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1.
Curr Opin Anaesthesiol ; 32(1): 72-79, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30507678

RESUMO

PURPOSE OF REVIEW: Spinal cord ischemia (SCI) is a devastating complication after open or endovascular aortic repair for thoracoabdominal aortic disease. The underlying pathogenesis is not fully understood but appears multifactorial. Multiple spinal cord protection strategies and monitoring techniques are currently utilized with variable results seen. The purpose of this review is to summarize important and recent findings related to cause, monitoring and impact of multiple spinal cord protection strategies. RECENT FINDINGS: Recent data suggests collateral blood flow as the major determinant of spinal cord perfusion instead of individual intercostal vessels, potential role of transcutaneous near-infrared spectroscopy for monitoring of spinal cord perfusion and positive impact of implementing multimodal spinal cord protection strategies on reducing the risk of SCI. SUMMARY: SCI leading to paraplegia is a multifactorial complication that remains a major concern in complex aortic surgeries. Although there are no sufficient data to document the efficacy of spinal cord protection techniques individually, their effect on lowering the risk of SCI is most evident when used concomitantly using a multimodal approach that encompasses the perioperative and early postoperative period.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Procedimentos Endovasculares/efeitos adversos , Monitorização Neurofisiológica Intraoperatória/métodos , Paraplegia/prevenção & controle , Isquemia do Cordão Espinal/prevenção & controle , Circulação Colateral , Procedimentos Endovasculares/métodos , Humanos , Hipotermia Induzida/métodos , Paraplegia/etiologia , Perfusão/métodos , Assistência Perioperatória/métodos , Reimplante/métodos , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Medula Espinal/irrigação sanguínea , Isquemia do Cordão Espinal/diagnóstico , Isquemia do Cordão Espinal/etiologia , Artérias Torácicas/cirurgia
2.
J Cardiovasc Surg (Torino) ; 60(1): 54-65, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30260147

RESUMO

Spinal cord injury is the most devastating complication after aortic surgery. Rates of spinal cord injury vary from 0% up to 40%. Predictive factors include extent of coverage, hypogastric artery occlusion, prior aortic repair and perioperative hypotension. This article summarizes current strategies that are utilized to minimize risk of spinal cord injury including use of cerebrospinal fluiddrainage, early limb reperfusion, staging and neuro-monitoring.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Procedimentos Endovasculares/efeitos adversos , Isquemia/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Traumatismos da Medula Espinal/prevenção & controle , Medula Espinal/irrigação sanguínea , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/mortalidade , Humanos , Complicações Intraoperatórias/prevenção & controle , Isquemia/etiologia , Paraplegia/etiologia , Paraplegia/prevenção & controle , Fatores de Risco , Medula Espinal/diagnóstico por imagem
3.
Gen Thorac Cardiovasc Surg ; 67(1): 180-186, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30187260

RESUMO

OBJECTIVE: To prevent paraplegia in patients undergoing thoracoabdominal aortic aneurysm repair, the importance of preoperative identification of the Adamkiewicz artery and reconstruction of critical intercostal artery have been advocated. Conversely, significance of collateral network for spinal cord perfusion has been recognized. We invented a new system consisting of a direct monitoring of cerebrospinal fluid temperature (CSFT) and differential selective hypothermic intercostal artery perfusion (D-HIAP). METHODS: After exposing a critical intercostal artery, a 10-mm prosthetic graft was anastomosed in an end to side fashion. A balloon-tipped catheter was inserted into the graft to perfuse with 15 °C blood. Neighboring intercostal arteries were also perfused in the same fashion. Serial monitoring of CSFT was performed. Between January 2011 and January 2015, D-HIAP was employed in 50 patients with Adamkiewicz artery that located within a reconstructed area. RESULTS: Significant CSFT drop was recorded after initiation of D-HIAP in 42 (84%) patients. Of those, 34 (68%) patients showed significantly lowered CSFT with D-HIAP into a single critical intercostal artery. Perfusion into plural intercostal arteries was necessary for CSFT drop in 2 cases (4%), and plural intercostal artery perfusion further enhanced CSFT drop that had been modestly achieved by single intercostal artery perfusion in 6 cases (12%). Eight (16%) patients did not exhibit a significant drop in CSFT even when D-HIAP was employed for the critical and neighboring intercostal arteries. CONCLUSIONS: The detection of a disparity in temperature between the intrathecal space and blood generated by D-HIAP revealed individual variability in CSFT changes, which may imply a complexity in spinal cord perfusion. Intraoperative D-HIAP may help to identify a major blood supply for spinal cord perfusion and underlying collateral network.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Parada Circulatória Induzida por Hipotermia Profunda , Paraplegia/prevenção & controle , Procedimentos Cirúrgicos Reconstrutivos , Isquemia do Cordão Espinal/prevenção & controle , Procedimentos Cirúrgicos Vasculares/métodos , Temperatura Corporal , Líquido Cefalorraquidiano/fisiologia , Humanos , Músculos Intercostais/irrigação sanguínea , Perfusão/métodos , Tomografia Computadorizada por Raios X
4.
J Surg Res ; 233: 124-131, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30502238

