Predicting the Need for Intra-operative Large Volume Blood Transfusions During Thoraco-abdominal Aortic Aneurysm Repair.

OBJECTIVE: Thoraco-abdominal aortic aneurysm (TAAA) repair is a complex procedure performed in patients at high cardiovascular risk. High volume intra-operative bleeding is often recorded, and the amount of intra-operative blood product transfusion is associated with relevant morbidity and mortality. The aim of the study was to identify pre-operative predictors of intra-operative large volume blood transfusions (LVBT) to stratify patients pre-operatively. METHODS: This was a retrospective analysis of prospectively collected data of all patients who underwent open TAAA surgery at San Raffaele Scientific Institute from January 2009 to December 2015. Intra-operative red blood cell (RBC) transfusions were administered to maintain a hematocrit of at least 30%. A LVBT was defined as a transfusion of at least four RBC units, corresponding to 1000 mL. RESULTS: The study population included 428 patients: 260 (61%) received fewer than 4 RBC units, and 168 (39%) were transfused with at least 4 RBC units. In patients who underwent LVBT, higher mortality was observed after surgery (p=.003), longer intensive care unit admission (p=.004), and longer mechanical ventilation compared with less transfused patients (p=.0002). The patients who received fewer units were administered a higher dose of heparin during the surgical operation compared with patients of the LVBT group: 3400±1100 vs. 2900±1300 IU (international units) (p=.0004). Pre-operative chronic renal failure (OR 1.8), the pre-operative haemoglobin value (OR 0.8), and the need for urgent or emergent surgery (OR 3.15) were independent predictors of LVBT on multivariate analysis. CONCLUSIONS: The identification of patients at risk of intra-operative LVBT during TAAA surgery is critical as these patients experience a worse outcome. Nevertheless, only few independent predictors are available for clinical practice.

An anatomical review of spinal cord blood supply.

Knowledge of the spinal cord (SC) vascular supply is important in patients undergoing procedures that involve the thoracic and thoracoabdominal aorta. However, the SC vasculature has a complex anatomy, and teaching is often based only on anatomical sketches with highly variable accuracy; historically, this has required a "leap of faith" on the part of aortic surgeons. Fortunately, this "leap of faith" is no longer necessary given recent breakthroughs in imaging technologies and postprocessing software. Imaging methods have expanded the non-invasive diagnostic ability to determine a patient's SC vascular pattern, particularly in detecting the presence and location of the artery of Adamkiewicz. CT is the imaging modality of choice for most patients with thoracic and thoracoabdominal aortic disease, proving especially useful in the determination of feasibility and planning of endovascular treatment. Thus the data set required for analysis of SC vascular anatomy is usually already available. We have concentrated our efforts on CT angiography, which offers particularly good imaging capabilities with state-of-the-art multidetector scanners. Multidetector row helical CT provides examinations of an extensive range in the craniocaudal direction with thin collimation in a short time interval, giving excellent temporal and spatial resolution. This paper provides examples of the SC vasculature imaging quality that can be obtained with 64 row scanners and appropriate postprocessing. Knowledge of the principal anatomical features of the SC blood supply of individual patients undergoing open or endovascular thoracoabdominal procedures has several potential benefits. For open surgery, analysis of the SC vasculature could tell us the aortic region that feeds the Adamkiewicz artery and thus needs to be reimplanted. For endovascular procedures, we can determine whether the stent-graft will cover the Adamkiewicz artery, thus avoiding unnecessary coverage. CT data can also be used to stratify risk of SC ischemia and guide the selective use of spinal cord injury prevention strategies.

Open treatment of extent IV thoracoabdominal aortic aneurysms.

