1 / 22

Spinal cord protection in surgery of descending thoracic aorta

Spinal cord protection in surgery of descending thoracic aorta. Present by R1 康庭瑞. Case . 55 y/o male, HTN for 20+ years with regular medical control for 5 years Chronic dissecting aortic aneurysm type III noted for 5 years Left chest pain for 1 week Denied other systemic diseases

snow
Download Presentation

Spinal cord protection in surgery of descending thoracic aorta

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Spinal cord protection in surgery of descending thoracic aorta Present by R1康庭瑞

  2. Case • 55 y/o male, HTN for 20+ years with regular medical control for 5 years • Chronic dissecting aortic aneurysm type III noted for 5 years • Left chest pain for 1 week • Denied other systemic diseases • Laboratory data: within normal range

  3. Case • Normal screening spirometry • 2-D echocardiography: dilated aortic root(diameter 63mm) & LA, mild MR, good LV contractility • Planning: 1.Left post-lat thoracotomy 2. Femoral-femoral CPB 3. Hypothermia with circulation arrest and retrograde cerebral perfusion via high CVP 18~20mmHg by femoral artery perfusion and partial clamp of venous drain tube 4. Restore proximal aorta perfusion after proximal anastomosis through graft cannulation 5. Open distal anastomosis

  4. Case • Cooling to 16℃ • Partial bypass: 3hr25min • Total bypass: 2hr30min • Aortic cross clamp: ?min • Circulatory arrest: 20min • Double lumen single-lumen ET tube ICU weaning and extubation on post-op day 3 without major complications

  5. Consequences of aortic cross-clamping • Spinal cord ischemia • Vascular anatomy: single ant. spinal a. from vertebral a.supply ant. 2/3 of spinal cord; pair of post. spinal a. from post. cerebellar a.supply remainder of spinal cord • Spinal cord perfusion from: vertebral, deep cervical, intercostal, and lumbar a.radicular a. • The largest radicular a. (artery of Adamkiewicz): origin from T9~12 intercostal a. supply the majority of blood to the lower 2/3 of the spinal cord

  6. Spinal cord ischemia • Paraplegia and paraparesis: major cause of morbidity and mortality after extensive TAAA repair • Incidence: 2~40%, depending on the site and the degree of aortic lesion, with/without dissection (2-fold), cross-clamp duration (less than 30min), ligation of the artery of Adamkiewicz, elevation in CSF pressure, reperfusion injury, perioperative hyperglycemia

  7. Spinal cord perfusion pressure • CSF pressure increases during aortic clamping “spinal cord compartment syndrome” • Reduction of CSF pressure improves SCPP • Lumbar drains • Combined with distal aortic perfusion

  8. Result • CSF pressure was maintained at 10mmHg or less • 148 nonemergent patients who received simple cross-clamping • 105 with combined adjuncts, 43 with or without the addition of a single adjunct • 0.9% vs 7% (p<0.04)

  9. Result • 2.6% vs 13.0% • Reduced immediate deficits, particularly paraplegia • Infrequent delayed neurologic deficits in both groups • The longer the ischemic time were, the greater the benefit afforded with CSFD

  10. Conclusions • Significantly reduced the rate of neurologic deficit during nonemergent repair of descending thoracic aortic aneurysms • The recently reports had convinced most surgeons of the benefit of CSF drainage in descending thoracic aortic aneurysm

  11. Other adjuncts • Selective cooling spinal cord via lavage of the epidural space: regional hypothemic (26 ℃) protection of at-risk thoracolumbar cord • Corticosteroid, thiopental, NMDA antagonist, papaverine

  12. Complications of lumbar drainage after TAAA repair • Postoperative lower extremity neurologic deficit: result of thromboembolic or delayed ischemic complication or resulting from lumbar drainage • Intradural hematoma: 3.2% in this study • CT, MRI

  13. Hypothermic cardiopulmonary bypass and circulatory arrest • Methylprednisone and thiopental are given during the period of cooling to 15℃ • Circulatory arrest intervals: mean, 38min • Postoperative neurologic injury: 2.7% • Conclusion: hypothermic circulatory arrest offers certain advantages over other techniques and using of other adjunctive measures is not necessary

  14. References • Hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoraco-abdominal aorta. Annals of thoracic surgery.74(5):S1885-7,2002 Nov. • Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. Journal of vascular surgery.35(4):631-9,2002 Apr. • Thoracoabdominal aneurysm repair: results with 337 operations performed over a 15-year interval. Annals of surgery.236(4):471-9,2002 Oct. • Complications of lumbar drainage after thoracoabdominal aortic aneurysm repair. Journal of vascular surgery.34(4):623-7,2001 Oct.

  15. Thanks for your attention！

More Related