RESUMO

BACKGROUND: Paraplegia remains a significant complication of thoracoabdominal aortic intervention. We previously reported that diazoxide (DZ), enhances the neuroprotective efficacy of erythropoietin (EPO). We hypothesized that DZ and EPO combined treatment attenuates spinal cord ischemic injury through upregulation of nerve growth factor (NGF). METHODS: DZ (pretreatment) was given to adult male C57/BL6 mice by oral gavage and EPO (before surgery) was intraperitoneally injected 32 h after administration of DZ. Spinal cords were harvested 0, 2, 4, and 6 h after injection of EPO. NGF expression was analyzed by western blot. After determining the optimal time, NGF expression was compared between DZ (pretreatment) + EPO (before surgery), DZ + PBS, PBS + EPO, and PBS + PBS (ischemic control). Four groups were studied to compare the motor function after ischemia: DZ + EPO (n = 11), ischemic control (n = 9), DZ + EPO + tropomyosin receptor kinase A receptor inhibitor (n = 9), and sham (without cross-clamp, n = 4). Spinal cord ischemia was induced by a 4-min thoracic aortic cross-clamp. Functional scoring (Basso Mouse Score) was done at 12-h intervals until 48 h, and spinal cords were harvested for evaluation of NGF expression and histological changes. RESULTS: NGF expression was significantly upregulated 4 h after administration of EPO. At 4 h after injection of EPO, NGF expression in the DZ + EPO group was significantly higher than that in the other groups. DZ + EPO significantly preserved motor function compared with all other groups. At 48 h after reperfusion, the level of NGF expression in the DZ + EPO group, was significantly higher than in all other groups. CONCLUSIONS: DZ + EPO attenuates spinal cord ischemic injury through upregulation of NGF. Better understanding of this mechanism may serve to further prevent ischemic complications for aortic intervention.


Assuntos
Diazóxido/administração & dosagem , Eritropoetina/administração & dosagem , Fator de Crescimento Neural/metabolismo , Isquemia do Cordão Espinal/prevenção & controle , Animais , Aneurisma da Aorta Torácica/cirurgia , Diazóxido/farmacocinética , Modelos Animais de Doenças , Sinergismo Farmacológico , Eritropoetina/farmacocinética , Humanos , Masculino , Camundongos , Paraplegia/etiologia , Paraplegia/prevenção & controle , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/farmacocinética , Medula Espinal/efeitos dos fármacos , Medula Espinal/metabolismo , Medula Espinal/patologia , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/patologia , Regulação para Cima/efeitos dos fármacos , Procedimentos Cirúrgicos Vasculares/efeitos adversos
5.
J Thorac Cardiovasc Surg ; 155(4): 1372-1378.e1, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29395204

RESUMO

BACKGROUND: The need for intercostal artery (ICA) reattachment in surgery for descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) remains controversial. We reviewed our experience over a 14-year period to assess the effects of ICA management on neurologic outcome after DTAA/TAAA repair. METHODS: Intraoperative data were reviewed to ascertain the status of T3-12 ICAs and L1-4 ICAs. Arteries were classified as reattached, ligated, occluded, or not exposed. Temporality of reattachment or ligation in response to an intraoperative ischemic event (ie, loss of motor evoked potentials [MEPs]) was noted. Adjustment for other predictors of immediate or delayed paraplegia (DP) was performed by multiple logistic regression. The effects of specific artery level and type of reattachment technique were assessed using stratified contingency tables. RESULTS: A total of 1096 DTAA/TAAAs were performed between 2001 and 2014. The mean patient age was 64 ± 15 years, and 37% were female. Spinal cord ischemia was identified in 10% of patients, including 35 (3%) immediate cases and 77 (7%) DP cases. Overall DP resolution was 47% at discharge. ICA ligation and intraoperative MEP changes were strong predictors of postoperative paraplegia. Multivariable analysis demonstrated that T8-12 ICA ligation significantly increased the risk for paraplegia (odds ratio, 1.3/artery; P < .041) even after adjustment for age >65 years, glomerular filtration rate, extent of II/III aneurysm, increased operative time, and intraoperative MEP loss. CONCLUSIONS: Loss of intraoperative MEPs is serious, and increases the risk of paraplegia in any ICA management strategy. Even with intact MEP, ligation of T8-12 ICAs is associated with increased risk. These findings support reattachment of T8-12 ICAs whenever feasible.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Paraplegia/prevenção & controle , Isquemia do Cordão Espinal/prevenção & controle , Artérias Torácicas/cirurgia , Procedimentos Cirúrgicos Vasculares/métodos , Idoso , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/fisiopatologia , Potencial Evocado Motor , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória , Ligadura , Masculino , Pessoa de Meia-Idade , Paraplegia/diagnóstico , Paraplegia/etiologia , Paraplegia/fisiopatologia , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Isquemia do Cordão Espinal/diagnóstico , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/fisiopatologia , Artérias Torácicas/diagnóstico por imagem , Artérias Torácicas/fisiopatologia , Resultado do Tratamento , Grau de Desobstrução Vascular , Procedimentos Cirúrgicos Vasculares/efeitos adversos
6.
Asian Cardiovasc Thorac Ann ; 25(9): 608-617, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29058970

RESUMO

Spinal cord complications including paraplegia and partial neurologic deficits remain a frequent problem during repair of descending thoracic or thoracoabdominal aortic aneurysms. Effective prevention of this dreaded complication is of paramount importance. Among the many adjuncts that have been proposed to prevent spinal cord complications, spinal fluid drainage is one that has been used by numerous teams. The aim of this review is to answer the following question: does spinal fluid drainage afford spinal cord protection during both open and endovascular repair of thoracic or thoracoabdominal aortic aneurysms?


