Intercostal Artery Management in Thoracoabdominal Aortic ... · Intercostal Artery Management in...
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Intercostal Artery Management in
Thoracoabdominal Aortic Surgery: To
reattach or not to reattach? Rana O. Afifi, MD
Department of Cardiothoracic and Vascular Surgery
McGovern Medical School
The University of Texas Science Center at Houston
Memorial Hermann Heart & Vascular Institute
Assistant Professor
1993
Extent <0.0001
Aortic Clamp Time <0.0001
Rupture 0.0073
Age 0.025 Proximal Aneurysm 0.034
Renal Dysfunction 0.040
SCI - Clamp and Go
ICA reattachment is of the
utmost importance for
preventing paraplegia
following TAAA repair.
Reattachment of ICA T11 -T12
significantly reduces the risk of
overall paraplegia
Reattachment of ICA T9 - T10
significantly decreases the risk
for delayed paraplegia.
Methods
We reviewed all cases of open D/TAAA repair between 2001-2014.
We retrospectively reviewed
Patient characteristics
Intraoperative variables and complications
Intraoperative data to ascertain the status of thoracic
ICAs 3-12 and lumbar arteries 1-4.
Postoperative paraplegia was evaluated for this
cohort.
Methods
ICA Status Determination:
Not manipulated
Natively occluded
Not exposed in the surgical field
Ligated
Reattached into the aortic circulation
Table1:PreoperativePatientDemographics
PatientVariable Overall(N=1,096)
ICAasFound(N=315)
ICALigatedOnly(N=273)
ICAReattached(N=508)
P-value
Age,years 67(56-74) 70(63-76) 62(50-72) 66(56-74) <.001Female 409(37.3) 118(37.5) 110(40.3) 181(35.6) 0.437Hypertension 973(88.8) 281(89.2) 234(85.7) 458(90.1) 0.165
Diabetes 132(12.0) 40(12.7) 33(12.1) 59(11.6) 0.897CAD 313(28.6) 118(37.5) 46(16.9) 149(29.3) <.001COPD 450(41.1) 157(49.8) 90(32.9) 203(39.9) <.001
Smoking 769(70.2) 253(80.3) 168(61.5) 348(68.5) <.001PVD 223(20.4) 94(29.8) 40(14.7) 89(17.5) <.001PriorStroke 98(8.9) 32(10.2) 21(7.7) 45(8.9) 0.577Rupture 136(12.4) 53(16.8) 42(15.4) 41(8.1) <.001
CKDStage1–eGFR>902–eGFR60-893a–eGFR44-593b–eGFR30-43
4–eGFR15-295–eGFR<15
376(35.2)280(26.2)191(17.9)127(11.9)
71(6.7)22(2.1)
72(23.6)62(20.3)70(22.9)51(16.7)
39(12.8)11(3.6)
123(46.1)76(28.5)26(9.7)23(8.6)
15(5.6)4(1.5)
181(36.6)142(28.7)95(19.2)53(10.7)
17(3.4)7(1.4)
<.0010.018<.0010.007
<.0010.084
Connectivetissuedisorder 205(18.7) 43(13.7) 62(22.7) 100(19.7) 0.014Marfan 82(7.5) 14(4.4) 19(6.9) 49(9.7) 0.021Chronicdissection 379(34.6) 40(12.7) 111(40.7) 228(44.9) <.001
PriorProximalAorticRepair 253(23.1) 35(11.1) 66(24.2) 152(29.9) <.001PriorDistalAorticRepair 296(27.0) 123(39.1) 38(13.9) 135(26.6) <.001PriorAVR 135(12.3) 18(5.7) 39(14.3) 78(15.4) <.001Emergency 116(10.6) 49(15.6) 35(12.8) 32(6.3) <.001
Redo 196(17.9) 89(28.3) 29(10.6) 78(15.4) <.001Extentofaneurysm TAAAI 127(11.6) 16(5.1) 23(8.4) 88(17.3) <.001TAAAII 113(10.3) 10(3.2) 11(4.0) 92(18.1) <.001
TAAAIII 118(10.8) 24(7.6) 15(5.5) 79(15.6) <.001
TAAAIV 217(19.8) 186(59.2) 8(2.9) 23(4.5) <.001
TAAAV 75(6.9) 13(4.1) 15(5.5) 47(9.3) 0.011
DTAA 445(40.6) 65(20.7) 201(73.6) 179(35.2) <.001
AVR=aorticvalvereplacement;CABG=coronaryarterybypassgrafting;CAD=Coronaryarterydisease;COPD=chronicobstructivepulmonarydisease;eGFR=estimatedglomerularfiltrationrate;PVD=peripheralvasculardisease;Smoking=anysmokinghistory.Continuousvariablesareexpressedasmedian(interquartilerange);categoricalvariablesareexpressedasnumber(%).
