Efficacy and Frequency of Cerebrospinal Fluid Drainage in Operative Management of Thoracoabdominal Aortic Aneurysms

E. Weigang; R. Sircar; P. von Samson; M. Hartert; M. P. Siegenthaler; M. Luehr; H. Richter; G. Szabó; M. Czerny; J. Zentner; F. Beyersdorf

doi:10.1055/s-2006-924708

The Thoracic and Cardiovascular Surgeon, Table of Contents

Thorac Cardiovasc Surg 2007; 55(2): 73-78
DOI: 10.1055/s-2006-924708

Original Cardiovascular

Efficacy and Frequency of Cerebrospinal Fluid Drainage in Operative Management of Thoracoabdominal Aortic Aneurysms

E. Weigang¹ , R. Sircar² , P. von Samson¹ , M. Hartert¹ , M. P. Siegenthaler¹ , M. Luehr¹ , H. Richter¹ , G. Szabó³ , M. Czerny⁴ , J. Zentner² , F. Beyersdorf¹

¹Department of Cardiovascular Surgery, University Medical Center Freiburg, Freiburg, Germany
²Department of Neurosurgery, University Medical Center Freiburg, Freiburg, Germany
³Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
⁴Department of Cardiothoracic Surgery, University of Vienna Medical School, Vienna, Austria

Abstract

All articles of this category

Abstract

Background: Paraplegia remains the most dreaded complication following thoracoabdominal aortic repair. We investigated the efficacy of cerebrospinal fluid drainage as a spinal cord-protecting modality. We also evaluated the correlation between the frequency of cerebrospinal fluid drainage and the Crawford classification. Methods: Spinal cord function was monitored during 20 open surgical procedures (group I) and 27 stent-graft implantations (group II). Evoked potentials and intracranial pressure were monitored in each operation. If intracranial pressure exceeded 15 mmHg, cerebrospinal fluid was drained. Results: Cerebrospinal fluid drainage was necessary in 75 % of patients in group I (Crawford type I: 33 %, type II: 40 %, type III: 20 %, type IV: 7 %) and in 22 % of patients in group II (Crawford type I: 33 %, type II: 66 %). Evoked potential alterations correlated with an increase in intracranial pressure. Timely cerebrospinal fluid drainage reversed these changes in 72 %. Three patients remained paraplegic. Conclusion: Cerebrospinal fluid drainage is a valuable neuroprotective interventional tool to lower the risk of spinal cord ischemia. The combination of neurophysiological monitoring and cerebrospinal fluid drainage optimizes the prevention of paraplegia during aortic repair.

Key words

aortic disease - aortic surgery - endovascular stent graft - spinal cord ischemia - evoked potential - cerebrospinal fluid drainage

