HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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): Joseph S. Coselli Scott A. LeMaire Lori D. Conklin Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Coselli, J. S. Articles by Adams, G. J. Search for Related Content PubMed PubMed Citation Articles by Coselli, J. S. Articles by Adams, G. J. Related Collections Great vessels

Ann Thorac Surg 2004;77:1298-1303
© 2004 The Society of Thoracic Surgeons

---

Original article: cardiovascular

Left heart bypass during descending thoracic aortic aneurysm repair does not reduce the incidence of paraplegia

^a The Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine and The Methodist DeBakey Heart Center, Houston, Texas, USA

^* Address reprint requests to Dr Coselli, 6560 Fannin, Suite 1100, Houston, TX 77030, USA.
e-mail: jcoselli{at}bcm.tmc.edu

Presented at the Forty-ninth Annual Meeting of the Southern Thoracic Surgical Association, Miami Beach, Florida, Nov 7–9, 2002. *Recipient of the 2002 Southern Thoracic Surgical Association President's Award.

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments Discussion References

 
BACKGROUND: The preferred technique for spinal cord protection during surgical repair of descending thoracic aortic aneurysms (DTAAs) remains controversial. The purpose of this retrospective analysis was to determine if the use of left heart bypass (LHB) reduced the incidence of paraplegia in patients who underwent DTAA repair.

METHODS: Over a 15-year period 387 consecutive patients underwent surgical repair of DTAAs using either the "clamp-and-sew" technique (341 patients, 88.1%) or distal aortic perfusion via a LHB circuit (46 patients, 11.9%). Data regarding patient characteristics, operative variables, and outcomes were retrieved from a prospectively maintained database. The impact of LHB on the frequency of paraplegia was determined using univariate and propensity score analyses.

RESULTS: There were 17 operative deaths (4.4%) including 11 patients (2.8%) who died within 30 days. Paraplegia occurred in 10 patients (2.6%). On univariate analysis increasing age (p = 0.03), increasing aortic clamp time (p < 0.001), increasing red blood cell transfusion requirements (p = 0.01), and acute dissection (p = 0.03) were associated with increased incidence of paraplegia. Patients who received LHB had a similar incidence of paraplegia (2/46, 4%) compared with those treated without LHB (8/341, 2.3%; p = 0.3). Both matching and stratification propensity score analyses confirmed that LHB was not associated with reduced risk of paraplegia.

CONCLUSIONS: On retrospective analysis the use of LHB during DTAA repair did not reduce the incidence of spinal cord injury. The "clamp-and-sew" technique remains an appropriate approach to DTAA repair.

	Introduction

Top Abstract Introduction Material and methods Results Comment Acknowledgments Discussion References

 
Paraplegia secondary to spinal cord ischemia remains a dreaded complication of descending thoracic aortic aneurysm (DTAA) repair. Perfusion of the spinal cord during clamping of the descending thoracic aorta is variable and tenuously dependent upon collateral circulation. Both the duration of ischemia and the permanent interruption of critical intercostal arteries play a role in the development of this complication. Several approaches have been advocated to reduce the degree and duration of spinal ischemia including distal aortic perfusion, hypothermia, cerebrospinal fluid (CSF) drainage, pharmacological agents, spinal cord monitoring, and expeditious surgery [1–15]. Methods of distal perfusion have included passive aortic shunts, partial femoral–femoral cardiopulmonary bypass with or without hypothermia, complete cardiopulmonary bypass usually with profound hypothermic circulatory arrest, and left heart (atrio–femoral) bypass usually with a centrifugal pump. Although great progress has been made in reducing the incidence of paraplegia, no technique has eliminated the risk of neurologic complications. Therefore the preferred technique for spinal cord protection during DTAA surgery remains controversial.

Over the last 15 years we have expanded our use of distal perfusion with left heart bypass (LHB) in patients undergoing surgical repair of extensive thoracoabdominal aortic aneurysms and have demonstrated that this adjunct reduces the incidence of paraplegia in this setting [16]. The benefit of LHB during less extensive repairs, however, remains unclear. The purpose of this retrospective analysis was to determine if the use of LHB reduced the incidence of paraplegia in patients who underwent DTAA repair.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Acknowledgments Discussion References

 
Patients
Over a 15-year period 428 consecutive patients underwent surgical repair of DTAAs by the senior author (J.S.C.). Profound hypothermic circulatory arrest was used in 41 patients (9.6%) due to inability to cross-clamp the aorta (eg, rupture, large aneurysms, and involvement of transverse aortic arch); these patients were excluded from further analysis.

