates, naloxone, PGEI,
allopurinol, oxygen carriers etc…
Spinal revascularization
• Systematic and blind
• Never
• Selective
– Size, topography and backflow of intercostal
arteries
– Intra-operative monitoring (evoked potentials)
– Pre-operative spinal angiography
Distal perfusion
• Improves the hemodynamic tolerance to
cross-clamping
• Reduces the duration of visceral and spinal
ischemia
Methods of distal perfusion
•
•
•
•
Passive shunt
Extra-anatomic bypass
Active shunt
Cardio-pulmonary bypass
–
–
–
–
Better control of flow
Better oxygen transfer
Better control of temperature
But necessitates high doses of heparin
Hypothermic circulatory arrest
• Visceral (and spinal) protection
• Avoids difficult or hazardous cross-clamping
– Dissection
– Redo surgery
– Inflammatory aneurysm
• Eases the anastomosis by the use of an open
technique
• But
– Bleeding
– Sub-optimal myocardial protection through thoracotomy among
cardiac patients
Methods
1990-2000
Xclamp
CBP
DHCA
Total
DTA % TAA I % TAA II % TAA III % TAA IV % Total %
21
5
0
0
1
0
3
1
92 22
23
5
51 12
56 13
31
7
13
3
42 10
11
144 34
36
8
94 22
70 16
3
66 15
91
21
13
3
235
56
0
0
97
23
82 19
426 100
Syndrôme compartimental médullaire
P(LCR)
PA
Ischémie
Ischémie-Reperfusion
PPerf Med ≈ PA(aortique distale) -P(LCR)
PA :  lors du clampage proximal
P(LCR) :  à cause de l’oedeme médullaire
 par phénomene de non réabsorption
 Ne prend pas en compte les résistances artériolo capillaires
 P veineuse
Delayed onset of neurological deficit:signifiance and management.HuynhT et al.Sem in Vasc Surg 2000
CSF drainage does not target
any other mechanism of
postoperative paraplegia
CSF drainage is useful at reducing
post-ischemic compression injury
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
Miyamoto K, Ueno A, Wada T, Kimoto S. A new and simple method of preventing spinal cord damage following temporary occlusion of the
thoracic aorta by draining the cerebrospinal fluid. J Cardiovasc Surg (Torino) 1960;1:188-97.
Oka Y, Miyamoto T. Prevention of spinal cord injury after cross-clamping of the thoracic aorta. Jpn J Surg 1984;14:159-62.
McCullough JL, Hollier LH, Nugent M. Paraplegia after thoracic aortic occlusion: influence of cerebrospinal fluid drainage. Experimental and
early clinical results. J Vasc Surg 1988;7:153-60.
Svensson LG, Grum DF, Bednarski M, et al. Appraisal of cerebrospinal fluid alterations during aortic surgery with intrathecal papaverine
administration and cerebrospinal fluid drainage. J Vasc Surg 1990;11:423-9.
Crawford ES, Svensson LG, Hess KR, et al. A prospective randomized study of cerebrospinal fluid drainage to prevent paraplegia after high-risk
surgery on the thoracoabdominal aorta. J Vasc Surg 1991;13:36-45; discussion 45-6.
Woloszyn TT, Marini CP, Coons MS, et al. Cerebrospinal fluid drainage and steroids provide better spinal cord protection during aortic crossclamping than does either treatment alone. Ann Thorac Surg 1990;49:78-82; discussion 83.
Safi HJ, Campbell MP, Ferreira ML, et al. Spinal cord protection in descending thoracic and thoracoabdominal aortic aneurysm repair. Semin
Thorac Cardiovasc Surg 1998;10:41-4.
Bethel SA. Use of lumbar cerebrospinal fluid drainage in thoracoabdominal aortic aneurysm repairs. J Vasc Nurs 1999;17:53-8.
Coselli JS, LeMaire SA, Schmittling ZC, Koksoy C. Cerebrospinal fluid drainage in thoracoabdominal aortic surgery. Semin Vasc Surg
2000;13:308-14.
Safi HJ, Miller CC, 3rd, Huynh TT, et al. Distal aortic perfusion and cerebrospinal fluid drainage for thoracoabdominal and descending thoracic
aortic repair: ten years of organ protection. Ann Surg 2003;238:372-80; discussion 380-1.
And at reversing it in some cases
Garutti I, Fernandez C, Bardina A, et al. Reversal of paraplegia via cerebrospinal fluid
drainage after abdominal aortic surgery. J Cardiothorac Vasc Anesth 2002;16:471-2.
And several unpublished personal cases
Etudes randomisées
Caractéristiques communes
Type d’études
Randomisation du drainage du LCR en chirurgie aortique thoracique.
Chirurgie ouverte seulement (≠endovasculaire)
Patients
ATA à haut risque (type I et II)
Technique
Drainage LCR par ponction lombaire
Autres techniques de protection équivalentes dans les groupes cas et témoin :
-CEC atriofémorale
-réimplantation de l’ADK
Objectif
Mesure du taux de parésie/paraplégie postopératoire des membres inférieurs
-Crawford (JVS, 1991)
-Svensson (Annals of Thoracic Surg, 1998)
-Coselli (JVS, 2002)
Etudes randomisées
-RésultatsEtude
Drainage
Contrôle
LCR
vol/pression
Drainage postop
Crawford
14/46 (30%)
17/52 (33%)
50ml
Non
Svensson
2/17 (11,8%)
7/16 (43,8%)
7-10 cmH2O
48h
Coselli
2/82 (2,7%)
9/74 (12,2%)
<10mmHg
48h
Indications du
drainage
Indic drainage:
-ATA I,II,III et IV si réimplantation ADK
Quel matériel:
-Kit drainage externe du LCR. Sophysa
(Tuohy 14G, KT multiperforé 60cm, poche de recueuil)
Indications
• SSI positive
– Spinal artery(ies) arising from aortic segment to
be repaired
– Adamkiewicz , MDA or SDA
• SSI negative
– No spinal artery arising from aortic segment
• Surgical risk
SSI negative
• No CSF drainage
• Endovascular or open repair in peace of
mind
SSI positive
Good surgical risk
Ak / MDA or SDA with large territory
• Open surgery with reattachment of critical
intercostal arteries using the best spinal protection
methods available
MDA or SDA with small territory
• Give objective information to patient
• If EVAR preferred, CSF drainage, spinal
monitoring etc.
•Ishimaru et al, J Thorac Cardiovasc Surg, 1998;115:811
• Retrievable stent-graft* ?
•Midorikawa et al. Jpn J Thorac Cardiovasc Surg
2000;48:761-8
SSI positive
Poor surgical risk
•
•
•
•
Give information to patient
EVAR if feasible
CSF drainage
Careful monitoring of systemic blood
pressure
• Retrievable stent-graft* under spinal
monitoring ?
* Midorikawa et al. Jpn J Thorac Cardiovasc
Surg 2000;48:761-8 & personal unpublished
designs
Personal results with EVAR
•
•
•
•
1996-2003
Systematic ESA
Only 66 TEVAR cases (612 EVAR cases in the same period)
One paraparesis in one hybrid one-stepped
elephant trunk under hypothermic
circulatory arrest
• No paraplegia
Conclusion
• Postoperative paraplegia remains a disaster for the patient
and a medicolegal concern for surgeons and radiologists
• Given the low rates of paraplegia after DTA repair and the
small number of patients in the series of TAA repair,
efficiency of protective methods is difficult to demonstrate
• The availability of SSI using CT renders blind repair of
DTA or TAA questionable