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Eur J Cardiothorac Surg 2000;18:162-167
© 2000 Elsevier Science NL

Single-clamp technique for aneurysms of the descending thoracic aorta: report of 132 consecutive cases

Texas Heart Institute at St. Luke's Episcopal Hospital, P.O. Box 20345, MC 3-258, Houston, TX 77225-0345, USA

Received 7 September 1999; received in revised form 18 January 2000; accepted 23 May 2000.

Corresponding author. Tel.: +1-713-791-4932; fax: +1-713-791-3424

	Abstract

Top Abstract 1. Introduction 2. Patients and Methods 3. Results 4. Discussion 5. Comment Appendix A Conference discussion Appendix B Editorial commentary References

 
Objective: To determine the efficacy of a single-clamp technique in preventing spinal cord ischemia during repair of aneurysms of the descending thoracic aorta. Patients and methods: From January 1989 to May 1999, 132 consecutive patients (91 men and 41 women, aged 31–86 years), with aneurysms of the descending thoracic aorta underwent repair using a single-clamp technique and temporary partial distal exsanguination. The diseased aortic segment was replaced with a Dacron graft. Blood was re-infused from an auto-transfusion device, and the segmental vessels were over-sewn but not implanted into the graft. Results: The average aortic cross-clamp time was 26.4 min (range, 11–67 min) for the overall group and 37.4 min for patients who had spinal cord complications. An average of 2066 ml of blood was auto-transfused (range, 450–6100 ml). During the first 30 postoperative days, 17 patients (12.9 %) died. Eleven patients (8.3%) had spinal cord dysfunction, six patients (4.5%) had lower-extremity paraparesis, and five patients (3.8%) had paraplegia. Nine patients (6.8%) had renal failure necessitating hemodialysis. Other complications included bleeding in 15 cases (11.4%), respiratory failure in 12 cases (9.1%), wound-related sequelae in five cases (3.8%), distal embolism in five cases (3.8%), and bowel ischemia in two cases (1.5%). Conclusion: The single-clamp technique yielded an acceptable complication rate, and the mortality was comparable to that seen after the use of more complex methods. For satisfactory results, the cross-clamp time should not exceed 30 min.

Key Words: Aneurysm • Aorta, descending thoracic • Single-clamp technique • Aortic cross-clamping • Spinal cord protection

	1. Introduction

Top Abstract 1. Introduction 2. Patients and Methods 3. Results 4. Discussion 5. Comment Appendix A Conference discussion Appendix B Editorial commentary References

 
Surgical treatment of aneurysms of the descending aorta may cause complications related to ischemia of vital organs during temporary aortic cross-clamping. The most vulnerable organ is the spinal cord, which, if deprived of blood flow for long enough, can incur a potentially devastating postoperative neurologic deficit. For almost half a century, prevention of this complication has been the subject of extensive reports in the medical literature, which will not be reviewed here. This article examines our experience with a simplified single-clamp technique for treating aneurysms of the descending thoracic aorta [1–5].

	2. Patients and Methods

Top Abstract 1. Introduction 2. Patients and Methods 3. Results 4. Discussion 5. Comment Appendix A Conference discussion Appendix B Editorial commentary References

 
2.1. Patients
From January 1989 to May 1999, 132 consecutive patients with aneurysms of the descending thoracic aorta underwent aortic repair using a single-clamp technique. The patients included 91 men (68.9%) and 41 women (31.1%), whose ages ranged from 31 to 86 years (mean, 64 years]. Table 1 shows the etiology of the aneurysms, which were located in the proximal descending aorta (24 cases; 18.2%), the mid descending aorta (54 cases; 40.9%), the distal descending aorta (nine cases; 6.8%), or the thoracoabdominal aorta (45 cases; 34.1%). Ten patients (7.6%) had impending or frank aortic rupture preoperatively. Fifty-four patients (40.9%) had undergone 67 operations for previous aortic aneurysms.

A longitudinal incision was made in the distal aorta and was extended the length of the aneurysm. Blood was aspirated and collected in an auto-transfusion device for later re-infusion. Segmental intercostal and visceral vessels were allowed to drain until both the distal and the proximal aortic anastomoses were completed. This method of partial distal exsanguination has been detailed elsewhere [1–5] (Fig. 1) .

View larger version (40K): [in this window] [in a new window]   Fig. 1. (A–D) Technique of single-clamp repair of aneurysms of the descending and proximal abdominal aorta (see text).

	3. Results

Top Abstract 1. Introduction 2. Patients and Methods 3. Results 4. Discussion 5. Comment Appendix A Conference discussion Appendix B Editorial commentary References

 
The average aortic cross-clamp time was 26.4 min (range, 11–67 min) for the overall group, 37.4 min for patients who had spinal cord complications, and 26.0 min for patients without such complications. An average of 2066 ml of blood was auto-transfused (range, 450–6100 ml).

During the first 30 postoperative days, 17 patients (12.9%) died. The cause of death was multi-system organ failure/sepsis in seven cases, hemorrhage in four cases, coexisting coronary artery disease in three cases, postoperative cardiac failure in one case, acute respiratory distress syndrome in one case, and stroke in one case.

Eleven patients (8.3%) had spinal cord dysfunction, six patients (4.5%) had lower-extremity paraparesis, and five patients (3.8%) had paraplegia. Nine patients (6.8%) had renal failure necessitating hemodialysis. Other complications included bleeding in 15 cases (11.4%), respiratory failure in 12 cases (9.1%), wound-related sequelae in five cases (3.8%), distal embolism in five cases (3.8%), and bowel ischemia in two cases (1.5%).

	4. Discussion

Top Abstract 1. Introduction 2. Patients and Methods 3. Results 4. Discussion 5. Comment Appendix A Conference discussion Appendix B Editorial commentary References

 
The rationale for this approach to aortic repair deserves some explanation. Increased cerebrospinal fluid (CSF) pressure during aortic cross-clamping has been implicated as a cause of neurologic complications [6–9]. Some studies have shown that adjunctive CSF drainage can prevent these problems [7,10–15]. Other studies have failed to confirm the value of this approach [16,17]. In some of our cases in which the CSF pressure was monitored during single cross-clamping and partial exsanguination, we noted a definite decrease in the CSF pressure [9]. When distal perfusion techniques are used, the CSF pressure actually increases during aortic cross-clamping, and this increase may have a detrimental effect unless CSF drainage is used. Studies of the central venous pressure during this critical ischemic period have shown that reductions in the central venous and CSF pressures parallel each other, thus possibly enhancing protection of the spinal cord.

Another concern involves the management of the segmental arteries in the distal aorta. During aortic cross-clamping with our technique, the arteries are allowed to drain, reducing the CSF pressure. Over-sewing the vessels before performing the distal and proximal aortic anastomoses may increase the CSF pressure during this critical period. Moreover, re-implantation of the arteries into the graft may prolong the cross-clamp period. When feasible, the distal anastomosis is obliquely tailored to include critical distal vessels such as the artery of Adamkiewicz [18]. In a recent report, Ross, Kron, and colleagues [19], who advocate the single-clamp technique, described their experience with re-implantation of segmental vessels into the graft in cases of thoracoabdominal aneurysms. They consider such re-implantation essential in preventing paraplegia. Safi and associates [11–13] also endorse this approach. However, determining which segmental vessels to re-implant into the graft requires judgment, and the long-term patency of the re-implanted vessels is questionable. Hemorrhage later, from the anastomoses, may increase blood loss. Because our main goal was to determine the efficacy of the single-clamp technique, we avoided using extra-corporeal circulation, CSF drainage, and re-implantation of segmental vessels into the graft.