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Drenagem/métodos , Procedimentos Endovasculares , Paraplegia/prevenção & controle , Isquemia do Cordão Espinal/prevenção & controle , Animais , Implante de Prótese Vascular/efeitos adversos , Pressão do Líquido Cefalorraquidiano , Drenagem/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Humanos , Paraplegia/líquido cefalorraquidiano , Paraplegia/etiologia , Paraplegia/fisiopatologia , Fatores de Risco , Isquemia do Cordão Espinal/líquido cefalorraquidiano , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/fisiopatologia , Resultado do Tratamento
7.
J Vasc Surg ; 65(6): 1577-1583, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28216346

RESUMO

OBJECTIVE: The aim of this study was to evaluate the impact of intercostal and lumbar segmental arteries (SAs) detectable on computed tomography angiography (CTA) on the risk of spinal cord ischemia (SCI) in patients undergoing single-step or two-staged branched endovascular aneurysm repair (BEVAR). METHODS: A retrospective analysis of patients treated with branched stent grafts for thoracoabdominal aortic aneurysm at a single institution from January 2009 to June 2015 was performed. Data including preoperative comorbidities, perioperative and aneurysm-related parameters, presence and type of endoleak, and rate of severe SCI at discharge or 30 days after the procedure were collected. Preoperative and postoperative contrast-enhanced CTA images were semiquantitatively analyzed by two independent investigators, and the number of visible SAs in the stented aorta before and after BEVAR was evaluated to find a possible correlation with severe SCI. RESULTS: Seventy-seven patients were treated for thoracoabdominal aortic aneurysm with BEVAR (47 men; mean age, 71.0 years), 40 (51.9%) of them with temporary aneurysm sac perfusion (TASP; open branch/TASP group) and 37 without (single-step group). The groups were comparable regarding parameters related to the patient, aneurysm type, and endovascular procedure. Severe SCI or paraplegia was observed in 10 patients (12.3%), and SCI was lower in the open branch/TASP group (2/40) compared with the single-step group (8/37; P = .032). The number of visible SAs in the intentionally overstented aortic segment was significantly reduced on postoperative CTA (10.0 vs 15.57 SAs; P < .001) in comparison to preoperative CTA imaging, with similar results in the open branch/TASP group (9.48 vs 15.83 SAs) and the single-step group (10.57 vs 15.30 SAs; P < .001 for both groups). Within the open branch/TASP group, more visible SAs were detected during the TASP interval in comparison to postoperative CTA after side branch completion (12.93 vs 9.48 SAs; P < .001). Receiver operating characteristic curve analysis in the single-step group revealed a cutoff point of 15 SAs on preoperative CTA with correlation to severe SCI (P = .006). In the high-risk subgroup of patients with 15 or more overstented SAs during BEVAR, staged open branch/TASP procedures again reduced the risk of SCI in comparison to the single-step patients (1/20 vs 8/22; P = .008). CONCLUSIONS: More spinal arteries are visible during the TASP interval, supporting the open branch and TASP concept with a reduction of severe SCI during BEVAR. An intentional coverage of more than 15 SAs is related to an increased risk of SCI, and the rate of paraplegia was reduced after staged BEVAR with open branch/TASP in these high-risk patients.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Aortografia/métodos , Artérias/diagnóstico por imagem , Implante de Prótese Vascular , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares , Coluna Vertebral/irrigação sanguínea , Lesões do Sistema Vascular/prevenção & controle , Idoso , Aneurisma da Aorta Torácica/diagnóstico por imagem , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Alemanha , Humanos , Masculino , Paraplegia/etiologia , Paraplegia/prevenção & controle , Valor Preditivo dos Testes , Desenho de Prótese , Fatores de Proteção , Estudos Retrospectivos , Fatores de Risco , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/prevenção & controle , Stents , Fatores de Tempo , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/etiologia
8.
Hiroshima J Med Sci ; 66(1): 1-5, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29986121

RESUMO

Transcranial electrical stimulation motor-evoked potential (TES-MEP) has been widely used to monitor major motor pathways in cranial and spinal surgeries. However, the results of TES-MEP might be strongly influenced by anesthetic agents and muscle relaxants. To compensate for this effect, a technique using compound muscle action potentials of the abductor pollicis brevis (APB-CMAP) evoked by median nerve stimulation has recently been reported. In this article, we adopted the transcranial electrical stimulation motor-evoked potential of facial muscles (TES-FMEP) instead of APB-CMAP as a reference waveform for compensation. Intraoperative monitoring in spinal surgeries using TES-MEP, TES-FMEP and APB-CMAP was performed in 64 patients. We compared with and without compensation methods using TES-FMEP and APB-CMAP to evaluate TES-MEP. The cases which demonstrated postoperative motor disturbance, including transient symptoms, were judged to be positive cases. Postoperative transient paraplegia was shown in one intramedullary tumor case among those 64 cases. Compensation by TES-FMEP exhibited the highest specificity (90.5%) and lowest false-positive rate (9.5%) among the three compensation modalities when evaluated at 80% amplitude decrease. TES-FMEP, being derived from motor cortex stimulation, is not influenced by the original spinal lesion or surgical manipulation of the spine. Therefore, compensation using TES-FMEP is suitable for intraoperative monitoring during spinal surgery. The authors advocate TES-FMEP as a reference waveform for the compensation of intraoperative TES-MEP.