Operative technique
The details of our surgical technique have been described elsewhere [17, 18]. All patients underwent DTAA repair via left thoracotomy often with division of the costal margin. We routinely used moderate systemic heparinization (1.0 mg/kg); the heparin was reversed with protamine sulfate after completing all anastomoses. Mild permissive hypothermia (32°–34°C, nasopharyngeal) was also used routinely to minimize ischemic complications. To reverse cooling at operative completion the field was irrigated with warm saline. Patent groups of intercostal arteries between T7 and T10 were reattached to the graft in 18 patients (4.7%) usually when larger extents of the descending thoracic aorta were replaced and particularly in patients with previous abdominal aortic graft replacement. Cerebral spinal fluid drainage was used in 24 patients (6.2%). We used LHB with a centrifugal pump in 46 patients (11.9%). In these patients blood was drained via a left atrial cannula (usually placed via the inferior pulmonary vein) and returned through a cannula in the distal descending thoracic aorta or left femoral artery. The closed LHB circuit did not include a cardiotomy reservoir, an oxygenator, or a warming device. In most cases LHB was used only during the proximal anastomosis. Neither somatosensory nor motor-evoked potential monitoring was used [19].

Study variables and definitions
All preoperative, intraoperative, and postoperative data were retrieved from a prospectively maintained database. Aneurysms associated with aortic dissection were considered acute if surgery was performed within 14 days of the onset of pain; after 14 days dissection was considered chronic. Patients were considered symptomatic when any symptom (acute or chronic, severe or mild) related to the aneurysm was present including pain, hoarseness, and dysphagia. Patients with acute presentations were defined as those with acute pain, rupture, contained rupture, or acute dissection. Preoperative renal insufficiency was defined as serum creatinine exceeding 3.0 mg/dl or need for hemodialysis.

The patients involved in this series included only those in whom the descending thoracic aorta, ie, the segment of aorta between the left subclavian artery and the diaphragm, was surgically replaced with a graft in continuity with the aortic lumen. The extent of repair was classified based on the descending thoracic aortic segments that were replaced, ie, proximal one-third (A), middle one-third (B), distal one-third (C), or any combination of these.

In accordance with established guidelines operative mortality included all deaths occurring within 30 days and all deaths occurring during the initial hospitalization. All patients with postoperative neurologic deficits involving the lower extremities were included in the paraplegia category regardless of whether the deficit was weakness (paraparesis) or paralysis, immediate or delayed, transient or permanent. This included patients with unilateral lower extremity deficits unless an associated deficit involving the ipsilateral upper extremity—indicating a stroke—was present.

Statistical analysis
Continuous variables are presented as mean ± standard deviation. Univariate analysis was performed using ² or Fischer exact tests for categorical data and Student t tests for continuous data. In an attempt to adjust for the confounding variables and minimize the impact of selection bias, several logistic regression models were constructed to estimate the probability of receiving LHB. The model that most accurately predicted LHB/no LHB was used as the propensity scoring model. This final model, which included 32 variables (Table 1), was used to calculate propensity scores for 385 patients (Fig 1) (2 patients with preoperative paraplegia were excluded). Cases with LHB and those without LHB were matched based on their propensity scores (calculated to two decimal places); the frequencies of paraplegia in the matched LHB and non-LHB groups were then compared. The propensity scores were also used for a stratified analysis in which scores for all 385 patients were consecutively ordered and divided into five groups of equal size. Patients within each of these quintiles had similar probabilities of receiving LHB thereby reducing bias (Figure 2). The frequencies of paraplegia between LHB and non-LHB patients were compared for each quintile. For all analyses, p values less than 0.05 were considered statistically significant.

