Thoracic and Thoracoabdominal Aneurysm Repair: Is Reimplantation of Spinal Cord Arteries a Waste of Time?

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1 CARDIOVASCULAR Thoracic and Thoracoabdominal Aneurysm Repair: Is Reimplantation of Spinal Cord Arteries a Waste of Time? Christian D. Etz, MD, James C. Halstead, MA (Cantab), MRCS, David Spielvogel, MD, Rohit Shahani, MD, Ricardo Lazala, MD, Tobias M. Homann, MS, Donald J. Weisz, PhD, Konstadinos Plestis, MD, and Randall B. Griepp, MD Departments of Cardiothoracic Surgery and Neurosurgery, Mount Sinai School of Medicine, New York, New York 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 segmental artery pairs were sacrificed overall, with an average of 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. (Ann Thorac Surg 2006;82:1670 8) 2006 by The Society of Thoracic Surgeons Accepted for publication May 8, Presented at the Poster Session of the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30 Feb 1, Address correspondence to Dr Etz, Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029; christian.etz@mountsinai.org. The impact of different strategies for management of intercostal and lumbar arteries during repair of thoracic and thoracoabdominal aortic aneurysms (TAA/A) on prevention of paraplegia remains poorly understood. In 1993, Svensson and associates [1] described the risk of paraplegia after TAA/A repair in a historic series of 1,509 patients as being 16% overall: according to the Crawford classification, spinal cord injury occurred in 15% of type I aneurysms, 31% of type II, 7% of type III, and 4% of type IV aneurysms. A variety of multimodality approaches has been developed to reduce spinal cord injury secondary to distal aortic surgery [2 4]. It has been assumed that injury arises primarily as a consequence of two mechanisms. The first involves an intraoperative insult: temporary interruption of spinal cord blood supply during the operative procedure of a duration sufficient to irreversibly damage cell bodies and nerve tracts in the spinal cord. The second is postoperative: permanent reduction of the blood supply secondary to sacrifice of critical blood vessels to a level incompatible with spinal cord viability. Fundamentally, the community of aortic surgeons is divided by their hypothesis as to the cause of postoperative paraplegia. Those who believe that paraplegia is the consequence of chronic hypoperfusion after sacrifice of segmental arteries critical to spinal cord blood supply reimplant segmental arteries, trading prolonged acute cord ischemia for the achievement of arguably superior postoperative perfusion. Believing that the blood supply to the spinal cord depends upon a highly variable collateral system capable of perpetuating sufficient spinal cord perfusion even after radical sacrifice of (almost all) segmental arteries under stable hemodynamic conditions encourages others to forego reimplantation, shortening acute spinal cord ischemia by cutting down aortic crossclamp time. Neurophysiologic monitoring assisted TAA/A repair aims to assess the functional status of the spinal cord during the procedure to guide operative strategy. In 2006 by The Society of Thoracic Surgeons /06/$32.00 Published by Elsevier Inc doi: /j.athoracsur

2 Ann Thorac Surg ETZ ET AL 2006;82: TAA/A REPAIR AND SPINAL CORD PROTECTION Table 1. Patient Characteristics, Risk Profile, and Symptoms at Hospital Admission (n 100) Characteristic Number Age, years (range) 67 (27 86) Male 49 Risk factors Hypertension 86 History of smoking 30 Diabetes mellitus 5 Coronary artery disease 19 Myocardial infarction 5 PTCA stent or CABG 11 Renal insufficiency 7 Chronic hemodialysis 3 COPD 3 Marfan s syndrome 7 Previous neurologic history 16 TIA 3 CVA 12 Paraplegia 1 a Symptoms Thoracic pain 30 Hemoptysis 2 Without symptoms 70 Enlargement (CT scan) 100 With compression 3 Esophageal 2 Tracheal 1 a After previous surgery in 1 patient. CABG coronary artery bypass graft surgery; COPD chronic obstructive pulmonary disease; CT computed tomography; CVA cerebral vascular accident/stroke; PTCA percutaneus transluminal coronary angioplasty; TIA transient ischemic attack. theory, it is helpful regardless of one s beliefs concerning the principal cause of paraplegia, since it aids in identifying when acute spinal cord hypoperfusion begins to have a functional impact. Somatosensory evoked potential (SSEP) monitoring alone during surgical cases involving the descending aorta has been associated with an unacceptably high rate of both false positive and false