Spinal cord ischemia in open and endovascular thoracoabdominal aortic aneurysm repair: new concepts

TY - JOUR

T1 - Spinal cord ischemia in open and endovascular thoracoabdominal aortic aneurysm repair: new concepts

AU - Etz, D C

AU - Luehr, M

AU - Aspern, K V

AU - Misfeld, M

AU - Gudehus, S

AU - Ender, J

AU - Koelbel, T

AU - Debus, E S

AU - Mohr, F-W

PY - 2014/4

Y1 - 2014/4

N2 - For more than half a century ischemic spinal cord injury (SCI) and consecutively permanent paraplegia remained the most devastating complication after open and endovascular thoracoabdominal aortic aneurysm (TAAA) repair. Various neuroprotective strategies (e.g., motor-/somatosensory evoked potential monitoring and cerebrospinal fluid drainage) used as adjuncts have lowered the SCI; maybe most importantly, the modern collateral network (CN) has begun to replace the classic understanding of spinal cord blood supply implying several consequences. Reliable non-invasive tools to monitor cord perfusion to detect imminent spinal cord malperfusion, ischemia and forthcoming neurologic injury (particularly early postoperatively) is not available, neither is a reliable strategy to prevent ischemic injury during distal circulatory arrest and after segmental artery occlusion. Currently, two promising new concepts--potentially advancing spinal protection in open and endovascular TAAA repair--address these issues: 1) non-invasive real-time monitoring of the paraspinous CN-oxygenation via near-infrared spectroscopy (NIRS) as an alternative to the demanding direct neuromonitoring; and 2) preconditioning of the CN as minimally invasive, endovascular "first stage" to increase the resilience of spinal cord perfusion prior to definite aortic repair. This article illustrates both concepts discussing: 1) the clinical application of thoracic and lumbar collateral NIRS monitoring to indirectly detect spinal cord hypoperfusion; and 2) minimally invasive selective segmental artery coil-embolization (MISACE) for (arteriogenic) preconditioning of the CN prior to extensive open or endovascular staged TAAA repair.

AB - For more than half a century ischemic spinal cord injury (SCI) and consecutively permanent paraplegia remained the most devastating complication after open and endovascular thoracoabdominal aortic aneurysm (TAAA) repair. Various neuroprotective strategies (e.g., motor-/somatosensory evoked potential monitoring and cerebrospinal fluid drainage) used as adjuncts have lowered the SCI; maybe most importantly, the modern collateral network (CN) has begun to replace the classic understanding of spinal cord blood supply implying several consequences. Reliable non-invasive tools to monitor cord perfusion to detect imminent spinal cord malperfusion, ischemia and forthcoming neurologic injury (particularly early postoperatively) is not available, neither is a reliable strategy to prevent ischemic injury during distal circulatory arrest and after segmental artery occlusion. Currently, two promising new concepts--potentially advancing spinal protection in open and endovascular TAAA repair--address these issues: 1) non-invasive real-time monitoring of the paraspinous CN-oxygenation via near-infrared spectroscopy (NIRS) as an alternative to the demanding direct neuromonitoring; and 2) preconditioning of the CN as minimally invasive, endovascular "first stage" to increase the resilience of spinal cord perfusion prior to definite aortic repair. This article illustrates both concepts discussing: 1) the clinical application of thoracic and lumbar collateral NIRS monitoring to indirectly detect spinal cord hypoperfusion; and 2) minimally invasive selective segmental artery coil-embolization (MISACE) for (arteriogenic) preconditioning of the CN prior to extensive open or endovascular staged TAAA repair.

KW - Aortic Aneurysm, Thoracic/diagnosis

KW - Blood Vessel Prosthesis Implantation/adverse effects

KW - Collateral Circulation

KW - Embolization, Therapeutic

KW - Endovascular Procedures/adverse effects

KW - Hemodynamics

KW - Humans

KW - Monitoring, Intraoperative/methods

KW - Paraplegia/diagnosis

KW - Regional Blood Flow

KW - Risk Factors

KW - Spectroscopy, Near-Infrared

KW - Spinal Cord/blood supply

KW - Spinal Cord Ischemia/diagnosis

KW - Treatment Outcome

M3 - SCORING: Review article

C2 - 24796909

VL - 55

SP - 159

EP - 168

JO - J CARDIOVASC SURG

JF - J CARDIOVASC SURG

SN - 0021-9509

IS - 2 Suppl 1

ER -