Operativecharacteristicscomparingintercostalarterymanagementstrategiesbyaneurysmextent
Variable ICALigated ICAReattach:
Island
ICAReattach:
Bypass
ICAReattach:
LoopTAAAI
Pumptime(minutes/artery) -0.9(0.149) 1.2(<.001) 1.1(0.147) 1.2(0.018)
Clamptime(minutes/artery) -1.0(0.964) 1.1(<.001) 1.0(0.997) 1.1(0.052)
Cellssaved(Units/artery) 1.0(0.484) 1.0(0.908) 1.1(0.501) 1.5(0.053)
Packedredbloodcells(Units/artery) -0.9(0.201) 1.2(0.039) -0.7(0.055) -0.9(0.776)
Freshfrozenplasma(Units/artery) 1.2(0.061) 1.4(0.019) -0.9(0.864) 1.9(0.029)
Platelets(Units/artery) 1.1(0.269) 1.3(0.084) -0.9(0.819) 2.2(0.029)
Intraoperativecoagulopathy(OR/artery) 1.1(0.596) 0.8(0.314) 1.4(0.137) 2.0(0.010)
Intraoperativecomplications(OR/artery) 1.0(0.727) 0.9(0.354) 1.3(0.196) 1.9(0.014)
TAAAII
Pumptime(minutes/artery) 1.0(0.001) 1.1(<.001) 1.2(<.001) 1.1(<.001)
Clamptime(minutes/artery) 1.0(0.001) 1.1(<.001) 1.1(0.009) 1.1(<.001)
Cellssaved(Units/artery) 1.1(0.035) 1.2(0.005) 1.2(0.172) 1.3(0.002)
Packedredbloodcells(Units/artery) -0.9(0.215) 1.1(0.189) -0.9(0.339) 1.2(0.015)
Freshfrozenplasma(Units/artery) -0.9(0.459) -0.9(0.569) 1.2(0.391) 1.3(0.059)
Platelets(Units/artery) 1.0(0.659) 1.0(0.755) 1.1(0.752) 1.4(0.065)
Intraoperativecoagulopathy(OR/artery) 1.1(0.097) 0.8(0.120) 1.4(0.125) 1.9(0.011)
Intraoperativecomplications(OR/artery) 1.1(0.146) 0.8(0.073) 1.4(0.159) 1.8(0.014)
TAAAIII
Pumptime(minutes/artery) -1.0(0.704) 1.2(<.001) 1.1(0.053) 1.0(0.732)
Clamptime(minutes/artery) -1.0(0.926) 1.1(<.001) 1.0(0.480) -1.0(0.532)
Cellssaved(Units/artery) 1.1(0.483) 1.3(0.033) -0.7(0.233) 1.5(0.094)
Packedredbloodcells(Units/artery) -0.9(0.399) 1.1(0.194) -0.5(0.002) 1.2(0.237)
Freshfrozenplasma(Units/artery) -0.9(0.685) 1.1(0.644) -0.3(0.001) 2.0(0.046)
Platelets(Units/artery) 1.2(0.535) -0.8(0.422) -0.2(0.001) 1.8(0.175)
Intraoperativecoagulopathy(OR/artery) 1.6(0.045) 1.1(0.674) 0.4(0.285) 2.0(0.039)
Intraoperativecomplications(OR/artery) 1.5(0.102) 1.0(0.909) 0.4(0.238) 1.7(0.075)
Results
MEPs were available for only 660/1,096 (60%) of the cohort.
MEPs were lost in 370/660 (56%) of cases during surgery
332 of these (90%) recovered in the operating room.
13 (3.5%) did so after anesthesia maneuvers
74 (20%) following distal aortic perfusion
112 (31%) after restoration of distal pulsatile flow
133 (36%) after segmental artery reattachment
(p<0.0001; Cochran-Armitage test for trend)
Study Limitations
A retrospective study.
MEP monitoring began only after 2004. Therefore, data on
MEPs were available for only (60%) of the cohort.
The analysis focused mainly on ICAs T8-12
The lack anatomical information regarding collateral
circulation status .
Conclusions
Increased risk of delayed paraplegia :
Loss of intraoperative MEPs.
Ligation of T8-12 ICA (even with intact MEPs).
These findings support reattachment of T8-12 ICA,
whenever feasible, to improve spinal cord perfusion and
prevent delayed paraplegia.