Eur J Cardiothorac Surg 2002;21:970-974
© 2002 Elsevier Science NL
Thoracoabdominal or descending aortic aneurysm repair after preoperative demonstration of the Adamkiewicz artery by magnetic resonance angiography
Nobuyoshi Kawaharadaa*,
Kiyofumi Morishitaa,
Johji Fukadaa,
Akira Yamadaa,
Satoshi Murakia,
Hideki Hyodohb,
Tomio Abea
a Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo 060-8543, Japan
b Department of Radiology, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo 060-8543, Japan
Received 16 September 2001;
received in revised form 6 February 2002;
accepted 11 February 2002.
* Corresponding author. Tel.: +81-11-611-2111, ext. 3312; fax: +81-11-613-7318
e-mail: nobuyosh{at}sapmed.ac.jp
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Abstract
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Objective: The outcome of thoracoabdominal or descending aortic aneurysm repair after preoperative demonstration of the artery of Adamkiewicz (ARM) by magnetic resonance angiography (MRA) was investigated. Methods: Between January 2000 and December 2001, 40 consecutive patients who had aneurysms of the thoracoabdominal or descending aorta underwent preoperative MRA to visualize the ARM. Thirty-two patients underwent replacement of the aneurysms, and 25 patients (TAAA, 11; TAA, 14) underwent replacement of the aneurysms with preoperative detection of the ARM. Only intercostal or lumbar arteries in aneurysms, which were detected as the origin of the ARM, were reattached to the graft. The results of thoracoabdominal aortic aneurysm operations in 11 patients in whom the ARM was preoperatively detected (group I) were compared with the results of TAAA operations in 26 patients in whom the ARM was not preoperatively detected (group II). Results: MRA demonstrated the ARM in 29 (73%) of the 40 patients. The laterality of the arteries originated from the left side in 29 (100%) and between Th9 and Th12 in 25 (86%), between Th9 and L1 in 28 (97%) of the 29 patients. No spinal cord injury occurred in patients (TAAA and TAA) in whom the ARM had been preoperatively detected. Major complications following TAAA operations included paraplegia (0% in group I and 8% in group II), respiratory failure (9% in group I and 23% in group II), and renal failure requiring hemodialysis (18% in group I and 22% in group II). Operation times were 439±99 min in group I and 620±200 min in group II (P=0.008). Conclusions: Preoperative detection of the ARM is possible by MRA and is very useful for reducing the incidence of ischemic injury of the spinal cord and for reducing the time of an operation for repair of an aneurysm of the thoracoabdominal or descending aorta.
Key Words: Thoracoabdominal aortic aneurysm • Thoracic aortic aneurysm • Magnetic resonance angiography • Adamkiewicz artery • Paraplegia
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1. Introduction
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Postoperative paraplegia or paraparesis is a serious complication of reconstructive surgery for thoracoabdominal or descending aorta, the major cause of which is thought to be spinal cord ischemia during and after the procedure. Due to advances in anesthetic and surgical techniques, the incidence of intractable neurological complications has declined, but the rate of paraplegia or paraparesis is still in the range of 4–16% [1–4]. In the thoracolumbar region, it is known that the great anterior medullary artery (the artery of Adamkiewicz, arteria radicularis magna: ARM) is the dominant feeder of the spinal cord. One source of paraplegia after aortic operations is the failure to re-establish the spinal cord blood supply, the origins of which are not evident at operation. Consequently, it has been suggested that reattachment of intercostals and lumbar arteries during replacement of a descending thoracic or thoracoabdominal aorta could minimize such complications. The importance of reattachment of the intercostal artery related to the ARM has been stressed in many reports [5–8]. To avoid neurological complication, it would be useful to know the level of the intercostal artery from which the ARM originates before reconstructive aortic surgery. Recently, magnetic resonance angiography (MRA), which is non-invasive, has been developed, and the usefulness of contrast MRA has been established in aortic and major peripheral arterial studies [9,10]. We investigated the outcome of thoracoabdominal or descending aortic aneurysm repair after preoperative detection of the ARM by MRA to prevent neurological deficit.
