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Prevention of spinal ischemia during repair of descending (DTA) or thoracoabdominal aortic aneurysms (TAA) Fabien Koskas, Julien Gaudric CHU Pitié-Salpêtrière,

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Présentation au sujet: "Prevention of spinal ischemia during repair of descending (DTA) or thoracoabdominal aortic aneurysms (TAA) Fabien Koskas, Julien Gaudric CHU Pitié-Salpêtrière,"— Transcription de la présentation:

1 Prevention of spinal ischemia during repair of descending (DTA) or thoracoabdominal aortic aneurysms (TAA) Fabien Koskas, Julien Gaudric CHU Pitié-Salpêtrière, Paris, France

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6 Ischémie médullaire Clampage médullaire Hémodynamique Hyperpression LCR Hypoxie PROTECTION MEDULLAIRE

7 Ischémie médullaire Clampage médullaire PROTECTION MEDULLAIRE Identification groupes à risque Clampage court <30mn Identification et réimplantation de lA. dAdamkiewicz Diminution métabolisme médullaire Hypothermie profonde / péridurale Perfusion aortique distale CEC/shunts Artifices techniques Potentiels évoqués somesthésiques/moteur Pharmacologie (papavérine intrathécale etc…)

8 Contrôle tensionnel per op -clampage proximal -déclampage CEC Contrôle tensionnel post-op Paraplégies 2 aires Contrôle pertes sanguines Cell saver, récupérateurs Ischémie médullaire Clampage médullaire Hémodynamique PROTECTION MEDULLAIRE

9 Oxygénateur/CEC PaO 2 post op Ischémie médullaire Clampage médullaire Hémodynamique Hypoxie PROTECTION MEDULLAIRE exclusion pulm G

10 Drainage per et post opératoire Ischémie médullaire Clampage médullaire Hémodynamique Hyperpression LCR Hypoxie PROTECTION MEDULLAIRE

11 Personal experience Open surgery of DTA-TAA

12 Mechanisms of postoperative paraplegia after T(EV)AR Reversible intraoperative spinal ischemia Reperfusion injury –Breakdown of cellular membranes : edema –Spinal compression injury Irreversible spinal ischemia –Permanent suppression of the spinal blood supply by the aortic procedure –Thromboembolic events within the spinal blood supply Poor perioperative systemic hemodynamics

13 Vascularisation médullaire ASP ASA ASP Lazorthes G et al. Arterial vascularization of the spinal cord. J Neurosurg 1971;35: ADK: D8-L2=85% Si ADK

14 480 personal cases using exhaustive spinal angiograpy J Vasc Surg 2002;35:262-8.

15 Ann Vasc Surg 1989;3: AK > AK< AK = AK ?

16 Risk of paraplegia/paresis after open surgical repair of TAA Type%Class% I15Ak><10 II15-40Ak<<10 III10Ak=5-50* IV10Ak?50 *Depending upon spinal arterial reattachment Ann Vasc Surg 1989;3:34-46.

17 Spinal angiography & Results

18 Risk of paraplegia/paresis after endovascular repair Unknown Probably globally lesser than after open surgery –Selection bias –Better perioperative hemodynamics –Conservation of collateral pathways Very low, especially in the Ak> and Ak< groups Not null, especially whenever Ak= or Ak?

19 Spinal angio versus spinal imaging Exhaustive spinal angio (ESA) is our gold standard, especially for open surgery of TAAs II ESA is technically demanding, time consuming, expensive and invasive EVAR might require a less exhaustive evaluation : selective spinal imaging (SSI) With modern CT technology, more and more cases can benefit from SSI without the need of another acquisition than that necessary to document the aortic lesion* * Kawaharada et al. Eur J Cardiothorac Surg 2002;21: * Yoshioka K et al. Radiographics 2003;23:

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21 Principles of selective spinal imaging Explore all intercostal arteries to be covered by the stent-graft and adjacent With multislice CT (16 bit +), using the same acquisition as that taken for imaging the aortic lesion With sequential catheterization only in case of a failure Classify according to the result

22 Methods of spinal protection Spinal revascularization Distal perfusion Spinal or general hypothermia Spinal drainage Intrathecal or IV drugs –Papaverin, steroïds, calcium blockers, radical scavengers, barbiturates, naloxone, PGEI, allopurinol, oxygen carriers etc…

23 Spinal revascularization Systematic and blind Never Selective –Size, topography and backflow of intercostal arteries –Intra-operative monitoring (evoked potentials) –Pre-operative spinal angiography

24 Distal perfusion Improves the hemodynamic tolerance to cross-clamping Reduces the duration of visceral and spinal ischemia

25 Methods of distal perfusion Passive shunt Extra-anatomic bypass Active shunt Cardio-pulmonary bypass –Better control of flow –Better oxygen transfer –Better control of temperature –But necessitates high doses of heparin

26 Hypothermic circulatory arrest Visceral (and spinal) protection Avoids difficult or hazardous cross-clamping –Dissection –Redo surgery –Inflammatory aneurysm Eases the anastomosis by the use of an open technique But –Bleeding –Sub-optimal myocardial protection through thoracotomy among cardiac patients

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28 Methods

29 Syndrôme compartimental médullaire PPerf Med PA (aortique distale) -P (LCR) PA : lors du clampage proximal P (LCR) : à cause de loedeme médullaire par phénomene de non réabsorption Ne prend pas en compte les résistances artériolo capillaires P veineuse Delayed onset of neurological deficit:signifiance and management.HuynhT et al.Sem in Vasc Surg 2000 IschémieIschémie-Reperfusion PA P (LCR)