View larger version (16K): [in this window] [in a new window]   Fig 1. Boxplots of the propensity scores in patients who underwent descending thoracic aortic repair without and with left heart bypass (LHB). For each distribution the upper horizontal line indicates the maximum score, theupper edge of the box indicates the 75th percentile, the middle horizontal line indicates the median (50th percentile), the lower edge of the box indicates the 25th percentile, and the lower horizontal line indicates the minimum value. The numbers of patients in the LHB and no LHB groups are shown below the horizontal axis.

View larger version (18K): [in this window] [in a new window]   Fig 2. Boxplots of the propensity scores in patients who underwent descending thoracic aortic repair without and with left heart bypass (LHB) grouped according to stratification into quintiles. For each distribution the upper horizontal line indicates the maximum score, the upper edge of the box indicates the 75th percentile, the middle horizontal line indicates the median (50th percentile), the lower edge of the box indicates the 25th percentile, and the lower horizontal line indicates the minimum value. The numbers of patients in the LHB and no LHB groups are shown below the horizontal axis.

	Results

Top Abstract Introduction Material and methods Results Comment Acknowledgments Discussion References

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments Discussion References

 
This retrospective analysis is fraught with the usual limitations, particularly the immeasurable impact of selection bias. So although the difference in postoperative paraplegia in LHB patients and non-LHB patients did not achieve statistical significance, the results are difficult to interpret. Clearly the two patient groups were not similar with respect to potential risk factors for paraplegia. A similar morbidity rate despite increased risk can be perceived as a benefit of LHB, ie, the incidence of paraplegia in the high-risk group should have been higher but was not because LHB provided spinal cord protection. Indeed we have used this rationale to support the use of LHB in patients undergoing extent I thoracoabdominal aortic aneurysm repair [16]. In light of this dilemma we used propensity score analyses to reduce the impact of selection bias and create groups that were more comparable. This statistical tool has been used to reduce bias in several recent retrospective analyses in the cardiothoracic surgery literature [20–25]. We used our propensity score model for matching and stratification analyses, both of which supported the conclusion that LHB did not prevent paraplegia.

Unfortunately prospective randomized trials are extremely difficult to perform in thoracic aortic surgery, primarily due to low patient volumes and tremendous variability in management strategies between different surgeons and institutions. Therefore we are often forced to rely on retrospective analyses to guide patient care decisions. Whereas statistical tools like propensity score analysis are not without limitations, they can add strength to retrospective studies.

In conclusion, in this retrospective analysis, the use of LHB during DTAA repair did not reduce the incidence of spinal cord injury. The "clamp-and-sew" technique remains an appropriate approach to DTAA repair.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments Discussion References

 
The authors gratefully acknowledge Autumn Jamison, Ada Kyriasoglou, Stacey Carter, Scott Weldon, Daniel J. DiBardino, MD, and R. Brandon Stacey for their assistance with the preparation of this manuscript.

	Discussion

Top Abstract Introduction Material and methods Results Comment Acknowledgments Discussion References

 
DR THORALF SUNDT (Rochester, MN): I assume you did all of these cases yourself?

DR COSELLI: Yes.

DR SUNDT: So statistical analysis having failed to demonstrate predictors of increased risk of paraplegia, and hence on which patients we should use left-heart bypass, maybe you can give us some insight into just what your clinical feeling is. How did you tend to decide during this interval on which patients to use left heart bypass and which not to? Are there some imponderables that cannot be statistically quantified that we can consider as we look at these data?

DR COSELLI: That is a good question. It turns out, from our analysis of this data, that my perceived bias toward using left heart bypass in patients that I thought were going to require longer cross-clamp times did pan out. In cases with longer total clamp times, spinal cord ischemic times, renal ischemic times, etcetera, I had a tendency to use left heart bypass. These were often patients that were operated upon for aortic dissection and patients in whom cross-clamping proximal to the left subclavian artery was required; as you might imagine, there was a great deal of overlap between those two groups.

DR SUNDT: So then could we conclude equally well that, by applying this technique in these higher risk patients, you were actually able to do the operation without an increased risk of paraplegia?

DR COSELLI: That is the initial assumption. If you just do univariate and multivariable analyses comparing the left heart bypass and no left heart bypass groups, that is what is distilled out; but, when you use a propensity score analysis to try to take out the surgical bias, it still holds up that left heart bypass does not have a statistically significant impact.