Assuntos
Potencial Evocado Motor , Músculos Faciais/inervação , Monitorização Neurofisiológica Intraoperatória/métodos , Procedimentos Ortopédicos , Coluna Vertebral/cirurgia , Estimulação Transcraniana por Corrente Contínua , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Ortopédicos/efeitos adversos , Paraplegia/etiologia , Paraplegia/fisiopatologia , Paraplegia/prevenção & controle , Valor Preditivo dos Testes , Tempo de Reação , Reprodutibilidade dos Testes , Coluna Vertebral/fisiopatologia , Resultado do Tratamento
9.
World Neurosurg ; 97: 750.e1-750.e3, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27794514

RESUMO

BACKGROUND: Foix-Alajouanine syndrome is defined as acute neurologic deterioration in the setting of a spinal dural arteriovenous fistula. CASE DESCRIPTION: This case report on a young patient with an unusual clinical onset of Foix-Alajouanine syndrome coincidentally occurring after his outpatient clinic appointment illustrates how prompt surgical treatment can result in rapid recovery of neurologic function despite preoperative paraplegia. CONCLUSIONS: Venous hypertension with subsequent rapid resolution after surgical treatment is the pathophysiological mechanism underlying a dural arteriovenous fistula, in contrast to historical views suggesting that these lesions result from irreversible venous thrombosis, resulting in necrotic myelopathy.


Assuntos
Malformações Vasculares do Sistema Nervoso Central/diagnóstico , Malformações Vasculares do Sistema Nervoso Central/cirurgia , Paraplegia/diagnóstico por imagem , Paraplegia/prevenção & controle , Doenças da Medula Espinal/diagnóstico , Doenças da Medula Espinal/cirurgia , Adulto , Diagnóstico Diferencial , Humanos , Masculino , Procedimentos Neurocirúrgicos/métodos , Síndrome
11.
Thorac Cardiovasc Surg ; 65(2): 126-129, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-27050813

RESUMO

Acute spinal cord ischemia during thoracoabdominal aorta replacement is a dreadful complication. Existing tools (motor evoked potential [MEP] and somatosensory evoked potential [SSEP]) do not allow differentiating between central and peripheral paraplegia. Therefore, the surgeon often performs unnecessary reimplantation of intercostal arteries: this is time consuming, and significantly increases bleeding complications. We present a simple technique combining MEP and peripheral compound muscle action potential induced by posterior tibialis nerve stimulation, enabling the surgeon to quickly discriminate between central and peripheral neurologic injury. The surgeon has one more tool to drive in real time the optimal surgical strategy. This strategy guides the decision as to which side branches ought to be reimplanted, thus minimizing the risk of paraplegia.


Assuntos
Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/métodos , Potencial Evocado Motor , Monitorização Neurofisiológica Intraoperatória/métodos , Paraplegia/prevenção & controle , Isquemia do Cordão Espinal/prevenção & controle , Traumatismos do Sistema Nervoso/prevenção & controle , Aorta Torácica/fisiopatologia , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/fisiopatologia , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Estimulação Elétrica , Humanos , Monitoração Neuromuscular , Paraplegia/diagnóstico , Paraplegia/etiologia , Paraplegia/fisiopatologia , Valor Preditivo dos Testes , Reimplante , Fatores de Risco , Isquemia do Cordão Espinal/diagnóstico , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/fisiopatologia , Artérias Torácicas/cirurgia , Nervo Tibial , Traumatismos do Sistema Nervoso/diagnóstico , Traumatismos do Sistema Nervoso/etiologia , Traumatismos do Sistema Nervoso/fisiopatologia , Resultado do Tratamento , Fluxo de Trabalho
12.
Gen Thorac Cardiovasc Surg ; 64(11): 639-650, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27501694

RESUMO

Hypothermic circulatory arrest is a critical component of aortic arch procedures, without which these operations could not be safely performed. Despite the use of hypothermia as a protective adjunct for organ preservation, aortic arch surgery remains complex and is associated with numerous complications despite years of surgical advancement. Deep hypothermic circulatory arrest affords the surgeon a safe period of time to perform the arch reconstruction, but this interruption of perfusion comes at a high clinical cost: stroke, paraplegia, and organ dysfunction are all potential-associated complications. Retrograde cerebral perfusion was subsequently developed as a technique to improve upon the rates of neurologic dysfunction, but was done with only modest success. Selective antegrade cerebral perfusion, on the other hand, has consistently been shown to be an effective form of cerebral protection over deep hypothermia alone, even during extended periods of circulatory arrest. A primary disadvantage of using deep hypothermic circulatory arrest is the prolonged bypass times required for cooling and rewarming which adds significantly to the morbidity associated with these procedures, especially coagulopathic bleeding and organ dysfunction. In an effort to mitigate this problem, the degree of hypothermia at the time of the initial circulatory arrest has more recently been reduced in multiple centers across the globe. This technique of moderate hypothermic circulatory arrest in combination with adjunctive brain perfusion techniques has been shown to be safe when performing aortic arch operations. In this review, we will discuss the evolution of these protection strategies as well as their relative strengths and weaknesses.