AIM: Extent IV thoracoabdominal aortic aneurysm (TAAA) open repair is considered relatively safer to repair than other extents of TAAA in terms of both perioperative mortality and spinal cord ischemia. Our purpose is to report our experience and to perform a literature review regarding extent IV TAAA open repair in order to provide an updated benchmark for comparison with any other alternative strategy in this aortic segment. METHODS: From 1993 to 2015 we performed 736 open repairs for TAAA (177 extent I, 196 extent II, 141 extent III, 222 extent IV). In extent IV group there were 164 men (73.9%) and the mean age was 67.4±9.3 years (range 32-84). The aneurysm etiology was degenerative in 198 patients (95.6%). Twelve patients (5.4%) underwent emergent operation. Totally abdominal approach was used in 22.0% of the cases. Until 2006 left heart bypass (LHBP) and cerebrospinal fluid drainage (CSFD) were almost never performed during extent IV repair. Since 2006 we changed our approach with a more aggressive use of LHBP (22.9%) and CSFD (43.4%) in 83 consecutive extent IV. Renal arteries perfusion was performed with 4 °C Ringer's solution until 2009 and with 4 °C Custodiol solution since September 2009 to date. Literature search was performed on several databases (PubMed, BioMedCentral, Embase, and the Cochrane Central Register of clinical trials). Research was updated on March 1th 2015. RESULTS: Perioperative mortality in our overall group of TAAA and in the extents IV was 10.7% and 4.9%, respectively (P=0.01); spinal cord ischemia rate 11.4% and 2.7%, respectively (P=0.0001). In the extents IV treated between 2006 and 2015 we observed a further trend of outcomes improvement with a rate of perioperative mortality and spinal cord ischemia of 1.2%, and 2.4%, respectively. Database searches yielded a total of 767 articles. Excluding non-pertinent titles or abstracts, we retrieved in complete form and assessed 27 studies according to the selection criteria. Nine studies were further excluded because of our prespecified exclusion criteria. The final 18 manuscripts included a total of 2098 patients. In this group median mortality rate was 4.8% (interquartile range 3-6) and the mean incidence of spinal cord ischemia was 1.56±1.54%. CONCLUSION: Perioperative outcomes after extent IV TAAA open repair were significantly better compared to our overall TAAA series. A more aggressive use of CSFD, LHBP and renal perfusion with Custodiol solution allowed a further trend of outcomes improvement in our series of extent IV TAAA open repair. Literature analysis confirmed during extent IV open repair very satisfactory perioperative outcomes with rates of mortality and spinal cord ischemia dropped to under 5% and 2%, respectively.

Strategies to treat thoracic aortitis and infected aortic grafts.

Infectious thoracic aortitis is a rare disease, especially since the incidence of syphilis and tuberculosis has dropped in western countries. However, the risk to develop an infectious aortitis and subsequent mycotic aneurysm formation is still present, particularly in case of associated endocarditis, sepsis, and in immunosuppressive disorders. Moreover, the number of surgical and endovascular thoracic aortic repairs is continuously increasing, and infective graft complications are observed more frequently. Several etiopathogenetic factors may play a role in thoracic aortic and prosthetic infections, including hematogenous seeding, local bacterial translocation, and iatrogenous contamination. Also, fistulization of the esophagus or the bronchial tree is commonly associated with these diseases, and it represents a critical event requiring a multidisciplinary management. Knowledge on underlying micro-organisms, antibiotic efficacy, risk factors, and prevention strategies has a key role in the management of this spectrum of infectious diseases involving the thoracic aorta. When the diagnosis of a mycotic aneurysm or a prosthetic graft infection is established, treatment is demanding, often including a number of surgical options. Patients are usually severely compromised by sepsis, and in most cases they are considered unfit for surgery for general clinical conditions or local concerns. Thus, results of different therapeutic strategies for infectious diseases of the thoracic aorta are still burdened with very high morbidity and mortality. In this manuscript, we review the literature regarding the main issues related to thoracic infectious aortitis and aortic graft infections, and we report our personal series of patients surgically treated at our institution for these conditions from 1993 to 2014.

Clinical use of extra-large self-expanding stents.