Full Text

References

1 Crawford E S, Svensson L G, Hess K R. et al . A prospective randomized study of cerebrospinal fluid drainage to prevent paraplegia after high-risk surgery on the thoracoabdominal aorta. J Vasc Surg. 1990; 13 36-46
2 Svensson L G. An approach to spinal cord protection during descending or thoraco-abdominal aortic repairs. Ann Thorac Surg. 1999; 67 1935-1936
3 Jacobs M J, de Mol B A, Elenbaas T. et al . Spinal cord blood supply in patients with thoracoabdominal aortic aneurysms. J Vasc Surg. 2002; 35 30-37
4 Estrera A L, Rubenstein F S, Miller III C C, Huynh T TT, 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
5 Cinà C S, Abouzahr L, Arena G O, Laganà A, Devereaux P J, Farrokhyar F. Cerebrospinal fluid drainage to prevent paraplegia during thoracic and thoracoabdominal aortic aneurysm surgery: a systematic review and meta-analysis. J Vasc Surg. 2004; 40 36-44
6 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
7 Meylaerts S A, Jacobs M J, van Iterson V, de Haan P, Kalkman C J. Comparison of transcranial motor evoked potentials and somatosensory evoked potentials during thoracoabdominal aortic aneurysm repair. Ann Surg. 1999; 230 742-749
8 Wan I YP, Angelini G D, Bryan A J, Ryder I, Underwood M J. Prevention of spinal cord ischemia during descending thoracic and thoracoabdominal aortic surgery. Eur J Cardiothorac Surg. 2001; 19 203-213
9 MacDonald D B, Janusz M. An approach to intraoperative neurophysiologic monitoring of thoracoabdominal aneurysm surgery. J Clin Neurophysiol. 2002; 19 43-54
10 Guérit J M, Dion R A. State-of-the-art of neuromonitoring for prevention of immediate and delayed paraplegia in thoracic and thoracoabdominal aortic surgery. Ann Thorac Surg. 2002; 74 1867-1869
11 Jacobs M J, Mess W H. The role of evoked potential monitoring in operative management of type I and type II thoracoabdominal aortic aneurysms. Semin Thorac Cardiovasc Surg. 2003; 15 353-364
12 Weigang E, Hartert M, von Samson P. et al . Thoracoabdominal aortic aneurysm repair: interplay of spinal cord protecting modalities. Eur J Vasc Endovasc Surg. 2005; 30 624-631
13 Weigang E, Hartert M, von Samson P. et al . Improved spinal cord perfusion during thoracoabdominal aortic repair. Thorac Cardiovasc Surg. 2005; 53 69-73
14 Gravereaux E C, Faries P L, Burks J A. et al . Risk of spinal cord ischemia after endograft repair of thoracic aortic aneurysms. J Vasc Surg. 2001; 34 997-1003
15 Greenberg R, Resch T, Nyman U, Lindh M, Brunkwall J, Brunkwall P. Endovascular repair of descending thoracic aortic aneurysms: an early experience with intermediate-term follow-up. J Vasc Surg. 2000; 31 147-156
16 Cheung A T, Pochettino A, McGarvey M L. et al . Strategies to manage paraplegia risk after endovascular stent repair of descending thoracic aortic aneurysms. Ann Thorac Surg. 2005; 80 1280-1289
17 Crawford E S, Crawford J L, Safi H J, Coselli J S, Hess K R, Brooks B B. Thoracoabdominal aortic aneurysms: postoperative and intraoperative factors determining immediate and long-term results of operation in 605 patients. J Vasc Surg. 1986; 3 389-404
18 Sloan T B, Heyer E J. Anesthesia for intraoperative neurophysiologic monitoring of the spinal cord. J Clin Neurophysiol. 2002; 19 430-443
19 Lotto M J, Banoub M, Schubert A. Effects of anesthetic agents and physiologic changes on intraoperative motor evoked potentials. J Neurosurg Anesthesiol. 2004; 16 32-42
20 Weigang E, Hartert M, Sircar R. et al . Setup of neurophysiological monitoring with tcMEP/SSEP during thoracoabdominal aneurysm repair. Thorac Cardiov Surg. 2005; 53 28-32
21 Michenfelder J D, Milde J H. The effect of profound levels of hypothermia (below 14 degrees C) on canine cerebral metabolism. J Cereb Blood Flow Metab. 1992; 12 877-880
22 Dong C CJ, MacDonald D B, Janusz M T. Intraoperative spinal cord monitoring during descending thoracic and thoracoabdominal aneurysm surgery. Ann Thorac Surg. 2002; 74 1873-1876
23 Safi H J, Estrera A L, Miller C C. et al . Evolution of risk for neurologic deficit after descending and thoracoabdominal aortic repair. Ann Thorac Surg. 2005; 80 2173-2179
24 Estrera A L, Miller C C, Huynh T T, Porat E E, Safi H J. Neurologic outcome after thoracic and thoracoabdominal aortic aneurysm repair. Ann Thorac Surg. 2001; 72 1225-1231
25 Cheung A T, Weiss S T, McGarvey M L. et al . Interventions for reversing delayed-onset postoperative paraplegia after thoracic aortic reconstruction. Ann Thorac Surg. 2002; 74 413-421
26 Cambria R P, Brewster D C, Lauterbach S R, Kaufman J L, Geller S, Fan C M. Evolving experience with thoracic aortic stent graft repair. J Vasc Surg. 2002; 35 1129-1136
27 Carroccio A, Marin M L, Ellozy S, Hollier L H. Pathophysiology of paraplegia following endovascular thoracic aortic aneurysm repair. J Card Surg. 2003; 18 359-366
28 Reuter D G, Tacker Jr W A, Badylak S F, Voorhees 3rd W D. Correlation of motor-evoked potential response to ischemic spinal cord damage. J Thorac Cardiovasc Surg. 1992; 104 262-272

MD, MBA Ernst Weigang

Department of Cardiovascular Surgery
University Medical Center Freiburg

Hugstetter Straße 55

79106 Freiburg

Germany

Phone: + 49 76 12 70 88 88

Fax: + 49 76 12 70 28 67

Email: ernst.weigang@web.de