Cerebrospinal fluid drainage in thoracoabdominal aortic surgery

Paraplegia caused by spinal cord ischemia remains a devastating complication after surgical repair of thoracoabdominal aortic aneurysms. Cerebrospinal fluid (CSF) drainage has been advocated as a protective adjunct to reduce the incidence of postoperative neurologic deficits. Studies in animals have shown that CSF drainage during thoracic aortic clamping reduces CSF pressure, improves spinal cord blood flow, and prevents paraplegia. Previous retrospective and randomized clinical studies, however, have been inconclusive because of confounding factors and other limitations. A recent prospective randomized trial focusing solely on CSF drainage during repair of extent I and II thoracoabdominal aortic aneurysms indicated an 80% reduction in the relative risk of paraplegia and paraparesis in patients who received this adjunct. Consequently, CSF drainage has emerged as an important addition to the multimodality strategy for preventing postoperative spinal cord deficits.     

Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial

OBJECTIVE: Despite the use of various strategies for the prevention of spinal cord ischemia, paraplegia and paraparesis continue to occur after thoracoabdominal aortic aneurysm (TAAA) repair. Although cerebrospinal fluid drainage (CSFD) is often used as an adjunct for spinal cord protection, its benefit remains unproven. The purpose of this randomized clinical trial was to evaluate the impact of CSFD on the incidence of spinal cord injury after extensive TAAA repair. METHODS: After randomization, 145 patients underwent extent I or II TAAA repairs with a consistent strategy of moderate heparinization, permissive mild hypothermia, left heart bypass, and reattachment of patent critical intercostal arteries. The repairs were performed with CSFD (n = 76) or without CSFD (n = 69). In the former group, CSFD was initiated during the operation and continued for 48 hours after surgery. The target CSF pressure was 10 mm Hg or less. RESULTS: The two groups had similar risk factors for paraplegia. Aortic clamp time, left heart bypass time, and number of reattached intercostal arteries were also similar in both groups. Thirty-day mortality rates were 5.3% (four patients) and 2.9% (two patients) for CSFD and control groups, respectively (P =.68). Nine patients (13.0%) in the control group had paraplegia or paraparesis develop. In contrast, only two patients in the CSFD group (2.6%) had deficits develop (P =.03). No patients with CSFD had immediate paraplegia. Overall, CSFD resulted in an 80% reduction in the relative risk of postoperative deficits. CONCLUSION: Perioperative CSFD reduces the rate of paraplegia after repair of extent I and II TAAAs.     

脑脊液引流在胸降及胸腹主动脉瘤腔内修复术中对截瘫的预防保护

目的:探讨脑脊液引流在胸降、胸腹主动脉瘤腔内修复术中对截瘫的预防保护作用。方法:回顾性分析我科于2007年9月至2009年12月期间的32例胸降、胸腹主动脉瘤行腔内修复术病人,在术中及术后予以脑脊液引流的效果。结果:所有病人痊愈出院,随访1个月~1年。4例病人术后出现轻瘫症状,经脑脊液引流后治愈;其余病人围手术期间及随访期间未出现截瘫表现,治疗期间无严重并发症。结论:脑脊液引流可在胸降、胸腹主动脉瘤腔内修复术中有效地预防及治疗轻瘫及截瘫。     

Systematic review of motor evoked potentials monitoring during thoracic and thoracoabdominal aortic aneurysm open repair surgery: a diagnostic meta-analysis

Motor evoked potential (MEP) monitoring has been used to prevent neurological complications such as paraplegia in patients who underwent thoracic or thoracoabdominal aortic aneurysm (TAA/TAAA) surgery. The object of this study was making a systematic review to survey the performance of MEP monitoring during TAA/TAAA open repair surgery. We searched electronic databases for relevant studies. We summarized the diagnostic data with summary sensitivity, summary specificity and forest plots of pooled sensitivity, and conducted sub-group analysis. The quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. We also surveyed the reporting rate of clinical key factors such as methods of anesthesia, surgery, and success rate of MEP. Nineteen studies met our criteria. The results of meta-analysis showed 89.1 % summary sensitivity (95 % confidence interval 47.9–98.6 %) and 99.3 % summary specificity (95 % confidence interval 96.1–99.9 %). Sub-group analysis of pooled sensitivity and specificity by all-or-none cut-off point were better than other cut-off points. The results of the QUADAS-2 were not good. The performance of MEP monitoring was good for detecting postoperative paraplegia in TAA/TAAA open repair surgery. The cut-off point of all-or-none may be the best, according to our review.     

Reversal of delayed-onset paraplegia after thoracic aortic surgery with cerebrospinal fluid drainage

We report two patients who had postoperative reversal of delayed-onset paraplegia after cerebrospinal fluid (CSF) drainage after type I thoracoabdominal aneurysm repair. CSF drainage was not initiated before operation because of the urgent presentation of both patients. Decompression of the spinal canal by CSF drainage may improve spinal cord circulation in certain patients and may avoid or decrease neurologic injury. In view of the low morbidity of this intervention, we recommend routine CSF drainage during elective repair of thoracic and thoracoabdominal aneurysms. (J VASC SURG 1994;20:315-7.)     

Prevention of postoperative paraplegia during thoracoabdominal aortic surgery

BACKGROUND: We present data showing the impact of sequential multisegmental aortic clamping accompanied by reimplantation of as many segmental arteries as possible on the prevention of postoperative paraplegia or paraparesis during thoracoabdominal aortic graft replacement. METHODS: Since 1987 we have performed graft replacements in 51 individuals undergoing thoracoabdominal aortic surgery using the technique of normothermic partial bypass with sequential multisegmental aortic clamping. The procedure was performed emergently in 10 patients and electively in 41 patients. The patients ranged in age from 22 to 82 years (mean, 57.6 +/- 13.8 years). Indications for surgery included dissecting thoracoabdominal aortic aneurysm (n = 19) and nondissecting thoracoabdominal aortic aneurysm (n = 32). The extent of aneurysm was Crawford type I in 19 patients, type II in 7 patients, type III in 12 patients, and type IV in 13 patients. Along the entire extent of aneurysm to be replaced, we reimplanted as many of the patent segmental arteries as feasible. RESULTS: Five patients died during hospitalization, for an in-hospital mortality rate of 9.8%. The number of aortic clampings per patient ranged from one to five (median, three). A total of 124 segmental arteries were reimplanted in 44 (86.3%) of 51 patients. Of the 124 arteries, 90 (72.6%) were distributed between T9 and L2. Postoperative paraplegia or paraparesis did not develop in any of the patients. CONCLUSIONS: Our results demonstrate that extensive reimplantation of segmental arteries using sequential multisegmental aortic clamping, accompanied by adequate intraoperative distal aortic perfusion, is effective in preventing spinal cord ischemia.     

Transient paraplegia after stent grafting of a descending thoracic aortic aneurysm treated with cerebrospinal fluid drainage

We present a case of descending thoracic aortic aneurysm repair using an endovascular stent graft, complicated by postoperative paraplegia, which was successfully treated by placing a spinal drain. The case highlights the importance of the concept of collateral flow to the spinal cord and of choosing an anesthetic technique that allows immediate postoperative evaluation of lower extremity neurologic function.     

Cerebrospinal fluid drainage and distal aortic perfusion: Reducing neurologic complications in repair of thoracoabdominal aortic aneurysm types I and II

Purpose: This study was conducted to evaluate the role of cerebrospinal fluid (CSF) drainage and distal aortic perfusion (DAP) in the prevention of postoperative neurologic complications for high-risk patients who had undergone type I and type II thoracoabdominal aortic aneurysm (TAAA) repair.Methods: CSF drainage and DAP were used as an adjunct in the treatment of 94 patients with TAAA (31 type I, 63 type II) between September 1992 and December 1994; 67 were men and 27 were women. The median age was 64 years (range, 28 to 88 years). Aortic dissection occurred in 35 of 94 patients (37%). Thirty-six of 94 patients (38%) had previously undergone proximal aortic surgery. All patients underwent intraoperative DAP and perioperative CSF drainage. Median aortic cross-clamp time was 67 minutes (range, 20 to 131 minutes).Results: The 30-day survival rate was 90% (85 of 94 patients). Early neurologic complications occurred in 5 of 94 patients (5%), and late neurologic complications occurred in 3 of 94 patients (3%). We compared the neurologic complications of our current group of 94 patients with the data from 42 patients (control group) who also underwent repair of TAAA type I and type II with only simple cross-clamp and without CSF drainage or DAP. Both groups were treated by the senior author (HJS) at the same institution. Total neurologic complications for the current group occurred in 8 of 94 patients (9%) versus 8 of 42 patients (19%) for the control group ( p = 0.090). Neurologic complications for patients with type II TAAA occurred in 8 of 63 patients (13%) versus 17 of 42 patients (41%) ( p = 0.014). For all patients with aortic clamp times ≥45 minutes, neurologic complications occurred in 7 of 55 (13%) versus 7 of 18 (39%) ( p = 0.033).Conclusion: The period of risk during aortic cross-clamp time is reduced with the adjuncts of CSF drainage and DAP, which significantly lower the incidence of neurologic complications after repair of TAAA types I and II. (J VASC SURG 1996;23:223-9.)     