The aim of this study is to describe our clinical experience with an extra-large self-expandable stent specifically designed to treat aortic lesions (E-XL, Jotec GmbH, Hechingen, Germany), now commercially available in Europe. The E-XL was used at our Institution in 14 patients (mean age, 56±12 years; 9 males) with the following indications: improve proximal fixation (4 cases), type I endoleak (2 cases), aortic dissection with static malperfusion (1 case) and dynamic malperfusion (7 cases). Early results have been shown to be safe and effective in different clinical settings, including in emergency cases. This peculiar aortic stent could be useful in the armamentarium of the endovascular surgeon.

Redo surgery in ascending aorta and aortic arch.

AIM: Reinterventions following previous ascending aorta and aortic arch repair are uncommon, but technically challenging and often burdened with high morbidity and mortality. The aim of this article is to present a single-center experience in the treatment of this complex pathology, using different surgical approaches. METHODS: Between 1999 and 2014, 17 patients (14 males, mean age 73±16 years) underwent ascending aorta and aortic arch redo surgery at our Department. A prospectively maintained database including thoracic aortic procedures was reviewed retrospectively to collect data on redo patients. RESULTS: In 13 cases the index procedure was an endovascular or hybrid procedure on the aortic arch performed at our Department, for an in-house reintervention rate of 6.9% (13/188). In 10 cases the cause of reintervention was stent-graft distal migration, treated by means of endovascular relining in all cases, associated with adjunctive supra-aortic trunks debranching via sternotomy in 6 cases. In 5 cases the cause of reintervention was retrograde ascending aortic dissection, in 1 case ascending aortic anastomotic pseudoaneurysm following supra-aortic trunk debranching, and in 1 case mediastinitis following implantation of an endovascular plug previously used to treat an ascending aortic pseudoaneurysm. In these last 7 cases, all patients were treated by means of ascending and arch surgical replacement under deep hypothermic circulatory arrest (DHCA) and antegrade cerebral perfusion (ACP). No 30-day mortality was observed. Major perioperative morbidity included 1 paraplegia, 1 minor stroke, 1 bleeding requiring reintervention, and 3 cases of respiratory failure requiring prolonged intubation (2) or tracheostomy (1). CONCLUSION: In our experience, incidence of serious complications requiring reinterventions following ascending aorta or aortic arch repair is not negligible. Redo surgery in ascending aorta and aortic arch is feasible in high-volume and experienced centers, as it often requires hybrid repair via midline sternotomy, or surgical replacement under DHCA and ACP.

Open repair for aortic occlusive disease: indication, techniques, results, tips and tricks.

AIM: The aim of this article was to review indications, techniques, and outcomes of a series of open repair for aortic occlusive disease. METHODS: Between 1991 and 2013, 1071 patients (917 men, 154 women; mean age 62.6 years) underwent open repair for aortoiliac occlusive disease. According to TASC II classification, 123 patients (11.5%) had type B lesions, 343 (32%) type C, and 605 (56.5%) type D. Among type D lesions, 138 patients had Leriche's Syndrome with complete aortic occlusion. Nine hundred and eight aortobifemoral bypasses, 114 axillo-bifemoral bypasses, 42 aortic endarterectomies with patch aortoplasty, and 7 thoracobifemoral bypasses were performed. Associated endarterectomy of abdominal aorta was required in 191 patients (18.5%), of the femoral arteries in 297 (28.7%). RESULTS: Perioperatively mortality was 0.6%; perioperative morbidity included cardiac (3.4% of patients), respiratory (2.6%), as well as acute renal insufficiency (2.6%). There were 26 (2.5%) cases of intraoperative distal embolization, 9 (0.8%) of acute graft thrombosis and 9 (0.8%) of bleeding requiring surgical revision within the first 24 hours after surgery. Sixty-one groin complications were reported in 57 patients (5.3%). During a mean follow-up time of 74 months (range 1-264), calculated actuarial occlusion-free survival at 12, 24, and 36 months was 94.8%, 91.8% and 87.2%, respectively. The limb-salvage rate in patients with critical limb ischemia was 87.3%. There were 11 (1%) graft infections. CONCLUSION: Open repair is a ductile strategy and may be tailored according to the patient clinical condition and disease anatomy. Long-term patency is excellent with low perioperative mortality and reasonable morbidity rates.