Assuntos
Aorta Torácica/cirurgia , Temperatura Corporal , Circulação Cerebrovascular , Parada Circulatória Induzida por Hipotermia Profunda/métodos , Encéfalo/irrigação sanguínea , Parada Circulatória Induzida por Hipotermia Profunda/efeitos adversos , Humanos , Paraplegia/prevenção & controle , Acidente Vascular Cerebral/prevenção & controle , Temperatura Ambiente
13.
J Card Surg ; 31(6): 383-9, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27193893

RESUMO

BACKGROUND: Motor evoked potentials (MEP) and somatosensory evoked potentials (SSEP) are established methods of neuromonitoring aimed at preventing paraplegia after descending or thoracoabdominal aortic repair. However, their predictive impact remains controversial. The aim of this study was to evaluate our single-center experience using this monitoring technique. METHODS: Between 2009 and 2014, 78 patients (mean age 66 ± 12, 53% male) underwent either descending or thoracoabdominal aortic repairs. Of these, 60% had an aortic aneurysm, 30% dissection, and 10% other etiologies. Intraoperatively, MEPs and SSEPs were monitored and, if necessary, clinical parameters (blood pressure, hematocrit, oxygenation) were adjusted in response to neuromonitoring signals. This analysis is focused on the neurological outcome (paraplegia, stroke) after the use of intraoperative neuromonitoring. RESULTS: Thirty-day mortality was 10 (12.8%). All patients with continuously stable signals or signals that returned after signal loss developed no spinal cord injury, whereas two out of six of the evaluable patients with signal loss (without return) during the procedure suffered from postoperative paraplegia (one transient and one permanent). Sensitivity and specificity of use of MEP and SSEP were 100% and 94.20% regarding paraplegia, respectively. CONCLUSIONS: (1) Preservation of signals or return of signals is an excellent prognostic indicator for spinal cord function. (2) Intraoperative modifications in direct response to the signal change may have averted permanent paralysis in the patients with signal loss without neurologic injury. We have found MEP and SSEP neuromonitoring to be instrumental in the prevention of paraplegia. doi: 10.1111/jocs.12739 (J Card Surg 2016;31:383-389).


Assuntos
Doenças da Aorta/cirurgia , Potenciais Somatossensoriais Evocados , Complicações Intraoperatórias/prevenção & controle , Monitorização Neurofisiológica Intraoperatória/métodos , Paraplegia/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Isquemia do Cordão Espinal/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Complicações Intraoperatórias/diagnóstico , Masculino , Pessoa de Meia-Idade , Paraplegia/etiologia , Estudos Retrospectivos , Sensibilidade e Especificidade , Isquemia do Cordão Espinal/diagnóstico , Isquemia do Cordão Espinal/etiologia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Resultado do Tratamento
14.
Ann Vasc Surg ; 34: 62-7, 2016 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-27177704

RESUMO

BACKGROUND: To retrospectively analyze the role of intercostal artery reconstruction in the spinal cord protection for patients undergoing extensive thoracoabdominal aortic aneurysm repair. METHODS: From August 2007 to 2014, thoracoabdominal aortas (Crawford II) of 81 consecutive patients with mean age 39.4 ± 10.32 years were repaired. Seventy-three of these patients (90.12%) were diagnosed with aortic dissection in our group, 25 (30.86%) with Stanford type A dissection and 48 (59.26%) with Stanford B aortic dissection. All 25 patients with type A dissection have previously undergone surgical procedures which include Bentall's procedures in 11 cases, ascending aortic replacement in 6 cases, and total aortic arch replacement in 8 cases. All procedures were performed under profound hypothermia with interval cardiac arrest after making a thoracoabdominal incision. Extracorporeal circulation was instituted with 2 arterial cannulae and a single venous cannula in the right atrium. T6-T12 intercostal arteries and L1 and L2 lumbar arteries were formed to a neo-intercostal artery in place and were connected to an 8 mm branch for maintaining spinal cord blood perfusion. Visceral arteries were joined into a patch and anastomosed to the end of the main graft. The left renal artery was anastomosed to an 8 mm branch or joined to the patch. The other 10 mm branches were anastomosed to iliac arteries. RESULTS: With 100% follow-up, early mortality was 7.4%. Six deaths were recorded; 1 patient died of cerebral hemorrhage, 3 of renal failure, 1 of heart failure because of myocardial infarction, and the last one died from the rupture of celiac artery dissection. The rate of postoperative spinal cord deficits was 3.7%, 2 patients with paraplegia and 1 patient with paraparesis. None had bladder or rectum dysfunction. Neo-intercostal arteries were clogged in 12 patients within follow-up period and formed pseudoaneurysm in 2 patients with Marfan syndrome. The mean survival time in this group was 54.22 ± 3.03 months (95% confidence interval 44.37-59.90 months) with survival rate of 92.37% after 1 year, 89.02% after 2 years, and 85.54% after 5 years. All patients were free from spinal cord deficits. CONCLUSIONS: Intercostal artery reconstruction is an effective technique for spinal cord protection in patients with the thoracoabdominal aortic repair. It can achieve favorable results and avoid spinal cord deficits with long-term follow-up.