negative predictions of postoperative motor function in the lower limbs [5 7]. These false positives and negatives can occur because Table 3. Intraoperative and Perioperative Details Variable 1671 Number Urgency Elective/urgent/emergent 66/29/5 Reoperation 66 Second stage of an elephant trunk 48 procedure Intraoperative diagnosis Atherosclerotic 45 Degenerative (media) 11 Dissection 37 Chronic 34 Acute 3 Recurrent coarctation 1 Patch aneurysm 1 Acute inflammation 2 Giant cell aortitis 3 Ruptured aneurysm 15 Aortic diameter (mm) Aortic grafts (mm) Size (range) 23 (18 28) Adjunctive grafts SMA/renal/celiac/IC 9/11/10/1 CSF cerebrospinal fluid; IC intercostal artery; SMA superior mesenteric artery. SSEPs reflect the integrity of the somatosensory system that lies in the dorsal spinal cord, whereas the neurons critical for motor function are located in more ventral areas of the cord [5]. During the last decade, motor evoked potential (MEP) monitoring has become clinically feasible [8]. Monitoring of MEPs allows for the early detection of spinal cord ischemia and is currently becoming an integral part of spinal cord protective strategies during TAA/A surgery [9 11]. Motor evoked potentials are not suitable for postoperative monitoring, however, so SSEP continue to be used to detect spinal cord dysfunction during the hours immediately after aortic surgery. We report our experience with monitoring of MEP and SSEP during repair of TAA/A in 100 consecutive patients in whom spinal cord artery reattachment was (with 1 exception) not carried out. CARDIOVASCULAR Table 2. Classification Number (P)CPB/LHB DHCA Patients Thoracic Crawford I Crawford II Crawford III 8 8 Crawford IV 6 6 DHCA deep hypothermic circulatory arrest; LHB left heart bypass; (P)CPB (partial) cardiopulmonary bypass. Material and Methods Patients The first 100 patients with intraoperative monitoring of MEPs and SSEPs during TAA/A repair involving serial segmental artery sacrifice (October 2002 to October 2004) at Mount Sinai Hospital were reviewed retrospectively, using data gathered contemporaneously in our departmental database, and supplemented from patient records. This research was approved by the Institutional Review Board without a requirement for individual patient consent.

3 CARDIOVASCULAR 1672 ETZ ET AL Ann Thorac Surg TAA/A REPAIR AND SPINAL CORD PROTECTION 2006;82: Table 4. LHB, (P)CPB, and DHCA Details LHB (P)CPB DHCA Patients Duration (min) Minimum pressure (mm Hg) Proximal Distal Ischemia time (min) Distal Renal Minimum temperature ( C) Esophageal Bladder SCP 16 Duration (min) DHCA deep hypothermic circulatory arrest; LHB left heart bypass (left atrial to femoral artery bypass); (P)CPB (partial) cardiopulmonary bypass; SCP selective cerebral perfusion. The underlying disease was atherosclerosis in 45 patients, dissection in 37 patients (34 chronic and 3 acute), and degeneration in 11 patients. Features of Marfan syndrome were present in 7 patients. The average aneurysm diameter measured mm. Further patient characteristics, and the risk profile for the group as a whole, are shown in Table 1. Two thirds of the patients were scheduled for the operation owing to enlargement of their known aneurysm. One third were admitted with acute symptoms. Fifteen patients underwent repair of ruptured aneurysms. Of the entire patient group, 66 had elective, 29 had urgent, and 5 underwent emergent procedures. Aneurysm classification and the adjunctive methods utilized to help preserve spinal cord integrity are shown in Table 2. Intraoperative Characteristics Forty-eight patients underwent replacement of the descending thoracic aorta as the second stage of an elephant trunk procedure, after previous replacement of their ascending aorta and entire arch. Seventeen patients underwent deep hypothermic circulatory arrest. Selective antegrade perfusion was used in 16 patients because longer hypothermic circulatory arrest times were anticipated. The mean total hypothermic circulatory arrest time was minutes, and the minimal esophageal temperature before hypothermic circulatory arrest was C. Further operative characteristics are outlined in Tables 3 and 4. existing graft in 1 patient. A sidearm of the implanted graft was used for circulation in 6 cases. In 1 patient, the cannula was switched from the common femoral artery to the graft during the procedure. For left atrial drainage, the left inferior pulmonary vein was cannulated in 45 cases (using a BioMedicus circuit with a reservoir for circulation). Partial cardiopulmonary bypass was used in 34 