On-label use of commercially-available abdominal endografts for para-anastomotic aneurysms and pseudoaneurysms after infrarenal abdominal aortic aneurysm open repair.

OBJECTIVES: To analyze feasibility and outcomes of endovascular aortic repair (EVAR) with a strictly on-label use of abdominal aortic endografts (OnL-EVAR) to treat para-anastomotic aneurysms (PAAs) and pseudoaneurysms (PSAs) after infrarenal abdominal aortic aneurysm open repair (OR). METHODS: The data of all consecutive patients treated between 1999 and 2012 for non-infected abdominal PAAs and PSAs at our center were prospectively collected. All cases fit for EVAR based on the instructions for use of a series of abdominal aortic endografts commercially available during the study period were scheduled for OnL-EVAR regardless of patients' surgical risk. Any patients unfit for OnL-EVAR underwent OR or other complex endovascular techniques. RESULTS: One hundred and forty-three patients were collected; 78 underwent OR and 65 endovascular repair with different strategies. Coil embolization, hybrid, and chimney/periscope grafts techniques were limited to seven patients unfit both for OR and OnL-EVAR. Inclusion criteria for OnL-EVAR were reached in 58 patients for an overall OnL-EVAR feasibility of approximately 40% (21% for PAAs and 55% for PSAs). In particular, OnL-EVAR feasibility was 19% in case of involvement of proximal aortic anastomosis, 71% for distal aortic anastomosis, and 80% for iliac arteries. Overall, 25 aortouniiliac and 11 bifurcated implants were performed, single proximal aortic cuffs were used in 10 patients, and iliac extension in 12. Primary technical success was 98% without perioperative mortality. At a median follow-up of 67 months (range: 1-144 months), cumulative aneurysm-related mortality was 7%, endograft migration 7%, and reintervention was 17%. Life-table analysis showed actuarial survival and freedom from aneurysm-related death at 1, 3, and 5 years of 100%, 98%, and 95%, and of 100%, 98%, and 95%, respectively. Freedom from aortic reintervention or open conversion at 1, 3, and 5 years was 94%, 90%, and 85%. CONCLUSIONS: Feasibility of OnL-EVAR was limited for PAAs and PSAs, with a rate that was lower than 20% in case of involvement of proximal aortic anastomosis. Aortouniiliac configuration was the most commonly feasible implant and, despite strict on-label use of abdominal devices, the rate of late complications and reinterventions was high.

Open repair for infrarenal AAA: technical aspects.

The aim of this study was to describe the technique and report our single center experience of abdominal aortic aneurysm (AAA) open surgical repair over the last 17 years. From 1993 to 2010, a total of 4347 open surgical procedures for repair of AAA were performed in our center. The details of 3857 (88.7%) patients undergoing infrarenal AAA open repair were analyzed; mean age at the time of surgery was 71.8 years ranging from 58 to 89 years. Among all repairs, 23.7% (914) were performed in women and 24.3% (937) in octogenarians; 3587 (93.0%) procedures were performed for degenerative aneurysms, 146 (3.8%) for inflammatory aneurysms, 100 (2.6%) for dissecting aneurysms, and 19 (0.5%) for other pattern of disease. In 162 cases (4.2%) surgery was performed for ruptured aneurysm. In most cases (N.=2596; 67.3%) infrarenal AAA open repair was performed by means of aorto-aortic bypass using a tube graft. A total of 1261 patients were treated using a bifurcated graft: 417 (33.1%) aorto-iliac bypasses, 530 (42.0%) aorto-femoral bypasses and 314 (24.9%) aorto-iliac-femoral bypasses were performed. In elective aorto-aortic bypass, mean aortic clamping time was 21.3+6.7 minutes. The average duration of the procedure was 126+84 minutes (range, 42-410 minutes). Mean intraoperative bleeding was 803.4+422.7 mL (range 250-3,100). Overall intraoperative mortality was 0.2%. Intraoperative mesenteric ischemia was observed in 3% of cases, all treated with inferior mesenteric artery reimplantation. The rate of intraoperative lower limbs ischemia was 2.2%. One intraoperative acute type A aortic dissection occurred. The overall 30-day mortality was 0.6%. Permanent renal function impairment occurred in 4.3% of cases. The rate of pulmonary complications was 9.8%. Other complications were myocardial infarction, congestive heart failure, late ischemic colitis, late leg ischemia, wound infection, urinary tract infection, and sepsis. Although endovascular techniques have emerged as a less invasive alternative to open repair, short- and long-term outcomes associated to the surgery of infrarenal AAAs remain satisfactory for a large range of patients.

Analysis of stroke after TEVAR involving the aortic arch.

OBJECTIVE: To analyse the incidence of stroke after thoracic endovascular aortic repair (TEVAR) for aortic arch disease. METHODS: In the last decade, 393 patients received TEVAR at our Institution; in 143 cases the aortic arch was involved (32 zones '0', 35 zones '1' and 76 zone '2'). The left subclavian artery (LSA) was revascularised selectively in 75 cases; the proximal LSA was ligated or occluded with a plug in 55 cases before endograft (EG) deployment. RESULTS: Initial clinical success, perioperative mortality, spinal cord ischaemia and stroke in TEVAR patients with or without arch involvement were, respectively, 86.7% vs. 94.4%, 4.2% vs. 2.4%, 2.1% vs. 3.6% and 2.8% vs. 1.2%. The stroke rate was 9.4% (P < 0.02) in 'zone 0', 0% in 'zone 1' and 1.3% in 'zone 2' with scans showing severe atheroma and/or thrombus in all cases. Stroke was observed in patients with 2.6% or without 2.9% LSA revascularisation; however, it was never observed in patients in whom the LSA was occluded before EG deployment and in 4.5% of patients in whom it was patent at the time of EG deployment. CONCLUSIONS: Stroke after TEVAR is not infrequent especially when the arch is involved. Careful patient selection together with a strategy to reduce embolisation such as occlusion of supra-aortic trunks before EG deployment may play a beneficial role.

Endovascular treatment of an early arch aneurysm rupture after open thoracoabdominal aortic repair.

Optimal treatment for synchronous aortic aneurysms is still debated. Staged repair is advocated as the standard of care. Its disadvantage however is the consistent risk of rupture of the untreated aortic segment during recovery; moreover a considerable percentage of patients either refuse the second stage or is lost to follow-up. We present the case of a patient with a ruptured aortic arch aneurysm after open-surgery for a type III thoracoabdominal aortic aneurysm. Our therapeutic decision is described and discussed, with all the related advantages and disadvantages.

Hybrid procedures for the treatment of thoracoabdominal aortic aneurysms and dissections.

