Maintenance of High Blood Pressure and Early Establishment of Pulsatile Blood Flow to the Spinal Cord during Thoracoabdominal Aortic Repair

An aortic aneurysm is an enlargement (dilation) of the aorta to greater than 1.5 times normal size. Thoracoabdominal aortic aneurysms (TAAAs) involve both the thoracic and abdominal aorta. Open surgery remains the standard treatment for TAAAs. However, surgical TAAA repair continues to pose a substantial risk of severe treatment-related complications such as spinal cord injury (SCI), renal failure, gastrointestinal problems, and stroke. Furthermore, the rate of improvement in surgical equipment for TAAA repair may be delayed because the incidence of TAAAs is much lower than that of other aneurysms. Therefore, it is desirable to develop a dedicated TAAA repair technique that takes advantage of current technologies and yet provides acceptable outcomes.

In this paper, the authors aimed to summarize the experience with a novel surgical strategy involving maintenance of high blood pressure and early establishment of pulsatile blood flow to the spinal cord. 

Between August 2011 and October 2017, 29 patients (age, 67 ± 12 years) underwent open surgery for TAAA. According to the Crawford classification, two aneurysms were type I, eight were type II, 12 were type III, and seven were type IV. The authors used partial cardiopulmonary bypass under mild hypothermia in all patients except one. By maintaining distal aortic perfusion pressure at 60 - 80 mmHg and creating the distal aortic anastomosis before visceral branch reconstruction, they established early perfusion of the hypogastric arteries with native pulsatile flow. Intraoperative spinal monitoring and cerebrospinal fluid drainage were performed in 26 (90%) and 23 (79%) patients, respectively. Nineteen patients (66%) underwent reconstruction of the intercostal arteries. During perioperative management, the mean arterial pressure was kept >80 mmHg. 

The results showed that no in-hospital deaths or acute neurological complications occurred. One patient (3.4%) experienced delayed temporal paraplegia. During follow-up, aorta-related death occurred in only one patient, who developed prosthetic vascular graft infection but did not undergo repeat graft replacement. The 3-year freedom from aortic-related death was 95%.

In conclusion, though secondary aortic infection occasionally occurred, the novel surgical strategy proposed in this study was safe and effective in preventing SCI, achieving good early and mid-term results.

Article by Koji Furukawa, et al, from Japan.

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