Assuntos
Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Procedimentos Cirúrgicos Reconstrutivos , Isquemia do Cordão Espinal/prevenção & controle , Medula Espinal/irrigação sanguínea , Artérias Torácicas/cirurgia , Adulto , Anastomose Cirúrgica , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/mortalidade , Aneurisma Dissecante/fisiopatologia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Aneurisma da Aorta Torácica/fisiopatologia , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Paraparesia/etiologia , Paraparesia/prevenção & controle , Paraplegia/etiologia , Paraplegia/prevenção & controle , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Procedimentos Cirúrgicos Reconstrutivos/mortalidade , Fluxo Sanguíneo Regional , Estudos Retrospectivos , Fatores de Risco , Isquemia do Cordão Espinal/diagnóstico , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/mortalidade , Isquemia do Cordão Espinal/fisiopatologia , Artérias Torácicas/diagnóstico por imagem , Artérias Torácicas/fisiopatologia , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento
15.
J Vasc Surg ; 64(2): 289-296, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26994955

RESUMO

OBJECTIVE: Intercostal artery (ICA) reimplantation (ICAR) is thought to decrease spinal cord injury (SCI) in thoracic aortic aneurysm and thoracoabdominal aortic aneurysm (TAAA) surgery. Patients treated from 1989 to 2005 without ICAR were compared with those treated from 2005 to 2013 with ICAR to determine whether ICAR reduced SCI. We hypothesized that ICAR would reduce SCI, especially in the highest-risk patients. METHODS: This was a retrospective analysis using a prospectively maintained Investigational Review Board-approved database from a university tertiary referral center. The analysis included all patients (n = 805) undergoing thoracic aortic aneurysm and TAAA surgery from 1989 to 2013. The main outcome measure was any transient or permanent paraplegia or paraparesis (SCI). From 1989 to 2004, ICAR was not performed in patients, and open ICAs were ligated; from 2005 to 2013, open ICAs at T7 to L2 were reimplanted in patients with Crawford type I, II, and III TAAAs. Surgical technique was cross clamp without assisted circulation. Anesthetic management was the same from 1989 to 2013. Demographic, intraoperative, and outcome variables were assessed by univariate and multivariate analysis. Observed/expected ratios for paralysis were calculated. RESULTS: A total of 540 patients had surgery before 2005, and 265 had surgery after 2005, when ICAR was begun. There were 275 type I, II, and III TAAAs before 2005 and 164 after 2005. Aneurysm extent, acuity, SCI, mortality, renal failure, and pulmonary failure were the same in patients treated before and after 2005. Multivariate modeling of all patients showed type II TAAA (P = .0001), dissection (P = .00015), and age as a continuous variable (P = .0085) were significant for SCI. Comparing only type I, II, and III TAAAs, there was no difference in SCI between those with ICAR after 2005 and those without ICAR before 2005 (5.1% vs 8.8%; P = .152). In a subanalysis of the highest-risk patients (type II, dissection, acute), ICAR was not significant (P = .27). Observed/expected ratios ratios were 0.23 before 2005 and 0.16 after 2005 (χ2 = .796; P = .37). CONCLUSIONS: Although there was a small decrease in SCI with ICAR, reattaching ICAs did not produce a statistically significant reduction in SCI, even in the highest-risk patients.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/métodos , Reimplante , Traumatismos da Medula Espinal/prevenção & controle , Artérias Torácicas/cirurgia , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Implante de Prótese Vascular/efeitos adversos , Distribuição de Qui-Quadrado , Bases de Dados Factuais , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Paraparesia/etiologia , Paraparesia/fisiopatologia , Paraparesia/prevenção & controle , Paraplegia/etiologia , Paraplegia/fisiopatologia , Paraplegia/prevenção & controle , Reimplante/efeitos adversos , Reimplante/mortalidade , Estudos Retrospectivos , Fatores de Risco , Traumatismos da Medula Espinal/etiologia , Traumatismos da Medula Espinal/mortalidade , Traumatismos da Medula Espinal/fisiopatologia , Centros de Atenção Terciária , Fatores de Tempo , Resultado do Tratamento , Wisconsin
16.
J Vasc Surg ; 63(6): 1458-65, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-26968081