The search for less invasive therapeutic approaches to thoracoabdominal aortic aneurysms (TAAAs) brought endovascular procedures to establish themselves as alternatives to open surgery in high-risk patients. Aim of this study is to illustrate the hybrid - open and endovascular - treatment of dissecting and non-dissecting TAAAs, and to analyze short and midterm results at our Center. We analyzed 41 high-risk patients who underwent hybrid TAAA repair (dissecting TAAA in 17% of cases) with a variety of visceral rerouting configuration and of commercially available thoracic endografts. Thirty-one simultaneous (76%) and 10 staged procedures (24%) were performed with a four-vessel revascularization in 13 cases (32%), a three-vessel in 9 (22%) and a two-vessel in 19 (46%). No intraoperative deaths were observed in our series, with a technical success in endovascular TAAA repair of 100%. Two patients died in the intersurgical time. A perioperative mortality of 13% and a perioperative morbidity of 32% were recorded, including one case (2.4%) of permanent paraplegia. At a median follow-up of 23.3 months, we observed a visceral graft occlusion rate of 6%, three type II endoleak and one endograft migration. Six patients died for unrelated events. Typical complications of conventional TAAA open surgery have been not eliminated by hybrid repair and still significant mortality and morbidity have been reported. Dissecting etiology did not negatively affect the outcome of hybrid repair in our experience. Fate of visceral bypasses and incidence of endoleak and other endograft-related complications need to be carefully assessed. Hybrid TAAA repair should nowadays be limited as alternative to simple observation in patients unfit for the conventional open repair.

Aorto-oesophageal and aortobronchial fistulae following thoracic endovascular aortic repair: a national survey.

OBJECTIVE: We evaluated the incidence of aorto-oesophageal (AEF) and aortobronchial (ABF) fistulae after thoracic endovascular aortic repair (TEVAR), and investigated their clinical features, determinants, therapeutic options and results. METHODS: We conducted a voluntary national survey among Italian universities and hospital centres with a thoracic endovascular programme. RESULTS: Thirty-nine centres were contacted, and 17 participated. Of the patients who underwent TEVAR between 1998 and 2008, 19/1113 (1.7%) developed AEF/ABF. Among indications to TEVAR, aortic pseudo-aneurysm was associated with the development of late AEF/ABF (P = 0.009). Further, emergent and complicated procedures resulted in increased risk of AEF/ABF (P = 0.008 and P < 0.001, respectively). Eight patients were treated conservatively, all of whom died within 30 days. Eleven patients underwent AEF/ABF surgical treatment, with a perioperative mortality of 64% (7/11). At a mean follow-up of 17.7 +/- 12.5 months, overall survival was 16% (3/19). CONCLUSIONS: The incidence of AEF and ABF following TEVAR is not negligible, and is comparable to that following open repair. This finding warrants an ad hoc long-term follow-up after TEVAR, particularly in patients submitted to emergent and complicated procedures. Both surgical and endovascular treatment of AEF/ABF are associated with high mortality. However, conservative treatment does not appear to be a viable option.

Management of thoracic endograft infection.

Thoracic endovascular aortic repair (TEVAR) has emerged as a promising, less invasive alternative to conventional open surgery for the treatment of thoracic aortic pathology. Most surveillance after TEVAR concentrates on the technical aspects of the procedure, including endoleak, device migration and endograft rupture; so far, the knowledge on endograft infectious complications is limited to anecdotal reports. Several etiopathogenetic factors may play a role in thoracic endograft infections (TEIs), including perioperative contamination, hematogenous seeding, and local bacterial translocation. Moreover, fistulization with the esophagus or the bronchial tree is a common mechanism of secondary TEI, and it represents a dramatic event requiring a multidisciplinary management. Risk factors assessment and prevention have a key role in avoiding the development of new TEIs. When a TEI is established, treatment is demanding, and includes several medical therapies associated with various surgical options. Patients are usually severely compromised by sepsis, and in most cases they are considered unfit for surgery for general clinical conditions or local concerns. Thus, results of different therapeutic strategies for TEI are still burdened with very high morbidity and mortality. In this paper, we reviewed the English literature regarding the main strategies proposed for operative management of TEI, we reported and analyzed our personal series of 7 patients treated at our institution for TEI from 1999 to 2009, and we summarized results from the data collected during a recent Italian multicenter national survey, performed to investigate aortoesophageal and aortobronchial fistulae treated with TEVAR or developed following TEVAR.

Endovascular treatment of descending thoracic aneurysms.

