Thoracic and thoracoabdominal aneurysm repair: is reimplantation of spinal cord arteries a waste of time?
BACKGROUND
The impact of different strategies for management of intercostal and lumbar arteries during repair of thoracic and thoracoabdominal aortic aneurysms (TAA/A) on the prevention of paraplegia remains poorly understood.


METHODS
One hundred consecutive patients with intraoperative monitoring of motor evoked potentials (MEP) and somatosensory evoked potentials (SSEP) during TAA/A repair involving serial segmental artery sacrifice (October 2002 to December 2004) were reviewed.


RESULTS
Operative mortality was 6%. The median intensive care unit stay was 2.5 days (IQ range: 1-4 days), and the median hospital stay 10.0 days (IQ range: 8-17 days). Potentials remained unchanged during the course of serial segmental artery sacrifice, or could be returned to baseline levels by anesthetic and blood pressure manipulation, in 99 of 100 cases. An average of 8.0 +/- 2.6 segmental artery pairs were sacrificed overall, with an average of 4.5 +/- 2.1 segmental pairs sacrificed between T7 and L1, where the artery of Adamkiewicz is presumed to arise. Postoperative paraplegia occurred in 2 patients. In 1, immediate paraplegia was precipitated by an intraoperative dissection, resulting in 6 hours of lower body ischemia. A second ambulatory patient had severe paraparesis albeit normal cerebral function after resuscitation from a respiratory arrest.


CONCLUSIONS
With monitoring of MEP and SSEP, sacrifice--without reimplantation--of as many as 15 intercostal and lumbar arteries during TAA/A repair is safe, resulting in acceptably low rates of immediate and delayed paraplegia. This experience suggests that routine surgical implantation of segmental vessels is not indicated, and that, with evolving understanding of spinal cord perfusion, endovascular repair of the entire thoracic aorta should ultimately be possible without spinal cord injury.
Etz
Christian D
CD
Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, New York 10029, USA. christian.etz@mountsinai.org
Halstead
James C
JC
Spielvogel
David
D
Shahani
Rohit
R
Lazala
Ricardo
R
Homann
Tobias M
TM
Weisz
Donald J
DJ
Plestis
Konstadinos
K
Griepp
Randall B
RB
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D001158:Arteries / Q000601:surgery; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D019054:Evoked Potentials, Motor; D005073:Evoked Potentials, Somatosensory; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D010264:Paraplegia / Q000209:etiology / Q000517:prevention & control*; D012092:Replantation / Q000009:adverse effects*; D012189:Retrospective Studies; D013116:Spinal Cord / Q000098:blood supply / Q000502:physiology