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2. Materials and methods
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2.1. Patients
Between January 2000 and December 2001, 40 consecutive patients who had aneurysms of the thoracoabdominal or descending aorta underwent preoperative MRA to visualize the Adamkiewicz artery. Thirty-two patients (TAAA, 13; TAA, 19) underwent repair of the aneurysms, and 25 patients (TAAA, 11; TAA, 14) underwent repair of the aneurysms with preoperative detection the Adamkiewicz artery. The results of thoracoabdominal aortic aneurysm operations in 11 patients in whom the Adamkiewicz artery was preoperatively detected (group I) were compared with the results of TAAA operations in 26 patients in whom the Adamkiewicz artery was not preoperatively detected (group II). The patients in group II underwent conventional elective operations between 1994 and 1999. The characteristics of the patients in the two groups are shown in Table 1. Cerebrospinal fluid (CSF) drainage was performed in nine of the 11 patients in group I, but it was not performed in any patient in group II, a group of patients who had been treated earlier than patients in group I. We have been using the sequential clamping technique for operations on thoracoabdominal aortic aneurysms, and no cases in which the deep hypothermia method was used are included in these groups. We now reconstruct intercostal arteries with 8-mm tube grafts using the interposition method or beveled aortic suture. Only intercostal or lumbar arteries in aneurysms, which were detected as the origin of the Adamkiewicz artery, were reattached to the graft in patients in group I.
2.2. Imaging protocol and data processing
MRI was performed using a 1.5-T unit (Sigma; GE Medical Systems, Milwaukee, WI, USA). Each patient was examined from the level of Th7 or Th8 to L2 using the enhanced 3D-fSPGR method (256x128, 1.6 mm, ZIP 4, ZIP 512, FOV 20 cm, oblique-coronal). Number of slices obtained using the 3D-fSPGR technique is 240 slices. Since the size of one voxel is 0.4 mm, the size of an image voxel is 0.78x1.56x0.4 mm. Gadolinium dimegulumine (Gd-DTPA; MAGNEVIST, Schering, Berlin, Germany) was injected from the cubital vein (0.2 mmol/kg, 3 ml/s; total, 20 ml) with saline flush (20 ml). A power injector (OPTISTAR MR; Mallinckrodt, St. Louis, MO, USA) was used in all patients. After the injection, dynamic studies were performed five times. Scan durations were 18–20 s. Patients were instructed to breathe calmly and not to move their bodies during imaging. After data acquisition, the images were transmitted to DICOM datasets and displayed on a diagnostic monitor using a 0.6-mm reconstruction pitch. At the same time, the datasets were transmitted to a workstation (ADVANTAGE WINDOWS, GE Medical Systems, Milwaukee, WI, USA) for additional image processing (partial maximum intensity projection (MIP), subtraction MIP, and four-dimensional movie MIP display). The side and the branching level of the ARM were evaluated using the paging image display and the above MIP display techniques (Fig. 1
).
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Fig. 1. Case 16 in TAAA, a 74-year-old male with thoracoabdominal aneurysm (Crawford type IV). The artery of ARM ascended from the left Th11 intercostal artery, and the anterior spinal artery was continuous to the ARM with a hairpin turn. This patient underwent graft replacement with beveled aortic suture line to encompass the proximal lower descending thoracic aorta distal to Th11 intercostal artery.
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2.3. Criteria for detection of the ARM
Criteria for detection of the ARM were: (1) being continuous to the ARM with the hairpin turn in an early phase image, (2) extension of the vessel to the anterior midsagittal surface of the spinal cord from the radicular-medullary artery originating from the dorsal branch of the intercostal or lumbar artery, and (3) signal intensity in early phase diminishing in the late phase.
