Spinal cord ischemia may be reduced via a novel technique of intercostal artery revascularization during open thoracoabdominal aneurysm repair.
OBJECTIVE
To describe a novel technique for maximal reimplantation of intercostal arteries during thoracoabdominal aortic aneurysm repair.


METHODS
Eight patients underwent thoracoabdominal aortic aneurysm (TAAA) repair with this new technique from 2005 to 2006. Follow-up ranged from 6 to 14 months. All patients had a previous type B dissection with subsequent aneurysmal degeneration into an extent I TAAA. Aneurysm repair was performed through a thoracoabdominal incision and circulatory arrest in seven and left atrial-left femoral (LA-FA) bypass in one. The grafts extended from the distal arch at the subclavian artery to the visceral and renal arteries. An 8 mm graft was then extended from the proximal to the distal graft with a spatulation of the graft allowing a side-to-side anastomosis of the graft to the posterior aortic wall incorporating multiple pairs of intercostal arteries. Intraoperative electroencephalogram (EEG) and somatosensory evoked potentials (SSEP) were monitored during each operation.


RESULTS
All patients were ambulatory at the time of admission. One patient had suffered a previous spinal cord infarction from the original dissection and had residual unilateral leg weakness prior to the TAAA repair. There was an average of seven pairs of patent intercostal arteries upon opening the aorta. We reimplanted an average of five pairs of vessels. There were no perioperative complications. No patients sustained transient or permanent paraplegia in the postoperative or follow-up period. The one patient with preoperative leg weakness had reported subjective increased strength in the affected leg after the operation. In four cases, normalization of SSEP waveforms did not occur until after reimplantation of the intercostal arteries despite full return of EEG waveforms, restoration of lower extremity perfusion, and rewarming of the patient. Follow-up CT scan angiogram demonstrated that all reconstructions were patent through the follow-up period.


CONCLUSIONS
Paraplegia is an extremely morbid complication associated with TAAA repair. We describe a technique that allows reimplantation of almost all intercostal arteries as one patch circumventing the need for selective reimplantation. Furthermore, our technique ensures continued patency of this patch graft as the outflow resistance is decreased by creating a continuous flow loop. Although this is a small case series, we had no incidence of acute or delayed paraplegia in this high risk group. Our technique of intercostal reimplantation is applicable to all open TAAA repair at high-risk for paraplegia and may be an important adjunct in preventing spinal cord ischemia.
Division of Vascular Surgery, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA. wooe@uphs.upenn.edu
Edward Y
EY
Woo
Michael
M
Mcgarvey
Benjamin M
BM
Jackson
Joseph E
JE
Bavaria
Ronald M
RM
Fairman
Albert
A
Pochettino
D000368:Aged; D000792:Angiography; D017544:Aortic Aneurysm, Abdominal / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D004569:Electroencephalography; D005073:Evoked Potentials, Somatosensory; D005500:Follow-Up Studies; D006801:Humans; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D012189:Retrospective Studies; D020760:Spinal Cord Ischemia / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D013895:Thoracic Arteries / Q000637:transplantation*; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods*