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Ann Thorac Surg 2002;74:83-89
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Open stent-grafting for aortic arch aneurysm is associated with increased risk of paraplegia

^a Department of Cardiothoracic Surgery, University of Tokyo, Tokyo, Japan

Accepted for publication March 12, 2002.

* Address reprint requests to Dr Miyairi, Department of Cardiovascular Surgery, Mitsui Memorial Hospital, 1 Kandaizumi-cho Chiyoda-ku, Tokyo 101-8643, Japan
e-mail: tmiyairi-tky{at}umin.ac.jp

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Open surgery using the endovascular stent-graft is a novel technique that lessens the invasiveness of surgery for the aortic arch. However, the outcome of this procedure remains uncertain.

Methods. Between November 1996 and July 2000, a total of 19 patients underwent open surgery using an endovascular stent-graft for thoracic aortic aneurysms. There were 15 men (78.9%) and 4 women (21.1%). Patient age ranged from 29 to 82 years (mean 69.3 years, median 74 years). Atherosclerotic thoracic aortic aneurysms were present in 17 patients (89.4%) and aortic dissection in 2 patients (10.5%).

Results. Two patients (10.5%) died in the hospital and 4 patients (21.1%) presented with paraplegia postoperatively. Among the 4 patients with postoperative paraplegia, 1 case was complicated with intraoperative aortic dissection. The other 3 patients with paraplegia had spinal cord ischemic time of more than 60 minutes and intraoperative body weight gain of more than 4 kg. Of these 3 patients, hemodynamic instability after cardiopulmonary bypass was observed in 1 patient and cholesterin embolus in the anterior spinal artery was found at autopsy in another. On univariate analysis, age greater than 75 years was the only risk factor associated with paraplegia (p < 0.05). Autopsy findings for the 2 patients showed that the Adamkiewicz arteries were not blocked by the stent-graft in either patient.

Conclusions. Intraoperative aortic dissection, embolization of the intercostal arteries, long ischemic time of the spinal cord, and excessive weight gain during operation may have been associated with the high incidence of paraplegia after open surgery using the endovascular stent-graft.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Catheter-based endovascular stent-grafting for the treatment of aortic aneurysm has been gaining acceptance because of its reduced invasiveness [1, 2]. The objective of the method is to interrupt blood flow into the aneurysm and promote thrombosis in the aneurysmal cavity. Since its first clinical application to aneurysms in the abdominal aorta, the method has been extended to aneurysms in the descending thoracic aorta and the distal aortic arch [2].

However, catheter-based endovascular stent-grafting is often difficult to apply to those aneurysms that are adjacent to or even involving the cephalic vessels, because sufficient area for landing the stent-grafts is hard to secure. Open surgery using the endovascular stent-graft, originally reported by Kato and colleagues [3, 4], is indicated for such aneurysms and can avert the problem of perivalvular leakage from the proximal end by surgically suturing the stent-graft and the aortic wall. The method has several advantages over conventional prosthetic replacement. By substituting the expansile force of the stent-graft for the distal anastomosis, this method can reduce time for dissection, injury to neighboring organs, excessive bleeding, and pump and operation time.

Since 1996, we have applied the method of open surgery combined with endovascular stent-graft in high-risk patients with distal aortic arch aneurysms, and have achieved a significant decrease in operation time and intraoperative bleeding volume [5]. Recently, however, we have encountered some patients who postoperatively developed paraplegia, which we had never experienced in patients undergoing conventional prosthesis replacement of the aortic arch through median sternotomy. In this article our clinical experience is reported along with an analysis of the relationships between the perioperative factors and the occurrence of paraplegia.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Between November 1996 and July 2000, a total of 19 patients underwent open surgery using endovascular stent-graft for thoracic aortic aneurysms. Patient characteristics at the time of operation are detailed in Table 1. There were 15 men (78.9%) and 4 women (21.1%). Patient ages ranged from 29 to 82 years (mean 69.3 years, median 74 years). Atherosclerotic thoracic aortic aneurysms were present in 17 patients (89.4%) and aortic dissection in 2 patients (10.5%).

In group I patients (n = 11) (Fig 1A), who required replacement of the distal part of the aortic arch, the stent-graft was delivered through the aortic incision. After the distal stented part was placed correctly in the descending aorta, the proximal end was trimmed and anastomosed to the aortic wall posteriorly, using the inclusion method, and anteriorly, closing the aortotomy. The cephalic vessels were reconstructed separately as needed (none in 2 patients; left subclavian artery only in 7 patients; and both left subclavian and left common carotid arteries in 2 patients).

View larger version (29K): [in this window] [in a new window]   Fig 1. Schematic drawing of the operative procedure. Group I: (A) The proximal end of the stent-graft that was inserted into the descending aorta is sutured with incised aorta. (B) The left subclavian artery is reconstructed with a prosthetic graft. Group II: (A) The proximal end of the stent-graft that was inserted into the descending aorta is sutured with transected distal aorta. (B) A branched graft is anastomosed to the proximal end of the stent-graft and the native aorta. Three arch vessels are reconstructed with the branches of the graft. Group III: (A) Three arch vessels are connected to the branches of the prosthesis that is attached to the side of the ascending aorta. The stent-graft is then delivered into the descending aorta using a sheath catheter. (B) The proximal end of the stent-graft is sutured to the aortic wall. Group IV: (A) The stent-graft is delivered into the true lumen of the descending aorta using the sheath catheter to seal the entry site of the chronic aortic dissection. (B) The ascending aorta is replaced with a prosthetic graft. (Reprinted with permission from The Society of Thoracic Surgeons [Ann Thorac Surg, 2002, 73, 1621–3] and from the American Association for Thoracic Surgery [J Thorac Cardiovasc Surg, 2001, 122, 1240–3].)

In group III patients (n = 3) (Fig 1C), who required replacement of the total aortic arch but were without atherosclerotic changes to the ascending aorta, a trifurcated graft, which was composed of a bifurcated graft and a straight graft, was attached to the anterior wall of the ascending aorta before institution of cardiopulmonary bypass. During perfusion cooling, the cephalic vessels were reconstructed separately using the limbs of the trifurcated graft. Under deep hypothermic circulatory arrest with selective cerebral perfusion through the graft, the ascending aorta just distal to the anastomosis was clamped and the aorta was incised just proximal to the brachiocephalic artery. The stent-graft was delivered in the same fashion as in the other groups and anastomosed to the site of the aortic incision.

In the group IV patient (n = 1) (Fig 1D), who presented with acute aortic dissection of DeBakey type II concomitant with chronic aortic dissection of DeBakey type III, graft replacement for the ascending aorta and intraoperative placement of the endovascular stent-graft to seal the entry site in the descending aorta were performed concomitantly. This case was recently reported elsewhere [6].

Concomitant coronary bypass grafting was performed in 4 patients. Distal anastomoses were performed during perfusion cooling or cardioplegic cardiac arrest and proximal anastomosis during rewarming.

Study variables and definitions
Preoperative paraplegia was not observed in any patient. Renal insufficiency was defined as serum creatinine exceeding 3.0 mg/dL or need for hemodialysis. Intraoperative body weight gain was calculated by subtracting the preoperative body weight from the postoperative weight. Formal evaluation by a neurologist was obtained in all patients in whom any neurologic deficit was noted. Paraplegia was defined as flaccid paralysis, regardless of whether the deficit was immediate or delayed. The position of stent-graft was defined as the vertebral level to which the distal end of the stent-graft reached in AP chest roentgenogram.

Statistical analysis
Statistical analyses were performed using the SPSS package for Windows (version 6.1.3; SPSS, Inc, Chicago, IL). All values were expressed as mean ± standard deviation. Mean values were analyzed with the unpaired t test. Risk factors were evaluated for association with paraplegia using univariate analyses; categorical variables were analyzed using Fisher’s exact test (two-tailed) and continuous data were analyzed using Student’s t test. Association with outcomes was considered to be statistically significant for p values less than 0.05.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Paraplegia was postoperatively observed in 4 patients (21.1%), 2 of whom (10.5%) died during hospitalization; 1 died of pneumonia 22 days after operation and the other of infectious mediastinitis 31 days after operation. There was no hospital mortality in patients without paraplegia. One paraplegia patient showed acute dissection of the descending aorta, which was treated medically (case 16).

Autopsy findings were obtained from the 2 patients with hospital mortality (cases 18 and 19). These 2 cases were recently reported elsewhere [7]. Briefly, the aneurysmal cavity was occluded with thrombus, although the orifices of the Adamkiewicz arteries (the 9th intercostal artery in case 18 and the 12th in case 19) were not blocked by the stent-graft in both cases. Histologic examination revealed spinal cord infarction at the very limited area of the 4th spinal anterior thoracic root in case 18 and in a diffuse area continuous from the level of C6 to Th11 in case 19. Neither thrombus nor embolus was observed in any of the arteries in case 18, although a few clusters of cholesterin emboli, occluding arteries that drained into the anterior or posterior spinal artery at the level of C8 and Th6, were observed in case 19.

Age was significantly higher and body weight gain during operation was significantly greater in paraplegia patients than in nonparaplegia patients (p < 0.05). There was no significant difference in the total operation time, total cardiopulmonary bypass time, and retrograde cerebral perfusion time between the two groups. Although the mean value of the spinal cord ischemic time was longer in paraplegia than in nonparaplegia patients, the difference was not significant (Table 1). Comparing procedure-based subgroups, the total operation time, total cardiopulmonary bypass time, and retrograde cerebral perfusion time were all significantly longer in group II than in group I. Spinal cord ischemic time was significantly longer in groups II and III than in group I. Paraplegia occurred in all but group IV (Table 2).

The total operation time ranged from 355 to 1095 minutes (mean 542 minutes), whereas there was a range of 140 to 423 minutes (mean 228 minutes) in the total bypass time. The spinal cord ischemic time ranged from 23 to 113 minutes (mean 59 minutes). Retrograde cerebral perfusion time ranged from 23 to 80 minutes (mean 52 minutes), whereas selective cerebral perfusion time ranged from 67 to 113 minutes (mean 85 minutes).

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
The incidence of paraplegia in these patients undergoing open surgery using endovascular stent-graft was extraordinarily higher than in reported series for thoracic aortic aneurysms [8, 9]. Generally, postoperative paraplegia is most common in patients undergoing surgery for thoracoabdominal aortic aneurysms, especially with the extensive forms such as Crawford type II [10, 11]. Surgery for aneurysms in the lower part of the descending aorta is also associated with hazard for spinal cord injury. However, the reported incidence of postoperative paraplegia in patients with aneurysms in the aortic arch or the upper part of the descending aorta is very low [7–9]. At our institute, from 1987 to 1998, we have never encountered postoperative paraplegia in patients who underwent conventional graft replacement for aortic arch aneurysms. The incidence of paraplegia in the present study is also higher than reported for the catheter-based endovascular stent-graft [2].

There have been only a few reports regarding this open procedure using the endovascular stent-graft for aortic arch aneurysms. Kato and colleagues [4] reported that among 26 patients with thoracic aortic aneurysms treated by this method, spinal cord injury was observed in only 1 patient, who underwent prolonged circulatory arrest time (35 minutes at 28°C). Orihashi and colleagues [12] demonstrated that in 16 patients undergoing this procedure, paraplegia developed in 1 patient in whom the stent-graft was intentionally implanted more distally than usual, at a level of 7 cm from the diaphragm. Most recently, it has been reported that paraplegia was observed in 9 of 137 patients who had undergone open surgery using the endovascular stent-graft [13]. As mentioned above, conventional surgery for the aortic arch through median sternotomy is rarely associated with paraplegia. Therefore, it was assumed that particular conditions associated with this procedure might be responsible for such a high incidence of paraplegia.