Hypothermia has proved efficacious for protecting the central nervous system [10,20–22], but it usually involves a total-body temperature reduction, which can cause coagulopathy, pulmonary complications, or other problems in large or obese patients. Local cooling of the spinal cord by means of epidural [23,24] or intrathecal [14,15] cold perfusion techniques should overcome some of these problems of total-body hypothermia. Some techniques designed to provide local cooling, however, may cause complications related to hemorrhage or excessive exposure of the spinal cord to cold. Selective cooling of the involved segment of the aorta may be expected to protect the spinal cord at the site of ischemia. This concept has been confirmed by animal experiments in our laboratory [25,26].

Recently, we used selective hypothermia in a 78-year-old patient undergoing repair of a massive thoracoabdominal aneurysm [26]. The patient had previously undergone graft replacement of the infrarenal aorta. In our previous experience with such cases, we had observed a heightened incidence of paraplegia. In this particular case, we induced selective hypothermia by means of left atrial-to-proximal descending aortic cannulation with the aid of a bypass pump, an oxygenator, and a heat exchanger (Fig. 2) , and the patient recovered uneventfully. This technique may be helpful in other high-risk cases.

View larger version (126K): [in this window] [in a new window]   Fig. 2. Technique of selective hypothermia used to protect the spinal cord during aortic cross-clamping.

	5. Comment

Top Abstract 1. Introduction 2. Patients and Methods 3. Results 4. Discussion 5. Comment Appendix A Conference discussion Appendix B Editorial commentary References

	Footnotes

 
Presented at the 13th Annual Meeting of the European Association for Cardio-thoracic Surgery, Glasgow, Scotland, UK, September 5–8, 1999.

	Appendix A Conference discussion

Top Abstract 1. Introduction 2. Patients and Methods 3. Results 4. Discussion 5. Comment Appendix A Conference discussion Appendix B Editorial commentary References

 
Dr A. El-Bishry (Cairo, Egypt): I would like to ask Dr Cooley about the relation of the clamp placement proximally. You have put the clamp, in some of your cases, between the left subclavian and the left carotid, does this relate to the mortality or to the incidence of spinal cord dysfunction?

Dr Cooley: The question is: have you seen any incidence of complications from clamping between the left carotid and the left subclavian?

When we first began doing this, I was anticipating some complications, but it does not seem to have any important effect. In fact, we have clamped briefly between the left carotid and the innominate artery without having cerebral complications. So I don't think that's a concern.

I know that the conventional thinking on aneurysms today includes some form of extracorporeal pump circulation. I have noted that if one is using perfusion distally and recording spinal fluid pressure, as soon as one starts the pump simultaneously, it raises spinal fluid pressure. So you may be doing the patient a disservice by pumping distally.

Another question that arises is: why not implant some of the segmental vessels? I could have done that in these cases, but I thought since this was more or less investigational or experimental, I didn't want to introduce one other factor to attribute a good result to the fact that we had reimplanted a vessel. Therefore, we left it rather pure and just followed this one technique. I think that this information might be useful for medical–legal reasons. I know in our country this is always a consideration, but now we have a reported series of cases done by the simple one-clamp technique.

Dr P.-A. Kling (Umea, Sweden): Do you make any investigations about the circulation to the spinal cord before your operations? You mentioned this artery called Adamkiewicz artery, does it really exist?

Dr Cooley: In answer to that, we do not. I find that it's more or less useless to attempt to identify the nutrient vessels to the spinal cord, because it's so highly variable. And if you don't know which vessel is critical, we speak of the artery of Adamkiewicz, but that artery itself may not be essential in preservation of the spinal cord. We all assume that it is, but I have serious doubt. I recently heard a presentation in Brazil where Dr Buffolo said that the injury to the spinal cord, in his opinion, is not from anoxia or ischemia but metabolic.

Dr R. Replogle (Chigago, IL, USA): I would like to ask Dr Cooley, in so many of these reoperations, perhaps you could give the younger surgeon your choice of incisions. I'm quite certain you're not using a 3 cm midaxillary thoracoscopic incision for these, and it might be of interest to the younger people to have you just give some indication of how you approach these difficult cases.

Dr Cooley: Well, most of them are done with a simple intercostal incision, with an extensive intercostal incision, either in the 4th or in the 6th space. But in many of these cases, it's necessary to do a dual intercostal incision to expose both the proximal and distal extent. I don't believe this type of surgery will lend itself to this minimal access approach.