A prospective randomized study of cerebrospinal fluid drainage to prevent paraplegia after high-risk surgery on the thoracoabdominal aorta

This article is concerned with the study of the effect of several variables, principally that of cerebrospinal fluid drainage, on the incidence of neurologic deficit in a prospective randomized series of patients with extensive aneurysms of the descending thoracic and abdominal aorta (thoracoabdominal type I and II). Forty-six patients had cerebrospinal fluid drainage, and 52 were controls, with a total of 98 available for study. Cerebrospinal fluid pressure was continuously monitored in the former group and pressure maintained less than or equal to 10 mm Hg in 20, less than or equal to 15 mm Hg in 20, and greater than 15 mm Hg in 6 patients during period of aortic clamping. The method of treatment including reattachment of intercostal and lumbar arteries (p = 0.2), temporary atriofemoral bypass during aortic occlusion (p = 0.3), and spinal fluid drainage (p = 0.8) were not statistically significant in reducing the incidence of neurologic deficits. Thus cerebrospinal fluid drainage as we used it, was not beneficial in preventing paraplegia. On appropriate statistical analysis we found that the only significant predictor of delayed deficits was postoperative hypotension (p = 0.006).     

Cefamandole levels during thoracoabdominal aortic aneurysm surgery

The pharmacokinetics of prophylactic antibodies may differ in cardiac and aortic aneurysm surgery for at least two reasons: aortic aneurysm surgery generally entails a greater blood volume loss and replacement, and aortic aneurysm surgery usually does not require extracorporeal cardiopulmonary bypass. We prospectively studied two different cefamandole dosing regimens in patients undergoing aortic aneurysm surgery (phase 1, 1 gm intravenously at the induction of anesthesia; phase 2, 2 gm intravenously at the induction of anesthesia followed by 1 gm intravenously every 2 hours during surgery). In phase 1 and 2 plasma levels were measured at the time of skin incision, aortic cross-clamping, aortic unclamping, and skin closure. In phase 2 cefamandole elimination in urine and cell-saver effluent was also determined. An adequate plasma level of 10 micrograms/ml was maintained in only 4 of 14 patients in phase 1, but in 10 of 10 patients in phase 2. Cefamandole loss in cell-saver effluent was 136 +/- 100 mg, which was 13% of the measured renally excreted amount. As has been previously shown in cardiac surgery, a cefamandole prophylactic antibiotic regimen of 2 gm intravenously at the induction of anesthesia followed by 1 gm every 2 hours during surgery provides a dependable and practical dosing regimen in patients undergoing aortic aneurysm surgery.     

Complications of cerebrospinal fluid drainage in thoracoabdominal aortic aneurysm repair

Spinal cord ischemia resulting in postoperative paraplegia is a devastating complication of thoracoabdominal aortic aneurysm repair, and has been attributed to many causes. To prevent spinal cord compartment syndrome, cerebrospinal fluid drainage has been used as an adjunct to thoracoabdominal aortic aneurysm repair, with procedure-related complications generally occurring infrequently. We present two case reports of serious complications from CSF drainage.     

Delayed paraplegia after thoracic and thoracoabdominal aneurysm repair: a continuing risk

BACKGROUND: Paraplegia or paraparesis after otherwise successful thoracic or thoracoabdominal aortic reconstruction is a devastating complication for patient and physician. Interventions for its prevention have focused primarily on the intraoperative period. We have recently noted a significant incidence of delayed-onset neurologic deficit. METHODS: We reviewed our most recent 5-year experience with thoracic and thoracoabdominal reconstruction to examine the incidence of and potential contributors to delayed paraplegia or paraparesis. RESULTS: Between June 1996 and June 2001, 60 patients (29 men, 31 women) underwent repair of isolated thoracic (n = 26) or thoracoabdominal aortic aneurysm (Crawford I, n = 7; Crawford II, n = 14; Crawford III, n = 12; Crawford IV, n = 1) by the cardiac and vascular surgical services collaboratively. Repair was performed endovascularly in 6, and open with either circulatory arrest in 12, partial left heart bypass in 37, or partial femorofemoral bypass in 5. Operative mortality was 9.3% (5 of 54 patients) for open repair and 0% for endovascular repair. Paraplegia or paraparesis occurred in 6 (10%) patients of which 83.3% (5 of 6) were delayed in onset. All patients with delayed paraplegia or paraparesis had degenerative aneurysms of Crawford extent II (n = 3) or III (n = 2), had intraoperative left heart bypass, and had perioperative spinal drainage. Delayed paraplegia or paraparesis occurred up to 27 days postoperatively, and was associated with a documented episode of hypotension in 60% (3 of 5) of patients. CONCLUSIONS: Improvements in intraoperative management may have reduced immediate paraplegia or paraparesis among vulnerable patients only to leave them at risk of delayed-onset deficit. Postoperative care, including assiduous attention to avoidance of even transient hypotension, must be tailored to this patient population.     

Cerebrospinal fluid drainage to treat delayed paraplegia after stent grafting of the descending thoracic aorta

Delayed onset of paraplegia secondary to spinal cord ischemia is a rare but serious complication that can appear after endovascular repair of an aneurysm in the descending thoracic aorta, although this complication is significantly less frequent after stent grafting than after conventional surgical repair. We report the case of a man who developed paraplegia 36 hours after insertion of 4 stents in the descending thoracic aorta. The paraplegia reversed after a spinal catheter was placed to monitor cerebrospinal fluid pressure and to provide drainage.