patients. In these cases, right atrial drainage was established through the common femoral vein and the catheter position controlled by transesophageal echocardiography. Arterial cannulation was performed through a common femoral artery in 30; axillary cannulation or side arms of the graft were used in 2 cases each. In 17 patients, full cardiopulmonary bypass and deep hypothermic circulatory arrest were utilized. All segmental vessels were sacrificed before bypass, so MEP/SSEP monitoring was possible. For visceral perfusion, additional catheters were used in 6 patients for the kidneys and in 1 for the superior mesenteric artery. In the remaining patients, a beveled distal anastomosis incorporating the visceral vessels was utilized. Operative Management All operations are carried out under at least moderately hypothermic conditions (Table 4). The aneurysm is dissected free from mediastinal tissue. The intercostal and lumbar arteries are dissected and temporarily occluded. If MEP and SSEP remain unchanged, the segmental vessels are sacrificed before opening the aneurysm, to avoid backbleeding and possible steal from the spinal cord circulation. The process of neurophysiologic evaluation and sacrifice of each pair of segmental arteries takes 3 to 5 minutes. If no changes in MEP are noted over the next 10 minutes or so, the next section of the aorta is dissected, 1 to 3 more segmental arteries are occluded, and evoked potentials are once again assessed. This process is repeated until the entire aneurysm has been mobilized. In general in view its importance in supporting spinal cord perfusion clamping of the left subclavian artery is avoided, and the internal mammary artery and the superior epigastric axis are preserved. If clamping of the distal aorta is not feasible or is unsafe, the distal anastomosis is done first, and distal perfusion restored after cross clamping of the graft. For the visceral segment, a beveled anastomosis is frequently utilized. If the visceral segment must be replaced circumferentially, the visceral vessels are occluded with a balloon catheter and intermittently perfused with cold blood before they are directly anastomosed to the graft or connected utilizing intervening graft segments (8 to 12 mm Dacron). Bypass Technique Left heart bypass was used in 49 patients. Left atrial to femoral artery bypass was adjusted to maintain equal pressures above and below (as detailed in Table 4). Cannulation was performed through a common femoral artery in 41 patients, through central arterial (ie, descending aortic) cannulation in 2 patients, and through an Graft Repair Vascular Dacron grafts (Hemashield; Boston Scientific, Natick, MA; 18 to 28 mm) with as many as three additional side arms were implanted in an end-to-end fashion. The superior mesenteric artery (SMA) was reimplanted in 9, renal arteries in 11, and the celiac in 10 patients. In only 1 patient, an island including intercostal

4 Ann Thorac Surg ETZ ET AL 2006;82: TAA/A REPAIR AND SPINAL CORD PROTECTION 1673 CARDIOVASCULAR Fig 1. (A) Shown are motor evoked potentials (MEP) recorded in the right arm (RA), right leg (RL), left arm (LA), and left leg (LL) after transcranial electrical stimulation over the motor cortex. The patient had segmental artery sacrifice from T3 to L1. Baseline MEPs are shown in panel a. Each trace shows 100 ms activity after stimulation. The MEPs and somatosensory evoked potentials (SSEP [not shown]) were reduced in amplitude during a period of ischemia but never completely disappeared (panel b). After flow restoration, the MEPs had increased to well over 50% baseline (panel c). The patient s postoperative motor strength was similar to its preoperative level. (B) Shown are SSEPs recorded at P z (4 to 5 cm posterior to vertex) referenced to Fz (near to forehead) after stimulation of the posterior tibial nerve at the right ankle followed 100 ms later by stimulation of the posterior tibial nerve at the left ankle. The patient had segmental artery sacrifice from T6 through L2. Baseline SSEPs are shown at the top of the waterfall. Both the SSEPs and MEPs (not shown) were lost temporarily during a period of distal ischemia, but returned to baseline levels by the end of the operation (bottom of waterfall). The patient s motor strength postoperatively was similar to its preoperative level. arteries was reimplanted because of extraordinary back bleeding from included intercostals. MEP Monitoring After induction, volatile anesthetics were discontinued, as were muscle relaxants, and narcotic anesthesia was substituted. Motor