INTRODUCTION: Current strategies for repair of descending thoracic aortic aneurysms consist of open repair with surgical graft replacement or thoracic endovascular aortic repair. We review and update our overall experience in aortic thoracic diseases and specifically analyzed our outcomes with thoracic endovascular aortic repair in patients with descending thoracic aortic aneurysms. METHODS: From 1993 to present a total of 1144 patients were treated in our Center for pathology involving the thoracic aorta. Since 1998, 322 patients underwent thoracic endovascular aortic repair, and among this group, in 188 cases the descending aorta was involved. In 74% of patients treated for a descending thoracic aortic lesion, a degenerative aneurysm was observed. RESULTS: In patients with descending thoracic aortic aneurysms receiving thoracic endovascular aortic repair, our technical success rate, i.e. deployment of endograft with complete exclusion of the lesion/minimal endoleak, was 99.5% (one case required emergent open conversion) with a perioperative mortality of 2.6% (five patients). The rate of spinal cord ischemia, manifesting either as paraplegia or paraparesis, was 4.7%. Delayed onset spinal cord ischemia ameliorated with adequate arterial pressure and cerebrospinal fluid drainage. CONCLUSIONS: Our experience of selected patients undergoing thoracic endovascular aortic repair of descending thoracic aorta aneurysms is satisfactory with very low mortality and morbidity. A large use of thoracic endovascular aortic repair is foreseen in the next future.

Open repair of descending thoracic aneurysms.

INTRODUCTION: Current strategies for operative treatment of a thoracic aortic aneurysm consist of open repair with surgical graft replacement or endovascular exclusion. To reduce mortality and morbidity of open repair, a multimodal approach has gradually evolved by maximizing organ protection. METHODS: On a total of 1108 patients treated in our Center from 1993 for pathology involving the thoracic aorta, we reviewed the prospectively collected data of 194 consecutive patients who underwent open thoracic aortic aneurysm repair, 104 (54%) for degenerative aneurysms, 65 (34%) for dissections, 25 (12%) for other pattern of disease. Left Heart Bypass was used in 82% of cases, clamp and sew technique in 16%, hypotermic circulatory arrest in 2%. RESULTS: Overall perioperative mortality was 4.1%. The rate of pulmonary complications was 8.8%. The rate of cardiac complications, i.e. new onset myocardial necrosis demonstrated by positive blood tests, was 6.2%. The rate of renal complications was 7.2%. Cerebrovascular accident, defined as a new neurologic deficit lasting more than 24 hours confirmed by imaging, occurred in 2.0% of patients. The rate of spinal cord ischemia, manifesting either as paraplegia or paraparesis, was 4.6%. CONCLUSIONS: Mortality and morbidity rates of open thoracic aortic aneurysm repair are currently satisfactory especially in fit patients. In order to define surgical indications and the role of endovascular repair, consideration of age of the patient, comorbidity, symptoms, life expectancy, likely quality of life (if asymptomatic), aortic diameter, aneurysm morphology, aneurysm extent, suitability of landing zones, and operator experience are all distinctly relevant.

Angio-CT imaging of the spinal cord vascularisation: a pictorial essay.

Knowledge of the spinal cord (SC) vascular supply is important in patients undergoing procedures that involve the thoracic and thoraco-abdominal aorta; the SC vasculature, however, has a complex and highly variable anatomy. Recent breakthroughs in imaging methods have expanded the non-invasive diagnostic ability to determine a patient's spinal cord vascular pattern, particularly in detecting the presence and location of the artery of Adamkiewicz. CT is the imaging modality of choice for most patients with thoracic and thoraco-abdominal aortic disease for pre-operative planning of endovascular treatment: thus the data set required for our analysis of spinal cord vascular anatomy is already available. This paper provides examples of the SC vasculature imaging that can be obtained with 64 row scanners and appropriate postprocessing.

Advances in imaging of the spinal cord vascular supply and its relationship with paraplegia after aortic interventions. A review.

INTRODUCTION: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.