Acute aortic dissection
Acute dissection of the descending aorta, which was caused by the intraoperative maneuver, appears to be associated with paraplegia in case 16. It has been reported that acute aortic dissection sometimes causes spinal cord injury by impairing blood flow in the segmental arteries [14]. This accounts for 1 of our early cases, when we used to push out the stent-graft from the sheath-catheter. We then changed the maneuver so as to pull out the sheath-catheter for the placement of the stent-graft, and have not seen this complication since.

Embolization of intercostal arteries
In case 19, the cholesterin embolus found in the anterior spinal artery at autopsy might, at least partly, be responsible for impaired blood flow to the spinal cord. This cholesterin embolus is considered to be generated from the atherosclerotic aortic wall during the procedure of stent-graft delivery. Emboli associated with aortic surgery are mainly derived from two major sources: an atherosclerotic aortic wall and thrombus in the aneurysmal cavity. Concerning the stent-graft, Dake and colleagues [2] reported that the incidence of paraplegia in 103 patients undergoing catheter-based stent-grafting for aneurysms of the descending thoracic aorta was 3%. They also found a rather high incidence of stroke (7%) and presumed that embolizing debris might be the common cause of these two complications. It is assumed that the condition after placement of the stent-graft might be one of increased risk for embolization of intercostal arteries. Dake and colleagues [2] reported that an early endoleak was seen in 24% of the patients. Although the proportion of endoleak in open surgery using stent-graft is supposed to be lower than that in catheter-based stent-grafting, minor leak is not rare (at least right after delivery of the stent-graft). This condition is completely different from that of conventional aortic replacement because blood flow due to endoleak running around the stent-graft might readily carry the embolizing debris (caused by delivery of the stent-graft) into the intercostal arteries. In the study, age greater than 75 years was the only risk factor associated with paraplegia on univariate analysis. Coselli and colleagues [11] reported that age and extent II thoracoabdominal aortic aneurysm were the only risk factors associated with paraplegia in univariate analysis. Svensson and colleagues [10] demonstrated that older patients with thoracoabdominal aortic aneurysm tend to have a more diseased aorta, resulting in reduced ability to reattach the intercostal arteries and an increased proportion of postoperative paraplegia. Although not systematically recorded in this study, it is our impression that the more diseased aorta characteristic of older patients contains more mural atherosclerotic debris, which might readily cause embolic episodes.

Spinal cord ischemic time and intraoperative body weight gain
It has been reported that the duration of circulatory arrest is strongly related to the incidence of paraplegia and a spinal cord ischemic time of more than 60 minutes carries substantially increased risk for paraplegia at normothermia [15]. Deep hypothermia is reported to increase ischemic tolerance of the spinal cord by means of metabolic down-regulation [16, 17]. In the study, the spinal cord ischemic time exceeded 60 minutes in all paraplegia patients except in the patient designated as case 16 (in whom aortic dissection might have been the cause of paraplegia). Prolonged spinal cord ischemia, although not critical in itself, might be complicated by paraplegia when accompanied by other deleterious factors. It is of note that, excluding case 16 with aortic dissection, all of the paraplegia patients had both spinal cord ischemic time of more than 60 minutes and intraoperative body weight gain of more than 4 kg. The patients with greater body weight gain are considered to have severe tissue edema of the whole body. It is assumed that edema of the spinal cord worsens the spinal cord circulation, leading to the observed spinal cord injury. Postoperative tissue edema may also reflect ischemia and reperfusion injury. As there was no significant correlation between total bypass time or spinal cord ischemic time and body weight gain, low blood hematocrit or low colloid pressure during cardiopulmonary bypass might be contributing factors for the greater weight gain in paraplegia patients. Further investigations that include factors influencing body weight gain during operation, association between body weight gain and paraplegia, and methods for lessening body weight gain are warranted.