evoked potentials were elicited by a train of nine transcranial electrical pulses delivered from a Digitimer D185 cortical stimulator (Welwyn, Garden City, United Kingdom). The stimuli were applied through two disposable corkscrew electrodes (Nicolet Biomedical, Madison, Wisconsin) anchored in the scalp overlying the left and right motor cortices, respectively, approximately 6 to 8 cm lateral from vertex. In response to stimulation, MEPs (composed of compound muscle action potentials) were recorded from the skin over the tibialis anterior (leg) and abductor pollicis (hand) muscles through subdermal needle electrodes. The recordings from the hands permit evaluation of the effects of anesthesia and temperature on the amplitudes of the MEPs. The signals were amplified, filtered, digitized, and saved to hard drive. The stimulation intensity was set to 10% above the level that elicited the maximal MEP amplitude for each patient. A decrease of 50% in amplitude of the leg MEPs in the presence of stable hand MEPs was considered to reflect a lower body ischemic event. In patients in whom hypothermic circulatory arrest was utilized, MEPs were measured during removal of the aneurysm under moderate hypothermia, before deep cooling, and again upon rewarming. SSEP Monitoring Somatosensory evoked potentials were elicited by stimulation of the left and right posterior tibial nerves

5 CARDIOVASCULAR 1674 ETZ ET AL Ann Thorac Surg TAA/A REPAIR AND SPINAL CORD PROTECTION 2006;82: Fig 2. The graph displays the extent of segmental artery sacrifice between T7 and L1 in 100 patients with TAA/A. The number of patients who had each number of sacrificed vessels in this high-risk region is shown. (TAA/A thoracic and thoracoabdominal aortic aneurysms.) through two surface disk electrodes placed approximately 2.0 cm apart below the medial malleolus at the ankle. Recordings were made from the scalp overlying the somatosensory cortex using subdermal needle electrodes placed approximately 3 to 4 cm behind vertex and referenced to an electrode at FPz on the forehead. A ground electrode was placed on the shoulder. The recorded signals were amplified, filtered, and saved to hard drive. The responses to 200 to 300 stimuli were averaged. Ischemic spinal cord dysfunction was defined as a decrease in SSEP amplitude of more than 50%. In 99 of 100 cases, MEP and SSEP remained unchanged during the course of serial segmental artery sacrifice, or could be returned to baseline levels (see Fig 1) by anesthetic and blood pressure manipulation, or with increase of distal perfusion during left heart bypass. One patient had loss of SSEP/MEP late intraoperatively (discussed below) and developed paraplegia. Figure 1 shows examples of neurophysiologic recordings from the operating room. Segmental Artery Sacrifice and MEP/SSEP An average of segmental artery pairs were sacrificed (Fig 2) overall, with an average of segmental pairs sacrificed between T7 and L1, where the artery of Adamkiewicz is presumed to arise, in 96 patients. In two thirds of all patients, more than 70% of all segmental arteries in this critical zone were sacrificed without MEP/SSEP loss. (One patient had an island of several segmental vessels with unusually vigorous backbleeding reimplanted, but this was unrelated to MEP/ SSEP readings.) The extent of segmental artery sacrifice in each patient, and the level of intersegmental artery resection, are shown in Figure 3, with the patients in chronologic order. Cerebrospinal Fluid Drainage A catheter for drainage of cerebrospinal fluid was placed routinely. An average of ml of cerebrospinal fluid per patient was drained, at a maximum rate of 15 cc/h as long as cerebrospinal fluid pressure remained above 10 mm Hg. Cerebrospinal fluid drainage was continued in most patients for 48 to 72 hours postoperatively. Postoperative Management Somatosensory evoked potentials are monitored until the patient awakens. Thereafter, hourly brief neurologic examinations are performed for 72 hours. High normal blood pressures are maintained, aiming for an aortic mean pressure of 80 mm Hg. Drainage is continued for 72 hours, and steroids are tapered over 48 hours. Statistical Methods Data were entered in an Excel (Microsoft Corp, Redmond, Washington) spreadsheet and transferred to a SAS file (SAS Institute, Cary, North Carolina) for data Fig 3. The extent of segmental artery sacrifice in each of the 100 patients (operated on October 2002 to December 2004) is shown in chronologic order. Postoperative death (*) and paraplegia (**) are indicated.

