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The Annals of Thoracic Surgery, Vol 36, 417-426, Copyright © 1983 by The Society of Thoracic Surgeons
JC Laschinger, JN Cunningham Jr, IM Nathan, EA Knopp, MM Cooper and FC Spencer
We studied both experimentally and clinically the efficacy of partial
bypass techniques in maintaining spinal cord blood flow and physiological
function during surgical procedures on the thoracoabdominal aorta. We
attempted to define the level of distal aortic pressure required to safely
ensure normal neurological function in the absence of critical intercostal
occlusion. Six dogs underwent left thoracotomy with baseline measurements
of spinal cord blood flow and spinal cord impulse conduction (somatosensory
evoked potentials). Following exclusion of the entire descending thoracic
aorta from the left subclavian artery to the T-13 level, partial left
atrium-femoral artery bypass was instituted, and baseline levels of
proximal and distal aortic pressure were maintained during a 30-minute
stabilization period. Mean distal aortic pressure then was progressively
altered at 30-minute intervals to 100, 70, and 40 mm Hg. Measurements of
spinal cord blood flow and somatosensory evoked potential were repeated at
the end of each interval for comparison with baseline. No significant
changes in spinal cord blood flow or somatosensory evoked potential were
observed in any animal with a distal aortic pressure greater than or equal
to 70 mm Hg. With a pressure of 40 mm Hg, normal flow and somatosensory
evoked potentials were maintained in 5 of the 6 dogs. Loss of somatosensory
evoked potential, with simultaneous loss of spinal cord blood flow at the
T-6 level, occurred in 1 dog. Restoration of distal aortic pressure to 70
mm Hg in all animals resulted in immediate return of somatosensory evoked
potential. Loss of somatosensory evoked potential routinely occurred in
animals with a distal aortic pressure less than 40 mm Hg. Clinically, 9
patients have undergone operation for lesions of the thoracoabdominal aorta
using shunt or bypass techniques. Normal somatosensory evoked potentials
were preserved in 7 patients with maintenance of adequate distal aortic
pressure (greater than or equal to 60 mm Hg) without evidence of
postoperative neurological deficit. Two patients showed hypotensive
somatosensory evoked potential loss (distal aortic pressure less than 40 mm
Hg). Prolonged distal hypotension (85 minutes of aortic cross- clamping) in
the latter resulted in paraplegia. We conclude that maintenance of a distal
aortic pressure greater than 60 to 70 mm Hg will uniformly preserve spinal
cord blood flow in the absence of critical intercostal exclusion. Should
distal aortic pressure be inadequate, early reversible changes in the
somatosensory evoked potential will alert the surgeon. Failure to institute
measures to reverse these changes may result in paraplegia.
ARTICLES
Experimental and clinical assessment of the adequacy of partial bypass in maintenance of spinal cord blood flow during operations on the thoracic aorta
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