Hemodynamics after cardiopulmonary bypass
Because the spinal cord after global ischemia is more vulnerable to additional ischemic damage during the hours of reperfusion and the first few postoperative days, hemodynamic stability after operation is important to ensure adequate spinal cord circulation. It has been reported that postoperative hypotension after thoracoabdominal aortic operation increased the risk for neurologic injury [18]. Griepp and colleagues [17] demonstrated that the incidence of spinal cord injury after surgery for thoracic or thoracoabdominal aortic aneurysms has been decreased by keeping the intraoperative blood pressure at a high normal level, even without reattaching the segmental vessels. There have also been some case reports demonstrating that paraplegia after catheter-based endovascular stent-grafting for thoracoabdominal aneurysm was associated with postoperative hypotension [19, 20]. Paraplegia in case 19 is at least partly attributable to hemodynamic instability during the 2 hours immediately after cardiopulmonary bypass, although there was no increased use of vasopressors.

Methods of brain protection
Does the method of brain protection affect the spinal cord injury? Our preferred method of brain protection is retrograde cerebral perfusion under deep hypothermia [21], and the spinal cord is left almost completely ischemic during the procedure. Selective cerebral perfusion, especially when perfusion of the left subclavian artery is included, may perfuse the anterior spinal artery through the vertebral artery. From this viewpoint, selective brain perfusion is considered to be more protective against spinal cord ischemia than is retrograde cerebral perfusion. However, operative procedures, including the methods of brain protection, were changed during the course of the study to decrease the operative risks for paraplegia; and it should be emphasized that paraplegia has occurred in all but one type of operative procedure, for both antegrade and retrograde cerebral perfusion.

The Adamkiewicz artery
The vertebral levels to which the distal ends of the endovascular stent-grafts reached bore no relation to the incidence of paraplegia; the most distal one was Th 8, beyond which level most of the Adamkiewicz arteries reportedly arise [22, 23]. Moreover, in the two cases of postoperative paraplegia for which autopsy findings could be obtained, the orifices of the Adamkiewicz arteries (which were clearly confirmed by anatomical observation) were not blocked by the stent-graft. These findings suggest that paraplegia as observed in our cases was not caused by mechanical interruption of blood flow from the Adamkiewicz arteries. Although it has been reported that the spinal cord is supplied by segmental arteries from the aorta at various vertebral levels [24], it is not likely that critical spinal cord ischemia is incurred by the stent-graft while the blood supply from the Adamkiewicz artery is preserved.

Cerebrospinal fluid drainage
To ameliorate the spinal cord circulation, cerebrospinal fluid (CSF) drainage has become the treatment of choice by many surgeons in recent years [19, 25]. In cases 18 and 19, we initiated CSF drainage immediately after noticing the spinal cord injury. Although the levels of CSF pressure were a little higher than normal, no symptomatic improvement was observed in either patient.

In summary, we have had experience with 4 patients with postoperative paraplegia (including 2 hospital mortalities) among 19 patients undergoing open surgery using endovascular stent-graft for aortic arch aneurysm. Intraoperative aortic dissection may have caused paraplegia in 1 patient. Excluding the patient with aortic dissection, all 3 patients with paraplegia had spinal cord ischemic time of more than 60 minutes and intraoperative body weight gain of more than 4 kg, both of which appeared to be associated with ischemia and reperfusion injury of the spinal cord. Of these 3 patients, cholesterin embolus in the anterior spinal artery may have contributed to paraplegia in 1 patient and hemodynamic instability after cardiopulmonary bypass in another. Although open surgery using endovascular stent-graft is a potentially less invasive technique for thoracic aortic aneurysm, further study and refinement is necessary to make this technique more secure and reliable.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Takeshi Miyairi Yutaka Kotsuka Tetsuro Morota Hiroshi Kubota Shinichi Takamoto Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Miyairi, T. Articles by Takamoto, S. Search for Related Content PubMed PubMed Citation Articles by Miyairi, T. Articles by Takamoto, S. Related Collections Great vessels