DR SUNDT: My only concern is the ability to truly model the subtleties of clinical assessment; regardless of the sophistication of the statistical analysis, I am not sure that one can account for that sixth sense that you bring to the table given your incredible experience and expertise in this complex area. I suspect that your own good judgment may play more of a role than you are giving it credit for.

DR COSELLI: Thank you.

DR CONSTANTINE MAVROUDIS (Chicago, IL): Congratulations on a great presentation. It seemed like you hit a home run here. Your statistical analysis is comprehensive and answers questions that any reader might have. You carried the analysis farther than I think any of us would have thought possible.

I rise to ask you a couple of questions and not only about your patient population but how it may relate to patients with coarctation of the aorta. The accumulated experience for repair of coarctation of the aorta has shown that intraoperative temperature elevation, elongated cross-clamp time, and significant decrease of downstream pressure during the cross-clamp are risk factors for the development of paraplegia. In our practice, we measure the pressure in the lower extremity in those cases that are in the older age groups.

Did you think about looking at the temperature of the patients and whether temperature elevations corresponded with paraplegia? Also do you think that measuring pressures distally has any effect on whether to use bypass or not? In other words, when you clamp what is the pressure distally and so forth?

Again congratulations on a great paper.

DR COSELLI: Thank you. These were not patients with coarctation although some patients who had had previous coarctations and later developed aneurysms were in this group.

We have not found temperature to be a predictive variable although due to an earlier experience, we do not put a heat exchanger in the circuit and deliberately keep these patients normothermic or warm. We operate in a relatively cool environment and allow the temperature to fall without trying to correct it.

In these patients we did not usually measure distal pressure so we did not use it as a variable in the analysis. Although, early on in the experience, pressure was one of the measurements we used to regulate pump flow, we found that other criteria are probably equally as important and easily measured, and, therefore, we do not routinely measure pressure distally anymore.

DR JOHN KRATZ (Charleston, SC): Thank you for this important piece of information. I think this might be a trendsetter paper around the country that a number of us will use as a tool.

My question is that most of us do not do 300 cases like this and perhaps our average cross-clamp times are going to be 10 or 15 minutes longer than somebody with your degree of experience. Do you think your data will translate to the average thoracic surgeon at 3 o'clock in the morning dealing with an aortic dissection?

DR COSELLI: Excellent question—I hope so. This does not say, "do not use left heart bypass." I showed a slide of some of the review of the literature, much of which makes rather profound, even dogmatic, statements about what we should and should not use. These statements can, on occasion, rise up to impact us in other ways including medico-legally. I think the importance of looking into this data, particularly in this way, is that it may help balance out some of those other efforts.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments Discussion References

 