6 Ann Thorac Surg ETZ ET AL 2006;82: TAA/A REPAIR AND SPINAL CORD PROTECTION Table 5. Postoperative Complications and Intensive Care Unit (ICU) and Hospital Stay Variable description and analysis. Characteristics are described as percentages or as means and standard deviations. Results Number Bleeding requiring rethoracotomy 5 Cardiac 4 Ventricular tachycardia 3 Low-output syndrome 1 Respiratory complications 7 Tracheotomy 4 Renal complications 9 Requiring temporary hemodialysis (after 4 (2) renal artery reimplantation) Neurologic dysfunction 3 TIA 1 CVA 2 ICU stay (days) 2.5 (IQ range: 1 4) Hospital stay (days) 10.0 (IQ range: 8 17) AV atrioventricular; CVA cerebral vascular accident/stroke; TIA transient ischemic attack. Postoperative hospital mortality defined as in-hospital mortality or death with 30 days was 6%. There were no intraoperative deaths. Two patients died after intracranial bleeding, 1 patient after rupture of an infrarenal aneurysm, and 3 after multiple septic complications. Paraplegia Postoperative paraplegia occurred in 2 patients. In 1, immediate paraplegia was precipitated by an intraoperative dissection resulting in 6 hours of lower body ischemia. The patient had an atherosclerotic aneurysm (Crawford III) and a longstanding history of peripheral artery disease (after 100 pack-years of smoking). She underwent second-stage completion of an elephant trunk with sacrifice of nine segmental arteries (T6 through L2): SSEP and MEP disappeared after release of the distal clamp and occlusion of both iliac arteries by dissection. Restoration of lower extremity perfusion by stent grafting did not restore neurologic function. A second patient had severe paraparesis albeit normal cerebral function after resuscitation from a respiratory arrest that occurred 3 weeks postoperatively, after discharge to a rehabilitation facility. The patient had segmental artery sacrifice from T3 to L3. No patient with fewer than nine intersegmental arteries severed had paraplegia, although 52 patients had nine or more segmental pairs sacrificed. Spinal cord ischemia detected by MEP (1) or SSEP (2) was reversible in 3 patients after adjunctive maneuvers (ie, lightening anesthesia and raising mean arterial blood pressure) were performed to improve perfusion. One patient had preoperative paraplegia that was unaffected by surgery. Other Complications The average intensive care unit stay was days, and the mean hospital stay was days. As detailed in Table 5, 4 patients had cardiac complications; 7 patients required prolonged ventilation, with an early tracheostomy in 4 patients; 9 patients had renal complications requiring temporary hemodialysis in 4 cases (none of the patients required chronic dialysis), and 5 patients required reoperation for bleeding. Comment 1675 In the past decade, the neurologic outcome of TAA/A surgery has improved markedly, coincident with the increasing use of direct spinal cord monitoring. However, there still is no strategy that can assure preservation of spinal cord integrity during aortic aneurysm resection and throughout the perioperative period. In the 1980s, SSEP monitoring began to be accepted as a sensitive method for detecting spinal cord injury, and became an established guide to spinal cord protection strategies during TAA/A surgery [12, 13]. But it is the motor neurons within the spinal cord whose functional impairment triggers paraplegia, and compromise of motor neurons can elude SSEP monitoring. Therefore, monitoring of motor neuron integrity would seem to be the next significant step toward finding a strategy to prevent paraplegia [6]. Somatosensory evoked potentials continue to have an important role in the immediate postoperative period, however, as MEPs cannot be carried out readily in unanesthetized patients. Motor evoked potential monitoring is the most sensitive tool available to assess the functional integrity of motor neurons and guide intraoperative strategies to restore blood supply to this most vulnerable part of the spinal cord, and prevent irreversible ischemic damage [11]. In clinical studies, MEP data appear to show a better correlation with neurologic outcome than SSEP [5, 6, 14], leading contemporary aortic aneurysm surgery to a further reduction in the prevalence of postoperative paraplegia. In 2000, Jacobs and associates [11] reported a significant reduction of neurologic complications to 2.3% with the monitoring of MEP in a series of 170 patients with TAA/A, using a reimplantation approach