	Appendix B Editorial commentary

Top Abstract 1. Introduction 2. Patients and Methods 3. Results 4. Discussion 5. Comment Appendix A Conference discussion Appendix B Editorial commentary References

 
It is a daunting task to offer a critique on data from one of the outstanding pioneers of cardiovascular surgery. In this issue of the Journal, Cooley et al. describe their experience using a single clamp technique with partial exsanguination for a heterogeneous group of descending thoracic and thoraco-abdominal aortic aneurysm between 1989 and 1999 [1]. The technique described involves proximal aortic clamping, opening of the aneurysm utilizing a cell salvage technique and performance of an open distal anastomosis followed by the proximal anastomosis. Over-sewing intercostal arteries that bleed back is delayed until after the aortic clamp is released. The reported 30-day mortality was 12.9% with a paraplegia/paraparesis rate of 8.3%. Renal failure occurred in 6.8% of patients and excessive bleeding in 11.4%. The authors are to be congratulated on these results. However, the role of this technique in the armamentarium of the cardiovascular surgeon requires some discussion.

The most devastating complication of descending and thoraco-abdominal aortic surgery is paraplegia secondary to spinal cord ischaemia. Once paraplegia or severe paraparesis is established, the patient's destiny includes substantial loss of independence, acceptance of disability and rehabilitation. The spinal cord blood supply has both anterior and posterior components [2]. The two posterior spinal arteries receive supplemental collateral supply at multiple levels allowing the posterior third of the spinal cord a relative resistance to ischaemia. The anterior two thirds of the spinal cord is served by a single anterior spinal artery which is often discontinuous. This arises from the basilar artery and is further supplied by radicular arteries from the vertebral arteries, the thyro-cervical trunk, the thoracic and lumbar intercostal arteries and the hypogastric arteries. The largest and most important radicular artery, known as the artery of Adamkiewicz or the arteria radicularis magna, most commonly arises from intercostal level T8–L2.

Maintenance of spinal cord blood supply during thoracic and thoraco-abdominal aortic aneurysm surgery is therefore dependent upon a variety of different supply routes, which may assume varying importance in different individuals. The relative contribution of each supply source may also change intra-operatively as inflows are occluded or reperfused. For instance during left subclavian occlusion, dependency on an intercostal-radicular supply source may increase. During descending aortic clamping, absolute ischaemia may or may not be attenuated by continued distal perfusion via the hypogastric collateral system. Thus, the spinal cord circulation may be able to tolerate acute adjustment of both the sources and relative contributions of its diverse arterial supply routes. This concept is supported by the observation that step-wise sacrifice of large numbers of thoracic and lumbar intercostal sacrifice can be associated with retention of somato-sensory evoked potentials and low paraplegia rates during thoraco-abdominal aneurysm repair [3,4].

The incidence of paraplegia/paraparesis would appear to be dependent on two key factors: (1) the duration of spinal cord ischaemia and (2) permanent interruption of spinal cord perfusion due to failure to reperfuse critically important intercostals in circumstances of inadequate collateral circulation. Once the cord suffers ischaemia, following reperfusion, it becomes more vulnerable to secondary ischaemic insults. Moreover, injury is associated with a rise in cerebro-spinal pressure, which may further compromise arterial perfusion. This extended vulnerability is associated with a continuing risk of developing paraplegia hours or days post-operatively. Any protection strategy must take account of the phenomena associated with reperfusion and the role of peri-operative hypoxia and hypertension in exacerbating spinal cord injury.

