Protection of the spinal cord during surgery of thoraco-abdominal aortic aneurysms

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Abstract
OBJECTIVE: To assess the risk of ischemic cord injury, we haveretrospectively studied the 115 patients who underwent a replacement of thethoracic descending or thoraco-abdominal aorta between January 1980 andDecember 1994. METHODS: In 72 patients the aortic lesion was located abovethe diaphragm. The aortic replacement was performed with the aid ofextracorporeal circulation in all but 2 patients (97.2%). Only two cases ofpostoperative paraplegia were observed (2.7%). In 43 patients (10 femalesand 33 males aged from 26 to 69 years), the occurrence of postoperativeparaplegia was considered as a major risk, because of the extension of theaortic lesions (Crawford types I, II and III). Twenty-six patients (60.4%)suffered from chronic dissection and 17 patients had atheromatousaneurysms. Sixteen patients (37.2%) had Marfan syndrome. Twelve patients(27.9%) had already undergone aortic replacement. A preoperative study ofthe spinal cord vascularization was carried out in 36 patients (83.6%) andthe Adamkiewicz artery was visualized in 28 patients (77.8%). In 17patients (39.5%, group I), the surgical procedure was performed without theaid of extracorporeal circulation. In the remaining 26 patients (60.5%,group II), the surgical procedure was carried out with the aid ofcardiopulmonary bypass and profound hypothermic circulatory arrest.Sequential unclamping of the aorta was used in all patients. The cordvascularization was surgically restored in 32 patients (74.4%). When theAdamkiewicz artery was identified, the critical intercostal artery wasreimplanted together with the two pairs of adjacent intercostal arteries(25 patients). When the origin of the Adamkiewicz artery remained unknown,the two or three most important patent pairs of intercostal arteries werereimplanted (7 patients). In 8 patients (18.6%) there were no patentintercostal arteries. RESULTS: Hospital mortality accounted for 37.2% (16patients, including 5 patients with paraplegia). On univariate analysis,extension of the aortic lesions, emergency and redo surgery were the onlysignificant risk factors of mortality (P = 0.05). Cord ischemia wasobserved in 9 patients (21%): permanent paraplegia in 7 patients (16.2%)and transient medullar disturbance in 2 patients (4.6%). The occurrence ofparaplegia was reduced, though not significantly, in group II (16%) vsgroup I (29%) and in patients with preoperative assessment of the cordvascularization (18% vs 38%). CONCLUSIONS: In our experience: 1) The riskof paraplegia is related to the extension and the type of the aorticlesions. 2) The preoperative study of the medullar vascularization and theuse of extracorporeal circulation with deep hypothermia and sequentialaortic unclamping, reduce the risk of severe cord ischemia, and 3)Occurrence of postoperative paraplegia depends on several factors andcannot be totally prevented by the surgical technique.

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