with left heart bypass and cerebrospinal fluid drainage. Van Dongen and colleagues [15] reported a 4.2% rate of postoperative paraplegia in a series of 118 patients, using hypothermia, left heart bypass, and a reimplantation strategy guided by MEP and SSEP monitoring. In 2002, Dong and coworkers [6] reported a 5.4% paraplegia rate in a series of 56 TAA/A operations utilizing MEP and SSEP monitoring with a reimplantation approach. Only 25% of Dong s patients with MEP evidence of spinal cord ischemia showed congruent SSEP changes, and 3 patients with persistent loss of MEP (and recovery of SSEP) suffered paraplegia despite segmental artery reimplantation, underlining the superior sensitivity and specificity of MEP in detection of spinal cord ischemia [6]. CARDIOVASCULAR

7 CARDIOVASCULAR 1676 ETZ ET AL Ann Thorac Surg TAA/A REPAIR AND SPINAL CORD PROTECTION 2006;82: The majority of the studies sought to prevent ischemia by reimplantating segmental arteries with particular focus on the area between T7 and L1, believing that paraplegia is the consequence of hypoperfusion after sacrifice of critical spinal cord arteries. Nevertheless, clinical use of MEP has not yet significantly impacted the strategy of reimplantation, as most of the surgeons used an empirical approach rather than a standardized sequence of maneuvers when MEP diminution occurred. But with or without neurophysiologic monitoring and other adjuncts, reimplantation remains the most widespread strategy for preserving spinal cord function. Several studies have demonstrated the arguable superiority of that approach: a recent study by Jacobs and coworkers [16] had 5 cases of paraplegia among 70 type II aneurysms (3 immediate and 2 delayed). LeMaire and associates [17] had earlier reported a series of 1,220 patients operated on by Coselli, using liberal reimplantation of segmental arteries, with an overall paraplegia rate of 4.6%; spinal cord injury occurred in 8.2% of 371 patients with type II aneurysms. In contrast, in 1994 and 1996, paraplegia rates as low as 3% in thoracoabdominal aneurysm repair without intersegmental artery reimplantation were described both in a series of 110 by Acher and colleagues [18], and in 95 consecutive patients by Griepp and associates [19]. According to our current protocol, which uses both MEP and SSEP monitoring, reimplantation was only utilized when all maneuvers involving anesthetic and hemodynamic optimization failed. In 98 of 100 consecutive patients, sacrifice of a total of more than 800 segmental arteries including radical sacrifice of an average of 4 segmental arteries between T7 and L1 was achieved without persistent intraoperative MEP loss, and therefore without reimplantation. (One patient was already paraplegic preoperatively, and in another, unusually vigorous backbleeding from intercostals prompted empirical reimplantation of a patch of aorta including these arteries). If there were an artery of Adamkiewicz whose integrity was critical for spinal cord function, more than half of these patients should have developed paraplegia. No patient with fewer than nine intersegmental arteries severed had paraplegia. Spinal cord ischemia was reversible in 3 patients after adjunctive maneuvers were performed to improve perfusion, suggesting that spinal cord blood supply is unlikely to depend upon a single segmental artery between T7 and L1. We therefore believe that it is not reasonable to search for a single artery of Adamkiewicz whose preservation will prevent paraplegia. Since the postoperative paraplegia rate in our series was 2%, which is lower than was found in several contemporary series, this suggests that blind reimplantation of as many spinal cord arteries as technically possible may not necessarily be a superior approach. Our operative strategy for avoiding paraplegia may owe much of its success to its effectiveness in avoiding backbleeding through intercostal and lumbar arteries, and thus preventing steal from the collateral circulation to the spinal cord. With our technique, intraoperative steal is prevented by sacrificing the segmental arteries before opening the aneurysm. Acher, who also has a very low incidence of paraplegia without segmental artery reimplantation, oversews the segmental arteries immediately after incising the aneurysm, thereby also limiting backbleeding and radically reducing steal. Available clinical data, particularly on the evoked potential response to cross-clamping, indicate that grey matter perfusion varies