1. Wakabayashi A., Connolly J.E., Stemmer E.A., Nakamura Y., Kubo T., Ino T. Heparinless left heart bypass for resection of thoracic aortic aneurysms. Am J Surg 1975;130:212-218.[Medline]
2. DeBakey M.E., McCollum C.H., Graham J.M. Surgical treatment of aneurysms of the descending thoracic aorta: long-term results in 500 patients. J Cardiovasc Surg 1978;19:571-576.[Medline]
3. Najafi H., Javid H., Hunter J., Serry C., Monson D. Descending aortic aneurysmectomy without adjuncts to avoid ischemia. Ann Thorac Surg 1980;30:326-335.[Abstract]
4. Livesay J.J., Cooley D.A., Ventemiglia R.A., et al. Surgical experience in descending thoracic aneurysmectomy with and without adjuncts to avoid ischemia. Ann Thorac Surg 1985;39:37-46.[Abstract]
5. Kazui T., Komatsu S., Yokoyama H. Surgical treatment of aneurysms of the thoracic aorta with the aid of partial cardiopulmonary bypass: an analysis of 95 patients. Ann Thorac Surg 1987;43:622-627.[Abstract]
6. Svensson L.G., Crawford E.S., Hess K.R., Coselli J.S., Safi H.J. Variables predictive of outcome in 832 patients undergoing repairs of the descending thoracic aorta. Chest 1993;104:1248-1253.[Free Full Text]
7. Verdant A., Cossette R., Page A., Baillot R., Dontigny L., Page P. Aneurysms of the descending thoracic aorta: three hundred sixty-six consecutive cases resected without paraplegia. J Vasc Surg 1995;21:385-391.[Medline]
8. Hessmann M., Dossche K., Wellens F., Vanermen H., De Geest R. Surgical treatment of thoracic aneurysm: a 5-year experience. Cardiovasc Surg 1995;3:19-25.[Medline]
9. Galloway A.C., Schwartz D.S., Culliford A.T., et al. Selective approach to descending thoracic aortic aneurysm repair: a ten-year experience. Ann Thorac Surg 1996;62:1152-1157.[Abstract/Free Full Text]
10. Hayashi J., Eguchi S., Yasuda K., et al. Operation for nondissecting aneurysm in the descending thoracic aorta. Ann Thorac Surg 1997;63:93-97.[Abstract/Free Full Text]
11. Biglioli P., Spirito R., Agrifoglio M., et al. Surgery of descending thoracic aortic aneurysms with centrifugal pump support. Cardiovasc Surg 1997;5:99-103.[Medline]
12. Okita Y., Takamoto S., Ando M., et al. Repair for aneurysms of the entire descending thoracic aorta or thoracoabdominal aorta using deep hypothermia. Eur J Cardiothorac Surg 1997;12:120-126.[Abstract]
13. Kouchoukos N.T. Hypothermic circulatory arrest and hypothermic perfusion for extensive disease of the thoracic and thoracoabdominal aorta. Jpn J Thorac Cardiovasc Surg 1999;47:1-5.
14. Plestis K.A., Nair D.G., Russo M., Gold J.P. Left atrial femoral bypass and cerebrospinal fluid drainage decreases neurologic complications in repair of descending and thoracoabdominal aortic aneurysms. Ann Vasc Surg 2001;15:49-52.[Medline]
15. Estrera A.L., Rubenstein F.S., Miller C.C., III, Huynh T.T.T., Letsou G.V., Safi H.J. Descending thoracic aortic aneurysm: surgical approach and treatment using the adjuncts cerebrospinal fluid drainage and distal aortic perfusion. Ann Thorac Surg 2001;72:481-486.[Abstract/Free Full Text]
16. Coselli J.S., LeMaire S.A. Left heart bypass reduces paraplegia rates following thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 1999;67:1931-1934.[Abstract/Free Full Text]
17. Coselli J.S., Plestis K.A., LaFrancesca S., Cohen S. Results of contemporary surgical treatment of descending thoracic aortic aneurysms: experience with 198 patients. Ann Vasc Surg 1996;10:131-137.[Medline]
18. Coselli J.S. Descending and thoracoabdominal aortic aneurysms. In: Edmunds L.H., ed. Cardiac surgery in the adult. McGraw-Hill: New York, 1996:1227-1244.
19. van Dongen E.P., Schepens M.A., Morshuis W.J., et al. Thoracic and thoracoabdominal aortic aneurysm repair: use of evoked potential monitoring in 118 patients. J Vasc Surg 2001;34:1035-1040.[Medline]
20. Stamou S.C., Jablonski K.A., Pfister A.J., et al. Stroke after conventional versus minimally invasive coronary artery bypass. Ann Thorac Surg 2002;74:394-399.[Abstract/Free Full Text]
21. Grunkemeier G.L., Payne N., Jin R., Handy J.R., Jr Propensity score analysis of stroke after off-pump coronary artery bypass grafting. Ann Thorac Surg 2002;74:301-305.[Free Full Text]
22. Grossi E.A., Goldberg J.D., LaPietra A., et al. Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications. J Thorac Cardiovasc Surg 2001;122:1107-1124.[Abstract/Free Full Text]
23. Gillinov A.M., Wierup P.N., Blackstone E.H., et al. Is repair preferable to replacement for ischemic mitral regurgitation?. J Thorac Cardiovasc Surg 2001;122:1125-1141.[Abstract/Free Full Text]
24. Miller D.C. Ischemic mitral regurgitation redux—to repair or to replace?. J Thorac Cardiovasc Surg 2001;122:1059-1062.[Free Full Text]
25. Blackstone E.H. Comparing apples and oranges. J Thorac Cardiovasc Surg 2002;123:8-15.[Free Full Text]

