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a Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY, USA
b Department of Neurophysiology, Mount Sinai School of Medicine, New York, NY, USA
c Department of Neuropathology, Mount Sinai School of Medicine, New York, NY, USA
Received 4 September 2007; received in revised form 23 January 2008; accepted 28 January 2008.
* Corresponding author. Address: Mount Sinai School of Medicine, Department of Cardiothoracic Surgery, One Gustave L. Levy Place, PO Box 1028, New York, NY 10029, USA. Tel.: +1 212 659 6800; fax: +1 212 659 6818. (Email: christian.etz{at}mountsinai.org).
Objective: Spinal cord blood flow (SCBF) after sacrifice of thoracoabdominal aortic segmental arteries (TAASA) during thoracoabdominal aortic aneurysm (TAAA) repair remains poorly understood. This study explored SCBF for 72 h after sacrifice of all TAASA. Methods: Fourteen juvenile Yorkshire pigs underwent complete serial TAASA sacrifice (T4–L5). Six control pigs underwent anesthesia and cooling to 32 °C with no TAASA sacrifice. In the experimental animals, spinal cord function was continuously monitored using motor evoked potentials (MEPs) until 1 h after clamping the last TAASA. Fluorescent microspheres enabled segmental measurement of SCBF along the entire spinal cord before, and 5 min, 1 h, 5 h, 24 h and 72 h after complete TAASA sacrifice. A modified Tarlov score was obtained for 3 days after surgery. Results: All the pigs with complete TAASA sacrifice retained normal cord function (MEP) until 1 h after TAASA ligation. Seven pigs (50%) with complete TAASA sacrifice recovered after 72 h; seven pigs suffered paraparesis or paraplegia. Intraoperatively, and until 1 h postoperatively, SCBF was similar among the three groups along the entire cord. Postoperatively, SCBF did not decrease in any group, but significant hyperemia occurred at 5 h in controls and recovery animals, but did not occur in pigs that developed paraparesis or paraplegia in the T8–L2 segments (p = 0.0002) and L3–S segments (p = 0.0007). At 24 h, SCBF remained marginally lower from T8 caudally; at 72 h, SCBF was similar among all groups along the entire cord. SCBF in the segments T8–L2 at 5 h predicted functional recovery (p = 0.003). Conclusions: This study suggests that critical spinal cord ischemia after complete TAASA sacrifice does not occur immediately (intraoperatively), but is delayed 1–5 h or longer after clamping, and represents failure to mount a hyperemic response to rewarming and awakening. The short duration of low SCBF associated with spinal cord injury suggests that hemodynamic and metabolic manipulation lasting only 24–72 h may allow routine preservation of normal cord function despite sacrifice of all TAASA secondary to surgical or endovascular repair of large TAAA.
Key Words: Spinal cord perfusion/protection • Paraparesis/paraplegia • Segmental artery sacrifice • Thoracoabdominal aortic aneurysm repair (TAA/A)
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