30 CSF drainage does not target any other mechanism of postoperative paraplegia

31 CSF drainage is useful at reducing post-ischemic compression injury 27.Miyamoto K, Ueno A, Wada T, Kimoto S. A new and simple method of preventing spinal cord damage following temporary occlusion of the thoracic aorta by draining the cerebrospinal fluid. J Cardiovasc Surg (Torino) 1960;1: Oka Y, Miyamoto T. Prevention of spinal cord injury after cross-clamping of the thoracic aorta. Jpn J Surg 1984;14: McCullough JL, Hollier LH, Nugent M. Paraplegia after thoracic aortic occlusion: influence of cerebrospinal fluid drainage. Experimental and early clinical results. J Vasc Surg 1988;7: Svensson LG, Grum DF, Bednarski M, et al. Appraisal of cerebrospinal fluid alterations during aortic surgery with intrathecal papaverine administration and cerebrospinal fluid drainage. J Vasc Surg 1990;11: Crawford ES, Svensson LG, Hess KR, et al. A prospective randomized study of cerebrospinal fluid drainage to prevent paraplegia after high-risk surgery on the thoracoabdominal aorta. J Vasc Surg 1991;13:36-45; discussion Woloszyn TT, Marini CP, Coons MS, et al. Cerebrospinal fluid drainage and steroids provide better spinal cord protection during aortic cross- clamping than does either treatment alone. Ann Thorac Surg 1990;49:78-82; discussion Safi HJ, Campbell MP, Ferreira ML, et al. Spinal cord protection in descending thoracic and thoracoabdominal aortic aneurysm repair. Semin Thorac Cardiovasc Surg 1998;10: Bethel SA. Use of lumbar cerebrospinal fluid drainage in thoracoabdominal aortic aneurysm repairs. J Vasc Nurs 1999;17: Coselli JS, LeMaire SA, Schmittling ZC, Koksoy C. Cerebrospinal fluid drainage in thoracoabdominal aortic surgery. Semin Vasc Surg 2000;13: Safi HJ, Miller CC, 3rd, Huynh TT, et al. Distal aortic perfusion and cerebrospinal fluid drainage for thoracoabdominal and descending thoracic aortic repair: ten years of organ protection. Ann Surg 2003;238:372-80; discussion And at reversing it in some cases Garutti I, Fernandez C, Bardina A, et al. Reversal of paraplegia via cerebrospinal fluid drainage after abdominal aortic surgery. J Cardiothorac Vasc Anesth 2002;16: And several unpublished personal cases

32 Etudes randomisées Caractéristiques communes Type détudes Randomisation du drainage du LCR en chirurgie aortique thoracique. Chirurgie ouverte seulement (endovasculaire) Patients ATA à haut risque (type I et II) Technique Drainage LCR par ponction lombaire Autres techniques de protection équivalentes dans les groupes cas et témoin : -CEC atriofémorale -réimplantation de lADK Objectif Mesure du taux de parésie/paraplégie postopératoire des membres inférieurs -Crawford (JVS, 1991) -Svensson (Annals of Thoracic Surg, 1998) -Coselli (JVS, 2002)

33 EtudeDrainageContrôle LCR vol/pression Drainage postop Crawford14/46 (30%)17/52 (33%)50mlNon Svensson2/17 (11,8%)7/16 (43,8%)7-10 cmH2O48h Coselli2/82 (2,7%)9/74 (12,2%)<10mmHg48h Etudes randomisées -Résultats-

34 Indications du drainage Indic drainage: -ATA I,II,III et IV si réimplantation ADK Quel matériel: -Kit drainage externe du LCR. Sophysa (Tuohy 14G, KT multiperforé 60cm, poche de recueuil)

35 Indications SSI positive –Spinal artery(ies) arising from aortic segment to be repaired –Adamkiewicz, MDA or SDA SSI negative –No spinal artery arising from aortic segment Surgical risk

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37 SSI negative No CSF drainage Endovascular or open repair in peace of mind

38 SSI positive Good surgical risk Ak / MDA or SDA with large territory Open surgery with reattachment of critical intercostal arteries using the best spinal protection methods available MDA or SDA with small territory Give objective information to patient If EVAR preferred, CSF drainage, spinal monitoring etc. Retrievable stent-graft* ? Ishimaru et al, J Thorac Cardiovasc Surg, 1998;115:811 Midorikawa et al. Jpn J Thorac Cardiovasc Surg 2000;48:761-8

39 SSI positive Poor surgical risk Give information to patient EVAR if feasible CSF drainage Careful monitoring of systemic blood pressure Retrievable stent-graft* under spinal monitoring ? * Midorikawa et al. Jpn J Thorac Cardiovasc Surg 2000;48:761-8 & personal unpublished designs

40 Personal results with EVAR Systematic ESA Only 66 TEVAR cases ( 612 EVAR cases in the same period ) One paraparesis in one hybrid one-stepped elephant trunk under hypothermic circulatory arrest No paraplegia

41 Conclusion Postoperative paraplegia remains a disaster for the patient and a medicolegal concern for surgeons and radiologists Given the low rates of paraplegia after DTA repair and the small number of patients in the series of TAA repair, efficiency of protective methods is difficult to demonstrate The availability of SSI using CT renders blind repair of DTA or TAA questionable


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