RESUMO

OBJECTIVE: Transient and permanent paraparesis and paraplegia (spinal cord injury [SCI]) are reported in up to 13% of patients undergoing thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm, thoracoabdominal aortic aneurysm, and thoracic aortic dissection. We hypothesize that aggressive intraoperative and postoperative neuroprotective interventions prevent or significantly reduce all SCI in TEVAR. METHODS: Using a prospectively maintained, Institutional Review Board-approved database, we retrospectively reviewed all TEVARs performed in a university tertiary referral center from 2005 to 2014 to study the incidence of all transient and permanent lower extremity SCI. Only TEVARs for traumatic aortic tear were excluded. Arch debranching and carotid subclavian bypass were performed before TEVAR in patients with arch involvement. All patients had moderate systemic hypothermia (34°C), mean arterial pressure ≥90 mm Hg, and hemoglobin ≥10 g/dL. Patients received mannitol (12.5 g), methylprednisolone (30 mg/kg), and naloxone (1 µg/kg/h). Patients in whom >12 cm of aortic coverage was planned had spinal fluid drained to a pressure of <8 mm Hg intraoperatively and postoperatively until normal leg strength was confirmed. The main outcome measure was transient or permanent SCI. RESULTS: One hundred fifty-five patients had TEVAR between 2005 and 2014. Mean age was 74 years, and 56.1% were male. Descending thoracic aortic aneurysm was present in 91.6%, thoracoabdominal aortic aneurysm in 8.4%, and dissection in 28.8%. Presentation was acute in 42.5%. The procedure included carotid-subclavian bypass in 18.7% of patients. Seventy-two percent of patients had spinal fluid drainage. Mean aortic coverage was 25 cm. Eighty-one percent of patients had >12 cm aortic coverage, and 49% had complete coverage of the thoracic aorta (coverage from subclavian to celiac artery). In-hospital mortality was 1.94%. Stroke occurred in 1.32% of patients. No patient had renal failure. SCI occurred in 0.65% (1 of 154) of patients. CONCLUSIONS: SCI in TEVAR can be significantly reduced by using proactive intraoperative and postoperative neuroprotective interventions that prolong spinal cord ischemic tolerance and increase spinal cord perfusion and oxygen delivery.


Assuntos
Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Drenagem/métodos , Procedimentos Endovasculares/efeitos adversos , Hipotermia Induzida , Cuidados Intraoperatórios/métodos , Traumatismos da Medula Espinal/prevenção & controle , Isquemia do Cordão Espinal/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/fisiopatologia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/fisiopatologia , Pressão Arterial , Criança , Pré-Escolar , Bases de Dados Factuais , Drenagem/efeitos adversos , Feminino , Humanos , Hipotermia Induzida/efeitos adversos , Lactente , Recém-Nascido , Cuidados Intraoperatórios/efeitos adversos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Paraparesia/etiologia , Paraparesia/prevenção & controle , Paraplegia/etiologia , Paraplegia/prevenção & controle , Cuidados Pós-Operatórios/métodos , Fluxo Sanguíneo Regional , Estudos Retrospectivos , Fatores de Risco , Traumatismos da Medula Espinal/diagnóstico , Traumatismos da Medula Espinal/etiologia , Traumatismos da Medula Espinal/fisiopatologia , Isquemia do Cordão Espinal/diagnóstico , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/fisiopatologia , Punção Espinal , Fatores de Tempo , Resultado do Tratamento , Wisconsin , Adulto Jovem
17.
Ann Neurol ; 79(4): 636-45, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26841128

RESUMO

OBJECTIVE: Motor evoked potentials (MEPs) monitoring can promptly detect spinal cord ischemia (SCI) from aortic clamping during open thoracoabdominal aneurysm repair (OTAAR) with distal aortic perfusion (DAP) and thus help decrease the risk of immediate postoperative SCI (IP-SCI). However, neither stable MEPs during aortic clamp interval (ACI) nor absence of IP-SCI eliminate the possibility of delayed postoperative SCI (DP-SCI). We hypothesized that extension of MEPs monitoring beyond ACI can also help decrease the risk of DP-SCI. METHODS: We identified 150 consecutive patients at our institution between April 2005 and October 2014 who underwent OTAAR with DAP and MEPs monitoring and had no IP-SCI. Using logistic regression analysis, we studied the independent effect of extended MEPs monitoring on the risk of developing DP-SCI. We used a propensity score analysis to adjust for potential confounders, such as poorly controlled hypertension, previous aneurysm surgery, splenectomy, acute aortic dissection, aneurysm type, older age, and history of diabetes and smoking. RESULTS: From the 150 patients, 129 (86%) remained neurologically intact whereas 21 (14%) developed DP-SCI. Nineteen of these twenty-one patients (90%) had no extended monitoring. Fifty-seven of fifty-nine (97%) patients who benefited from extended monitoring had no DP-SCI (p = 0.003). Extended MEPs monitoring was independently associated with decreased risk of DP-SCI (odds ratio = 0.14; 95% confidence interval: 0.03, 0.65; p = 0.01). INTERPRETATION: MEPs detect the lowest systemic blood pressure that ensures appropriate spinal cord perfusion in the postoperative period. Thus, they inform the hemodynamic management of patients post-OTAAR, particularly in the absence of a reliable neurological exam.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Potencial Evocado Motor/fisiologia , Monitorização Neurofisiológica/métodos , Paraplegia/prevenção & controle , Complicações Pós-Operatórias/diagnóstico , Isquemia do Cordão Espinal/diagnóstico , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Paraplegia/etiologia , Complicações Pós-Operatórias/etiologia , Isquemia do Cordão Espinal/etiologia , Resultado do Tratamento
18.
World Neurosurg ; 88: 695.e11-695.e14, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26748170

RESUMO

BACKGROUND: Paraplegia after intracranial aneurysmal subarachnoid hemorrhage (SAH) is a rare condition, and its pathogenesis is still unclear. CASE DESCRIPTION: We present a case of a ruptured basilar dissecting aneurysm treated with the stent-assisted coiling procedure. Progressive weakness of the lower limbs developed within 5 days postoperatively. Spinal magnetic resonance image showed SAH accumulation in the lumbosacral area. Emergency lumbar drainage was performed, and the patient's symptoms improved dramatically. CONCLUSIONS: To the best of our knowledge, this is the first report to describe the successful treatment of paraplegia after intracranial aneurysmal SAH.