considerably even among patients with equivalent TAA extent. Factors such as development of the anterior spinal cord artery, and the particulars of collateral circulation, are likely to account for this variability, and cannot be influenced by reimplantation, particularly when individual intercostal aortic ostia are already occluded. We monitor MEPs to try to identify critical individual intercostals for reimplantation, but have not found any. Attempts to identify and reimplant segmental arteries may jeopardize motor neuron integrity by increasing intraoperative spinal cord ischemia by prolonging aortic crossclamp duration. Jacobs and coworkers [20] reported that increasing distal perfusion to physiologic levels during left heart bypass can correct MEPs in 27% of the patients with intraoperative MEP loss, underlining the presence of an efficient network of collaterals capable of providing sufficient perfusion to the cord under physiologic conditions. We postulate that an adequate cord blood supply based on a network of natural vessels is present at the end of the operation in patients with intact MEPs [20]. The advantage of segmental artery reimplantation clearly is to establish a redundant blood supply, which should provide protection against the inadequacy of a marginal collateral network in the face of perioperative instability, which therefore may pose less of a threat to cord viability. But reimplantation has the disadvantage of removing a stimulus to the growth of the collateral network, leaving cord viability dependent upon vascular grafts, which may thrombose. Without reimplantation, although this collateral network is marginal, normal compensatory mechanisms should result in its augmentation over time. Until such augmentation occurs, however, avoidance of postoperative hypotension and spinal cord edema seem to be the most effective strategies for preventing deficits in the acute postoperative interval [4]. If delayed paraplegia occurs in patients who have no reimplanted segmental arteries, it is more likely to be functional rather than anatomic (thrombosis), and should therefore be easier to treat (by raising blood pressure and using cerebrospinal fluid drainage). Risk factors compromising the collateral network such as atherosclerosis may have an impact on the occurrence of paraplegia: both cases in our cohort were octogenarians with severe generalized atherosclerosis and sacrifice of at least nine segmental arteries. From this surgical experience of extensive aneurysm resection without segmental artery reimplantation, one would anticipate that, with suitable precautions, endovascular repair of the entire thoracic aorta should be possible without spinal cord injury. The experience with these 100 cases suggests that serial sacrifice of almost all intersegmental pairs gradually, over a period of time

8 Ann Thorac Surg ETZ ET AL 2006;82: TAA/A REPAIR AND SPINAL CORD PROTECTION during the operative procedure, and in a way which prevents any backbleeding and steal from the collateral network is safe. With physiologic monitoring to guide surgical segmental artery sacrifice, it is possible to modify the operative strategy to accommodate loss of those arteries which threaten function, as reflected by diminution in MEP or SSEP. Endovascular stent grafting precipitates simultaneous occlusion of intersegmental arteries, which may result in a more severe insult. It is possible that physiologic monitoring, combined with endovascular techniques to reduce steal, can help diminish the incidence of spinal cord injury after endovascular TAA/A repair. We hope that further improvements in understanding the dynamics and patterns of adaptation of the collateral circulation will enable marked reduction of paraplegia rates with endovascular repair in the near future. In conclusion, this experience suggests that routine surgical implantation of segmental vessels is not indicated. There is still much to learn concerning the anatomy and physiology of spinal cord blood supply if paraplegia is to be eliminated as a complication of TAA/A repair, but recent advances suggest that such a goal is achievable. References 1. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg 1993;17: Minatoya K, Karck M, Hagl C, et al. The impact of spinal angiography on the neurological outcome after surgery on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg 2002;74(Suppl):1870 2;discussion Yamada N, Okita Y, Minatoya K, et al. Preoperative demonstration of the Adamkiewicz artery by magnetic resonance angiography in patients with descending or thoracoabdominal aortic aneurysms. Eur J Cardiothorac Surg 2000;18: Cambria RP, Giglia JS. Prevention of spinal cord ischaemic complications after thoracoabdominal aortic surgery. Eur J Vasc Endovasc Surg 1998;15: Meylaerts SA, Jacobs MJ, van Iterson V, De Haan P, Kalkman CJ. Comparison of transcranial motor evoked potentials and somatosensory evoked potentials during thoracoabdominal aortic aneurysm repair. Ann Surg 1999;230: Dong CC, MacDonald DB, Janusz MT. Intraoperative spinal cord monitoring during descending thoracic and thoracoabdominal aneurysm surgery. Ann Thorac Surg 2002;74(Suppl):1873 6;discussion Robertazzi RR, Cunningham JN Jr. Monitoring of somatosensory evoked potentials: a primer on the intraoperative 1677 detection of spinal cord ischemia during aortic reconstructive surgery. Semin Thorac Cardiovasc Surg 1998; 10: de Haan P, Kalkman CJ, Jacobs MJ. Spinal cord monitoring with myogenic motor evoked potentials: early detection of spinal cord ischemia as an integral part of spinal cord protective strategies during thoracoabdominal aneurysm surgery. Semin Thorac Cardiovasc Surg 1998;10: Jacobs MJ, Elenbaas TW, Schurink GW, Mess WH, Mochtar B. Assessment of spinal cord integrity during thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 2002;74: ;discussion Jacobs MJ, de Mol BA, Elenbaas T, et al. Spinal cord blood supply in patients with thoracoabdominal aortic aneurysms. J Vasc Surg 2002;35: Jacobs MJ, Meylaerts SA, de Haan P, de Mol BA, Kalkman CJ. Assessment of spinal cord ischemia by means of evoked potential monitoring during thoracoabdominal aortic surgery. Semin Vasc Surg 2000;13: Cunningham JN Jr, Laschinger JC, Spencer FC. Monitoring of somatosensory evoked potentials during surgical procedures on the thoracoabdominal aorta. IV. Clinical observations and results. J Thorac Cardiovasc Surg 1987;94: Guerit JM, Verhelst R, Rubay J, Khoury G, Matta A, Dion R. Multilevel somatosensory evoked potentials (SEPs) for spinal cord monitoring in descending thoracic and thoracoabdominal aortic surgery. Eur J Cardiothorac Surg 1996;10: van Dongen EP, ter Beek HT, Schepens MA, et al. The relationship between evoked potentials and measurements of S-100 protein in cerebrospinal fluid during and after thoracoabdominal aortic aneurysm surgery. J Vasc Surg 1999;30: van Dongen EP, Schepens MA, Morshuis WJ, et al. Thoracic and thoracoabdominal aortic aneurysm repair: use of evoked potential monitoring in 118 patients. J Vasc Surg 2001;34: Jacobs MJ, Mess W, Mochtar B, Nijenhuis RJ, Statius van Eps RG, Schurink GW. The value of motor evoked potentials in reducing paraplegia during thoracoabdominal aneurysm repair. J Vasc Surg 2006;43: LeMaire SA, Miller CC, 3rd, Conklin LD, Schmittling ZC, Coselli JS. Estimating group mortality and paraplegia rates after thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 2003;75: Acher CW, Wynn MM, Hoch JR, Popic P, Archibald J, Turnipseed WD. Combined use of cerebral spinal fluid drainage and naloxone reduces the risk of paraplegia in thoracoabdominal aneurysm repair. J Vasc Surg 1994;19: Griepp RB, Ergin MA, Galla JD, et al. Looking for the artery of Adamkiewicz: a quest to minimize paraplegia after operations for aneurysms of the descending thoracic and thoracoabdominal aorta. J Thorac Cardiovasc Surg 1996;112: Jacobs MJ, Meylaerts SA, de Haan P, de Mol BA, Kalkman CJ. Strategies to prevent neurologic deficit based on motorevoked potentials in type I and II thoracoabdominal aortic aneurysm repair. J Vasc Surg 1999;29: CARDIOVASCULAR INVITED COMMENTARY In this article, the Mount Sinai group [1] raises a provocative issue in claiming that serial sacrifice of as many as 15 intercostal arteries can be safely done with motorevoked potential (MEP) and somatosensory-evoked potential (SSEP) monitoring during thoracic and thoracoabdominal aortic aneurysm surgery. The authors obtained a remarkable neurologic outcome in a series of 100 patients, with only 2% of the patients experiencing postoperative paraplegia. With such an outstanding result, it is hard to find arguments against their proposed strategy, which should otherwise come to be viewed by many cardiovascular surgeons as rather dangerous in at least some specific situations. Descending thoracic aortic aneurysm repair without 2006 by The Society of Thoracic Surgeons /06/$32.00 Published by Elsevier Inc doi: /j.athoracsur

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