TAAA / Spinal Cord Protection
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1 TAAA / Spinal Cord Protection Hazim J. Safi, MD Professor and Chair Department of Cardiothoracic and Vascular Surgery McGovern Medical School The University of Texas Science Center at Houston Memorial Hermann Heart & Vascular Institute International Cardiovascular Surgery Mini-Symposium 2018
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8 January 1984
9 Uni P = Multi P = H.R. 1.6
10 SCI - Clamp and Go Extent < Aortic Clamp Time < Rupture Age Proximal Aneurysm Renal Dysfunction
11 Classification 15% 31% 7% 4%
12 Clamp and Go Era
13 All Aneurysm Types
14 Rationale for Spinal Cord Protection
15 Spinal Cord Protection 1. Distal aortic pressure 2. Moderate hypothermia 3. CSF pressure
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18 patient s back is near edge of table 60 hip rotation 90 to table
19 CSF Drainage
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33 1286 TAAA & DTAA Repairs: (Jan 1991 Aug 2006) Median age: 67 (8-92) 64% 36%
34 Pre-Operative Characteristics Variable % Smoking 32 Hypertension 73 Cerebrovascular Disease 11 Coronary Artery Disease 27 Renal Disease 19 Acute Dissection 4 Chronic Dissection 25
35 Operative Factors Variable Intercostal Artery Reattachment 39% Pump time 44 min Aortic Cross-Clamp Time 46 min Adjunct use 74%
36 Evolution of TAAA Surgery in Quartiles Jan 91 Jan 95 Feb 95 May 98 Jun 98 Jul 01 Aug 01 Aug 04
37 Results Neurologic Deficit n % Overall 36/ (-) Adjunct 16/ (+) Adjunct 20/ p=0.008
38 Aortic Clamp Time 35 sec/yr p<0.0001
39 All Aneurysm Extents p=0.02
40 TAAA II p=0.0001
41 Neurologic Deficit Multiple Logistic Regression Analysis Variable OR p TAAA Extent II Renal Dysfunction (+) Adjunct Aortic Clamp Time
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43 Neurologic Deficit X-Clamp and Go Era No Adjunct
44 Neurologic Deficit Adjunct Era
45 Conclusions Despite increased aortic cross-clamp times, adjunct has reduced overall risk of neurologic deficit Adjunct use has blunted effect of aortic cross-clamp time Adjunct may allow surgeon to operate without pressure of time
46 Median Age: 67 (8 85) 64% 36% Adjunct 246/300* (82%) *Now 394
47 Classification
48 Classification DTAAA
49 Results Overall 30-day mortality 8.0% (24/310) (In-hospital mortality) 8.7% (26/310) Neurological Deficit 2.3% (7/300)
50 Results *Neurologic Deficit Adjunct Group 1.2% (3/238) Non-Adjunct 6.4% (4/62) * p=0.02
51 Results Neurologic Deficit Adjunct Group Immediate 0.8% (2) Delayed 0.4% (1) Non-Adjunct Immediate 4.7% (3) Delayed 1.6% (1)
52 Freedom From Reoperation TAAA AAA Fistula
53 Results DAP & CSFD can be performed with acceptable morbidity and mortality significantly reducing the incidence of neurological deficits during repair of DTAA Open Repair appears durable Classification - prognostic significance
54 Delayed Neurological Complication
55 +CSFD -CSFD Immediate 20.1% 21.2% Delayed 8.3% 11.5% 1990
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59 Results Multivariate Analysis OR p Extent II 3.12 < Acute diss < Renal insuff <0.0013
60 Results 75% 43% 0% Delayed Improved
61 Results Univariate Analysis Cases Controls OR P Hemoglobin <9 61% 22% MAP <60 61% 19% CSF Drain 33% 4% Complication
62 Results* OR 95% CI P MAP < CSF Drain Complication *Adjusted for: Extent and Dissection
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64 Correctly Classified N GFR / Ab Cr N Cr / Ab GFR
65 1106 TAAA & DTAA Repairs: ( ) Median age: 67 (8-92) 64% 36%
66 30-Day Mortality p = Patients Deaths
67 30-Day Mortality 27% 18% 10% 5% Patients Deaths
68 Conclusion Subclinical pre-existing renal disease is prevalent in TAAA patients GFR versus serum creatinine More sensitive index of renal function Better predictor of mortality
69 Neuromonitoring
70 Methods Jan Jan SSEP in DTA/TAA repair 68 years (20-87 years) 286 (64%) 158 (36%) Data collected prospectively & reviewed retrospectively
71 SSEP Monitoring Rate = 4.7 Hz Stimulus Duration = sec Intensity = 0.3 Amp Right & left PTN alternatively stimulated at the ankle to get a sustained waveform
72 Sensory
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74 10% 50%
75 SSEP Monitoring SSEP changes classified into three groups Group 1 Normal SSEP Group 2 Transient Change Group 3 Persistent Change
76 Results Sensitivity for immediate ND: 62.5 Specificity for immediate ND: 81.2 NPV of SSEP for immediate ND: 99.2%
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78 Overall ND: 8/233 (3.1%) Permanent SSEP Change: 9/233 (3.8%) Permanent MEP Change: 11/233 (4.7%)
79 Sensitivity: 37.5% SSEP 62.5% MEP Specificity and negative predictive value >97% for both
80 Any Change (Transient and permanent) Sensitivity Specificity False Positive
81 Conclusion If there is no change at the end of operation, > 97% awakening with no ND MEP have not added any additional benefit in detecting ND
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86 Thank You
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