Assuntos
Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/cirurgia , Paraplegia/etiologia , Paraplegia/prevenção & controle , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/cirurgia , Doença Aguda , Adulto , Drenagem/métodos , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico , Paraplegia/diagnóstico , Doenças Raras/diagnóstico , Doenças Raras/etiologia , Doenças Raras/prevenção & controle , Hemorragia Subaracnóidea/diagnóstico , Resultado do Tratamento
19.
Semin Thorac Cardiovasc Surg ; 28(2): 221-237, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-28043422

RESUMO

The primary risks associated with thoracoabdominal aortic aneurysm (TAAA) repair-namely operative death, paraplegia, and renal failure necessitating dialysis-are commonly related to the distal ischemia that occurs during aortic clamping and the disruption of vital branching arteries. Our technique for open TAAA repair has evolved over the course of 3 decades, from the unheparinized, simple "clamp-and-sew" approach learned directly from E. Stanley Crawford himself to a contemporary, multimodal strategy that uses an array of surgical adjuncts. Today, our approach to TAAA repair is largely standardized and based on the Crawford extents of TAAA repair, but we have maintained flexibility to explore new techniques and to adapt to the specific needs of patients. To protect the spinal cord, we routinely use mild passive hypothermia, cerebrospinal fluid drainage, left heart bypass, and reimplantation of crucial intercostal or lumbar arteries. The renal arteries are perfused with cold solution to protect the kidneys from ischemic damage, and the celiac axis and superior mesenteric artery are perfused with isothermic blood from the left heart bypass circuit, which minimizes the duration of abdominal-organ ischemia. The most extensive repair, Crawford extent II repair, typically replaces the aorta from just beyond the left subclavian artery to the aortic bifurcation; unsurprisingly, it commonly poses greater operative risk than do less extensive TAAA repairs (extent I, III, and IV). Subsequently, most surgical adjuncts used today were developed to ameliorate risk in extent II repair. Here, we provide a detailed description of our approach to open extent II TAAA repair.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/métodos , Anestesia Geral , Aneurisma da Aorta Torácica/diagnóstico por imagem , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Constrição , Humanos , Paraplegia/etiologia , Paraplegia/prevenção & controle , Posicionamento do Paciente , Perfusão , Desenho de Prótese , Insuficiência Renal/etiologia , Insuficiência Renal/prevenção & controle , Fatores de Tempo , Resultado do Tratamento
20.
Semin Thorac Cardiovasc Surg ; 28(2): 378-387, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-28043447

RESUMO

The objective of this study was to investigate the functional differences between paraspinal and intraspinal compartments of the spinal collateral network and the importance of circular epidural arcades in thoracic aortic surgery. N = 33 pigs (mean body weight: 34 ± 3kg) were included. A single-inlet-model of spinal collateral flow was created: paraspinal inflow into the collateral network was isolated by cephalad and caudal interruption of inflow into epidural arcades using laminectomies. Animals were assigned to treatment groups (Treatment "open" [patent epidural arcades, n = 10] and Treatment "closed" [closed epidural arcades, n = 10]) and Sham groups (Sham "open" n = 8 and Sham "closed" n = 5). Treatment was a simulated Frozen Elephant Trunk procedure with occlusion of left subclavian and thoracic segmental arteries under mild permissive hypothermia. Observation time was 3 hours. Endpoints were motor and somatosensory evoked potentials (motor evoked potentials and sensory evoked potentials), spinal cord perfusion pressure, cerebrospinal fluid pressure, regional spinal cord blood flow, and neurologic outcome. Animals with interrupted inflow into epidural arcades (Group Treatment "closed") had higher cerebrospinal fluid pressure levels (P < 0.05), were not able to maintain sufficient spinal cord perfusion pressure during Frozen Elephant Trunk procedure (P < 0.001) and did not generate reactive hyperemia as did group Treatment "open." spinal cord blood flow was strongly decreased in group Treatment "closed" (P < 0.001) at 0 hour, did not recover out to 3 hours of observation and 90% of the animals suffered flaccid paraplegia (P < 0.05). Immediate spinal cord backup blood flow is almost exclusively delivered using the system of epidural arcades in the immediate setting, serving as an immediate backup system. Intraspinal arcades are responsible for generating sufficient intraspinal perfusion pressures, reactive hyperemia, and spinal cord integrity. Paraspinal collaterals might need to undergo arteriogenesis, and thus serve as a long-term backup system.


Assuntos
Aorta Torácica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Circulação Colateral , Espaço Epidural/irrigação sanguínea , Paraplegia/fisiopatologia , Isquemia do Cordão Espinal/fisiopatologia , Medula Espinal/irrigação sanguínea , Animais , Pressão do Líquido Cefalorraquidiano , Modelos Animais de Doenças , Potencial Evocado Motor , Potenciais Somatossensoriais Evocados , Hemodinâmica , Hiperemia/fisiopatologia , Monitorização Neurofisiológica Intraoperatória/métodos , Laminectomia , Masculino , Paraplegia/diagnóstico , Paraplegia/etiologia , Paraplegia/prevenção & controle , Fluxo Sanguíneo Regional , Medula Espinal/cirurgia , Isquemia do Cordão Espinal/diagnóstico , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/prevenção & controle , Suínos , Fatores de Tempo
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