Thus, aortic clamp time and the extent of aortic resection are directly related variables. Paraplegia risk is lowest in operations on the proximal descending aorta with short clamp times and adequate collateralization (e.g. coarctation repair). When less collateral supply is present, ischaemic tolerance is reduced. In these circumstances, if the spinal cord blood supply is interrupted transiently and then restored (e.g. repair of traumatic aortic transection without shunt or bypass support), the risk of paraplegia increases with the duration of aortic cross clamping as a sigmoid curve. When clamping time is less than 30 min the risk is <10%. The risk then increases towards unity with clamp times in excess of 1 h. As the extent of aortic replacement increases so does the risk of paraplegia. The following list places aortic replacements in ascending paraplegia risk order: proximal descending<distal descending,<entire descending<Crawford extent III<Crawford Extent I<Crawford Extent II. As repairs become more extensive the parallel aims of reducing clamp time and ensuring restoration of spinal cord blood supply appear mutually exclusive objectives. If intercostals are separately re-implanted, the clamp time or ischaemic period may be prolonged. If critical intercostals are not reperfused then even short clamp times may results in paraplegia. The surgeon is thus faced with a conundrum of whether to try to achieve expeditious surgery with short clamp times or to proceed with intercostal re-implantation, thereby inevitably increasing the duration of ischaemia.

This conundrum has been addressed in several ways. There is compelling evidence that distal perfusion of the aorta during aortic repair can reduce the risk of paraplegia, even when such perfusion does not include the T8–L2 aortic segment [5]. In these circumstances, distal perfusion may improve spinal cord perfusion during the clamp period via lower lumbar intercostals, hypogastric vessels and visceral-somatic collaterals. Even if distal perfusion is only feasible during construction of a proximal anastomosis, the period of spinal cord ischaemia is reduced by its use. Hypothermia has been an important neurological protective technique for nearly half a century. Modest hypothermia can increase ischaemic tolerance and may account for some of the protection afforded by partial cardiopulmonary bypass and left heart-distal techniques. Deep hypothermia, so important in brain protection during aortic surgery, has also produced excellent results in the prevention of paraplegia in extensive thoraco-abdominal repairs [6–9]. Increasing ischaemic tolerance induced by the metabolic down-regulation of hypothermia allows an unhurried aortic reconstruction with visualization and re-implantation of identifiable thoraco-lumbar intercostals.

Even when temporary spinal cord ischaemia is an inevitable consequence of the repair there is increasing evidence that manipulation of reperfusion conditions may attenuate paraplegia risk [10–13]. Spinal cord perfusion pressure is related to the difference between arterial driving pressure and cerebro-spinal fluid (CSF) pressure. During aortic clamping CSF pressure rises, potentially reducing cord perfusion [14]. Drainage of CSF both intra-operatively and post-operatively has been increasingly used in clinical practice [10–13,15]. Although an early trial suggested no benefit, this has been criticized for utilizing an inadequate volume and duration of CSF drainage and pressure monitoring [16]. Compelling data is now becoming available attesting to the efficacy of this technique in the prevention of spinal cord complications during thoraco-abdominal aneurysm repair [11,12,17].

In the report by Cooley et al. [1], the success of the described technique would appear dependent on two factors, (a) speed of surgery and (b) the role of distal exsanguination during the repair. The effect of clamp time on paraplegia risk is again demonstrated with an observed cut-off of 30 min tolerated ischaemia. It is argued that distal exsanguination (with non-oversewing of intercostals during the clamp period) may attenuate the rise in CSF pressure seen with proximal aortic clamping and thereby theoretically improve spinal cord perfusion. It is also possible, that intercostal bleed-back during the clamp period may reduce cord arterial perfusion and thus increase cord ischaemic jeopardy. Regrettably, other factors that may affect paraplegia rate have not been separately analyzed in this report and thus the role of this technique on the surgery of the various anatomical subtypes of aneurysm cannot be judged with certainty. For instance the anastomotic technique suggests that steps were taken to bevel anastomoses and reperfuse lower thoracic intercostals. Thus, although, 34% of cases were reported to be thoraco-abdominal aneurysms, these would have to be anatomically limited to allow construction of a single open distal anastomosis. This method may well be the technique of choice for mid-descending aneurysms with a technically straightforward proximal and distal extent allowing expeditious replacement without the need for additional’ intercostal or visceral re-implantation. For more extensive aneurysms, the technique will probably have limited application by most cardiovascular surgeons.