This article has been cited by other articles:

				K. Toda, K. Taniguchi, S. Kainuma, and T. Yokota Novel technique for reimplantation of intercostal arteries using tailored patch graft. Eur. J. Cardiothorac. Surg., August 1, 2008; 34(2): 458 - 459. [Abstract] [Full Text] [PDF]

				K. Minatoya, H. Ogino, H. Matsuda, H. Sasaki, T. Yagihara, and S. Kitamura Replacement of the descending aorta: recent outcomes of open surgery performed with partial cardiopulmonary bypass. J. Thorac. Cardiovasc. Surg., August 1, 2008; 136(2): 431 - 435. [Abstract] [Full Text] [PDF]

				H. J. Patel, D. M. Williams, G. R. Upchurch Jr, N. L. Dasika, M. C. Passow, R. L. Prager, and G. M. Deeb A comparison of open and endovascular descending thoracic aortic repair in patients older than 75 years of age. Ann. Thorac. Surg., May 1, 2008; 85(5): 1597 - 1603. [Abstract] [Full Text] [PDF]

				A. Khoynezhad, C. E. Donayre, J. Smith, G. E. Kopchok, I. Walot, and R. A. White Risk factors for early and late mortality after thoracic endovascular aortic repair. J. Thorac. Cardiovasc. Surg., May 1, 2008; 135(5): 1103 - 1109.e4. [Abstract] [Full Text] [PDF]

				J. S. Coselli, J. Bozinovski, and C. Cheung Hypothermic Circulatory Arrest: Safety and Efficacy in the Operative Treatment of Descending and Thoracoabdominal Aortic Aneurysms Ann. Thorac. Surg., March 1, 2008; 85(3): 956 - 964. [Abstract] [Full Text] [PDF]

				J. S. Coselli and S. A. LeMaire Descending and Thoracoabdominal Aortic Aneurysms Card. Surg. Adult, January 1, 2008; 3(2008): 1277 - 1298. [Full Text]

				L. G. Svensson, N. T. Kouchoukos, D. C. Miller, J. E. Bavaria, J. S. Coselli, M. A. Curi, H. Eggebrecht, J. A. Elefteriades, R. Erbel, T. G. Gleason, et al. Expert Consensus Document on the Treatment of Descending Thoracic Aortic Disease Using Endovascular Stent-Grafts Ann. Thorac. Surg., January 1, 2008; 85(1_Supplement): S1 - S41. [Abstract] [Full Text] [PDF]

				P. C. Austin Propensity-score matching in the cardiovascular surgery literature from 2004 to 2006: a systematic review and suggestions for improvement. J. Thorac. Cardiovasc. Surg., November 1, 2007; 134(5): 1128 - 1135. [Abstract] [Full Text] [PDF]

				M. Czerny, D. Zimpfer, S. Rodler, M. Funovics, M. Dorfmeister, M. Schoder, G. Marta, E. Weigang, R. Gottardi, J. Lammer, et al. Endovascular Stent-Graft Placement of Aneurysms Involving the Descending Aorta Originating From Chronic Type B Dissections Ann. Thorac. Surg., May 1, 2007; 83(5): 1635 - 1639. [Abstract] [Full Text] [PDF]

				J. E. Bavaria, J. J. Appoo, M. S. Makaroun, J. Verter, Z.-F. Yu, R. S. Mitchell, and Gore TAG Investigators Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low-risk patients: A multicenter comparative trial J. Thorac. Cardiovasc. Surg., February 1, 2007; 133(2): 369 - 377. [Abstract] [Full Text] [PDF]

				H. J. Patel, D. M. Williams, G. R. Upchurch Jr, M. S. Shillingford, N. L. Dasika, M. C. Proctor, and G. M. Deeb Long-Term Results From a 12-Year Experience With Endovascular Therapy for Thoracic Aortic Disease Ann. Thorac. Surg., December 1, 2006; 82(6): 2147 - 2153. [Abstract] [Full Text] [PDF]

