The impact of spinal angiography on the neurological outcome after surgery on the descending thoracic and thoracoabdominal aorta

doi:10.1016/S0003-4975(02)04149-8

The Annals of Thoracic Surgery

Volume 74, Issue 5, November 2002, Pages S1870-S1872

Presented at the Aortic Surgery Symposium VIII, May 2–3, 2002, New York, NY.

https://doi.org/10.1016/S0003-4975(02)04149-8 Get rights and content

Abstract

Background

Neurologic complications remain one of the major concerns in surgery on the descending thoracic and thoracoabdominal aorta. The impact of preoperative spinal angiography on postoperative neurologic outcome was assessed.

Methods

Between September 1993 and December 1999, 109 patients (mean age, 58.2 years; range, 24 to 77) underwent preoperative spinal angiography: 50 (45.9%) for aneurysm and 59 (54.1%) for chronic dissection. Sixty-one patients (56.0%) underwent replacement of the descending thoracic aorta whereas the thoracoabdominal aorta was replaced in 48 (44.0%) patients. All intercostal or lumbar arteries that had previously been visualized as the origin of the great radicular artery (GRA) were preserved.

Results

The origin of the GRA was located by spinal angiography in 65 of the 109 patients (59.6%). It was found between level T-5 and L-3 and on the left side in 75.4% (49 of 65) patients. In patients with aneurysms, it was identified less frequently (48%) compared with patients with chronic dissection (69.5%,p = 0.02). The overall operative mortality rate was 5.5% (6 of 109 patients). There were 7 patients (6.4%) with postoperative paraplegia. In 3 of them the origin of the GRA had been reimplanted.

Conclusions

Even in patients with an identified and subsequently reimplanted GRA, postoperative paraplegia could not always be prevented. Spinal angiography has no impact on the neurologic outcome of thoracic and thoracoabdominal aortic replacement.

Section snippets

Patient population

Between September 1993 and December 1999, 109 patients underwent preoperative spinal angiography before descending and thoracoabdominal aortic replacement according to the neuroradiological technique described previously [3]. Patient-related preoperative variables are summarized in Table 1. In 61 patients (56%), aortic pathology was limited to the descending aorta whereas the thoracoabdominal segment was affected in 48 patients (44%). On the basis of the classification by Crawford and

Spinal angiographical results

The origin of the GRA was located by spinal angiography in 65 of 109 patients (59.6%). It was found between T-5 and L-3, and the most common source was the left 11th intercostal artery (16 of 65, 24.6%). In the majority of the patients, it was identified on the left side of the respective intercostal or lumbar artery (49 of 65 patients, 75.4%) and between T-8 and L-2 (62 of 65 patients, 95.4%).

The rate of identification in patients with aneurysms (24 of 50 patients, 48.0%) was lower than that

Comment

The role of the GRA for maintenance of spinal cord blood supply is controversial [5]. In this study, preoperative identification of the GRA had no impact on the incidence of severe postoperative neurologic complications after descending or thoracoabdominal aortic replacement. This result indicates the importance of other risk factors such as perioperative hypotension, duration of intraoperative spinal cord ischemia or thromboembolism of collaterals to the anterior spinal artery.

ISA reattachment

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A hypertensive 83-year-old male with chronic obstructive pulmonary disease presented with a 2.3-cm right iliac artery dissecting aneurysm. Paraplegia occurred on the first day after endovascular repair of iliac artery aneurysm. Postoperative magnetic resonance imaging showed multiple foci of spinal cord ischemia involvement from T10 to L1. Neither arterial pressure augmentation nor steroid therapy was effective. We hypothesized that the compromised blood flow from the artery of Adamkiewicz, combined with the transient hypotension and embolism, resulted in spinal cord infarction. The patient was eventually transferred to a nursing facility, with no improvement in his neurological status.
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We report the case of a patient who developed paraplegia following a low lumbar epidural steroid injection. Alternative approaches to (or alternative means of) performing transforaminal injections should be considered, in order to avoid devastating neurological complications.
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Il s’agit d’un homme de 54 ans, opéré 14 ans auparavant d’une cure de hernie discale L5-S1, pour une sciatique S1 droite, souffrant d’une lombosciatique gauche, depuis six semaines. Lors de la réalisation d’une seconde infiltration d’acétate de prednisolone, il signale une sensation de chaleur des membres inférieurs, concomitante d’un flush sur le visage. S’installe alors rapidement une paraplégie flasque T7 ASIA A. L’IRM médullaire au troisième jour montre un hypersignal médullaire spontané en T2 au niveau du cône et de T6 à T9, évoquant une myélite ischémique. La récupération est lente. Après quatre mois de prise en charge en médecine physique et de réadaptation (MPR), le patient peut marcher sans aide 200 m. Ils persistent des troubles sensitifs et sphinctériens (paraplégie T7 ASIA D). Les images IRM sont inchangées à trois mois.
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Malgré sa grande rareté, cette complication grave mérite d’être connue du patient. Son pronostic fonctionnel est imprévisible.
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The aetiology of perioperative SC ischaemia is multi-factorial, and various efforts to reduce this complication have been made, including improving surgical technique12 (sequential clamping,13 prevention of steal phenomenon13–15 and intercostal artery re-implantation1,16,17), adjuncts (distal perfusion,2,3,13,17 hypothermia,2,13 cerebrospinal fluid drainage,2,3,7,13,18–21 etc.), monitoring (motor-evoked potentials2,14,21–24) and anaesthesia (rapid infusion systems, vital parameters monitoring,7,13 arterial pressure management,2,7,13,18,21 pharmacological strategies,7,13 etc.). Although strategies for preventing SC injury have evolved steadily since the 1980s, paraplegia has not been eliminated.2,7,20,25,26 Accurate preoperative knowledge of the arterial supply to the SC would be extremely useful for procedure planning and risk stratification.
Preoperative knowledge of the spinal cord (SC) vasculature could be useful for stratifying and decreasing the risk of perioperative paraplegia after thoracic and thoraco-abdominal aortic surgery. Recent advances in magnetic resonance (MR) and computed tomography (CT) angiography and post-processing techniques have improved this knowledge.
A search of MEDLINE/Pubmed and SCOPUS databases identified 1414 pertinent abstracts; 123 full-length manuscripts were screened to identify relevant studies with acceptable design and patient numbers. Forty-three were selected.
SC circulation was studied in 1196 patients to detect the great radicular artery: 522 by MR-angiography and 674 by CT angiography. Detection rates were 67–100% (mean 80.8%) with MR-angiography being 18–100% (mean 72%) with CT angiography. The side and level of the great radicular artery were consistent between the methods. Several authors tried to use the imaging results to guide clinical management.
Non-invasive imaging of the SC blood supply allows preoperative definition of the vasculature in many, but not all, cases. The impact of these findings on clinical management is potentially beneficial but still uncertain. Further improvements in image acquisition and post-processing techniques are needed. Future studies need to be large enough to compensate for inter-individual variability in SC vasculature in health and disease; however, even a partial reduction of paraplegia rate offers a formidable motivation for further research in this area.

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Original article: aortic surgery symposiumThe impact of spinal angiography on the neurological outcome after surgery on the descending thoracic and thoracoabdominal aorta