References
[1]Cooley D, Golino A, Frazier O. Single-clamp technique for aneurysms of the descending thoracic aorta: report of 132 consecutive cases. Eur J Cardio-thorac Surg 2000;18:162–167.

[2]Svensson L, Klepp P, Hinder R. Spinal cord anatomy of the baboon: comparison with man and implications for spinal cord blood flow during thoracic aortic cross clamping. S African J Surg 1986;24:32–34.

[3]Galla J, Ergin M, Lansman S, McCullough J, Nguyen K, Speilvogel D, Klein J, Griepp R. Use of somato-sensory evoked potentials for thoracic and thoraco-abdominal aortic resections. Ann Thorac Surg 1999;67:1953–1958.

[4]Griepp R, Ergin M, Galla J, Klein J, Spielvogel D, Griepp E. Minimizing spinal cord injury during repair of descending thoracic and thoraco-abdominal aneurysms. Semin Thorac Cardiovasc Surg 1998;10:25–28.

[5]Coselli J, LeMaire S. Left heart bypass reduces paraplegia risk after thoraco-abdominal aortic aneurysm repair. Ann Thorac Surg 1999;67:1931–1934 (discussion 1953–1958).

[6]Carrel T, Berdat P, Robe J, Gysi J, Nguyen T, Kipfer B, Althaus U. Outcomes of thorac-abdominal aortic operations using deep hypothermia and distal exsangunination. Ann Thorac Surg 2000;69:692–695.

[7]Kouchoukos N, Dailey B, Rokkas C, Murphy S, Bauer S, Abboud N. Hypothermic bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg 1995;67–76.

[8]Safi H, Miller C. Spinal cord protection in descending thoracic and thoraco-abdominal aortic repair. Ann Thorac Surg 1999;67:1937–1939.

[9]Rokkas C, Kouchoukos N. Profound hypothermia for spinal cord protection in operations on the descending thoracic and thoraco-abdominal aorta. Semin Thorac Cardiovasc Surg 1998;10:57–60.

[10]Hamilton I, Hollier L. Adjunctive therapy for spinal cord protection during thoracoabdominal aortic aneurysm repair. Semin Thorac Cardiovasc Surg 1998;10:35–39.

[11]Safi H, Campbell M, Ferreira M, Azizzadeh A, Miller C. Spinal cord protection in descending thoracic and thoracoabdominal aortic aneurysm repair. Semin Thorac Cardiovasc Surg 1998;10:41–44.

[12]Safi H, Ill CM. Spinal cord protection in descending thoracic and thoraco-abdominal aortic repair. Ann Thorac Surg 1999;67:1937–1939.

[13]Svensson L, Hess K, D'Agostino R, Entrup M, Hreib K, Kimmel W, Nadolny E, Shahian D. Reduction of neurologic injury after high risk thoraco-abdominal aortic operation. Ann Thorac Surg 1998;66:132–138.

[14]Piano G, Gewertz B. Mechanism of increased cerebrospinal pressure with thoracic aortic occlusion. J Vasc Surg 1990;11:695–701.

[15]Hollier L. Protecting the brain and spinal cord. J Vasc Surg 1987;5:524–528.

[16]Crawford E, Svensson L, Hess K, Shenaq P, Coselli J, Safi H, Mohindran P, Rivera P. A prospective randomised study of cerebropsinal fluid drainage to prevent paraplegia after high risk surgery on the thoracoabdominal aorta. J Vasc Surg 1991;13:36–46.

[17]LeMaire S, Koksoy C, Schmittling Z, Miller C, Oberwalder P, Curling P, Coselli J. Cerebrospinal fluid drainage during thoraco-abdominal aortic aneurysm repair prevents spinal cord ischaemia. J Vasc Surg 2000 in press.

Robert S. Bonser

(Advisory Board Member)

	References

Top Abstract 1. Introduction 2. Patients and Methods 3. Results 4. Discussion 5. Comment Appendix A Conference discussion Appendix B Editorial commentary References

 

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