				B. Marcheix, C. Dambrin, J.-P. Bolduc, C. Arnaud, C. Cron, L. Hollington, A. Mugniot, P. Soula, M. Bennaceur, V. Chabbert, et al. Midterm results of endovascular treatment of atherosclerotic aneurysms of the descending thoracic aorta. J. Thorac. Cardiovasc. Surg., November 1, 2006; 132(5): 1030 - 1036. [Abstract] [Full Text] [PDF]

				H. J. Patel, M. S. Shillingford, S. Mihalik, M. C. Proctor, and G. M. Deeb Resection of the descending thoracic aorta: outcomes after use of hypothermic circulatory arrest. Ann. Thorac. Surg., July 1, 2006; 82(1): 90 - 95. [Abstract] [Full Text] [PDF]

				S. A. LeMaire, S. A. Carter, and J. S. Coselli The Elephant Trunk Technique for Staged Repair of Complex Aneurysms of the Entire Thoracic Aorta. Ann. Thorac. Surg., May 1, 2006; 81(5): 1561 - 1569. [Abstract] [Full Text] [PDF]

				J. J. Appoo, W. G. Moser, R. M. Fairman, K. F. Cornelius, A. Pochettino, E. Y. Woo, J. E. Kurichi, J. P. Carpenter, and J. E. Bavaria Thoracic aortic stent grafting: Improving results with newer generation investigational devices J. Thorac. Cardiovasc. Surg., May 1, 2006; 131(5): 1087 - 1094. [Abstract] [Full Text] [PDF]

				J. A. Crestanello, K. J. Zehr, C. J. Mullany, T. A. Orszulak, J. A. Dearani, F. J. Puga, T. M. Sundt III, C. G. A. McGregor, R. C. Daly, and H. V. Schaff The Effect of Adjuvant Perfusion Techniques on the Incidence of Paraplegia After Repair of Traumatic Thoracic Aortic Transections Mayo Clin. Proc., May 1, 2006; 81(5): 625 - 630. [Abstract] [Full Text] [PDF]

				L. G. Svensson Device discordancy: Lost cords, quick-fix seekers, quality, and ethics J. Thorac. Cardiovasc. Surg., February 1, 2006; 131(2): 261 - 263. [Full Text] [PDF]

				T. G. Gleason Thoracic aortic stent grafting: Is it ready for prime time? J. Thorac. Cardiovasc. Surg., January 1, 2006; 131(1): 16 - 18. [Full Text] [PDF]

				A. T. Cheung, A. Pochettino, M. L. McGarvey, J. J. Appoo, R. M. Fairman, J. P. Carpenter, W. G. Moser, E. Y. Woo, and J. E. Bavaria Strategies to Manage Paraplegia Risk After Endovascular Stent Repair of Descending Thoracic Aortic Aneurysms Ann. Thorac. Surg., October 1, 2005; 80(4): 1280 - 1289. [Abstract] [Full Text] [PDF]

				A. L. Estrera, C. C. Miller III, E. P. Chen, R. Meada, R. H. Torres, E. E. Porat, T. T. Huynh, A. Azizzadeh, and H. J. Safi Descending Thoracic Aortic Aneurysm Repair: 12-Year Experience Using Distal Aortic Perfusion and Cerebrospinal Fluid Drainage Ann. Thorac. Surg., October 1, 2005; 80(4): 1290 - 1296. [Abstract] [Full Text] [PDF]

				R. Greenberg and E. Roselli Expert Commentary Perspectives in Vascular Surgery and Endovascular Therapy, September 1, 2005; 17(3): 223-1 - 225. [PDF]

				A. G. Verdant Left Heart Bypass During Descending Thoracic Aneurysm Repair Ann. Thorac. Surg., May 1, 2005; 79(5): 1825 - 1825. [Full Text] [PDF]

				J. S. Coselli Left Heart Bypass During Descending Thoracic Aneurysm Repair: Reply Ann. Thorac. Surg., May 1, 2005; 79(5): 1825 - 1825. [Full Text] [PDF]

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): Joseph S. Coselli Scott A. LeMaire Lori D. Conklin Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Coselli, J. S. Articles by Adams, G. J. Search for Related Content PubMed PubMed Citation Articles by Coselli, J. S. Articles by Adams, G. J. Related Collections Great vessels