2.4. Surgical procedure
The patients were treated according to a previously reported procedure [11]. Forty patients underwent repair of the aneurysm of the descending or thoracoabdominal aorta using a partial cardiopulmonary bypass under double-lumen endotracheal-tube anesthesia. After the left thoracic cavity and/or left retroperitoneal space had been entered, cannulation into the right femoral artery and femoral vein was used in all patients. For thoracoabdominal aortic aneurysm repair, a left thoracoabdominal incision was made with circumferential division of the left hemidiaphragm. The segmental arteries below the T8 level, if patent, were reconstructed using the inclusion button technique or by interposition 8-mm tubular grafts for reattachment of individual intercostal or lumbar arteries. The reason for reimplanting all patent arteries between T8 and L1 is that the blood supply to the spinal cord has been reported to be provided by some arteries from T8 through to L1 in 91% of cases and the arteria radicularis magna does not always originate from the larger segmental arteries [12]. However, the T8-through-L1 operative strategy has the following problems: (1) reattaching all of these arteries from T8 to L1 prolongs the clamping time, which may cause spinal cord injury and (2) some of the arteries that are reattached may not need to be reattached. Obviously, an accurate and reliable technique for identifying arteries that need to be reattached is needed. If the ARM existed in the region of graft replacement in TAAA, only intercostal or lumbar arteries in aneurysms that were detected as the origin of the ARM were reattached to the graft. Visceral and renal arteries were also reimplanted by an island cuff technique or preserved in a beveled distal aortic anastomosis. During reconstruction, selective visceral and renal perfusion with 10-12 F balloon cannulas was performed by clamping the outflow tubing to the lower extremities.
2.5. Statistical analysis
Data were processed using Stat View J-5.0 software (Abacus Concepts Inc, Berkeley, CA, USA). Variables in groups I and II were compared using the 
2 test, Fisher's exact test, and the Mann–Whitney U-test. Data for times and age are presented as means±SD.
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3. Results
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Table 1 summarizes the results of this study. MRA demonstrated the ARM in 29 (73%) of the 40 patients. The laterality of the arteries originated from the left side in 29 (100%) and between Th9 and Th12 in 25 (86%), between Th9 and L1 in 28 (97%) of the 29 patients (Fig. 2
). Although the differences were not statistically significant, the rate of ARM detection was lower in patients who had aortic dissection (Table 2).
During the period from 1994 to 1999, 26 consecutive elective TAAA procedures in whom the ARM was not preoperatively detected (group II) were performed, compared with the elective TAAA operations in 11 patients in whom the ARM was preoperatively detected (group I). Table 3 shows the preoperative clinical data for groups I and II. There were no significant differences between the two groups with regard to preoperative characteristics. With regard to intraoperative techniques (Table 4), the distal aortic perfusion time, total aortic clamp time, and operation time were all shorter in group I. Distal aortic perfusion times were 92±58 min in group I and 165±51 min in group II (P=0.0007), total aortic clamp times were 92±44 min in group I and 149±59 min in group II (P=0.007), and operation times were 439±99 min in group I and 620±200 min in group II (P=0.008). Total selective visceral and renal perfusion times were not significantly different in the two groups. Major complications following TAAA operations were paraplegia (0% in group I and 8% in group II) and renal failure requiring hemodialysis (18% in group I and 22% in group II). There was no significant difference between in-hospital mortality rates in the two groups (Table 5). In-hospital mortality was due to pneumonia in one patient in group I and due to sepsis and hemorrhage in two patients and one patient, respectively, in group II.
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Table 3. Comparison of preoperative characteristics in patients in whom the ARM was identified by MRA before the operation and in those in whom it was not
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Table 4. Comparison of intraoperative variables in patients in whom the ARM was identified by MRA before the operation and in those in whom it was not
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Table 5. Comparison of postoperative results in patients in whom the ARM was identified by MRA before the operation and in those in whom it was not
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4. Discussion
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There is almost always a dominant anterior medullary artery in the thoracolumbar region, which is called the ARM. The Adamkiewicz artery supplies most of the blood to the anterior spinal artery, which perfuses the anterior two-thirds of the spinal cord. In anatomical studies, the ARM was found to originate from the left side in 68% [13] to 72% of patients [12], between T9 and T12 levels in 68% of patients [13], and between T8 to L1 levels in 91% of patients [12]. The results of this study coincide with results in these reports.
Koshino et al. reported that there was no significant correlation between the diameter of the ARM and those of the intercostal artery and lumbar artery from which the ARM originated. Furthermore, within the T8 to L1 vertebral level, the diameters of the intercostal artery and lumbar artery varied considerably and did not correlate with the diameter of the ARM [12]. Therefore, during operations for repair of thoracoabdominal aortic aneurysm, we have routinely reconstructed the intact intercostal arteries and lumbar arteries within the T8 to L1 vertebral level to maintain the blood supply to the spinal cord, assuming that the ARM originated from one of these levels. The problems with the operative strategy of reattaching all intercostal lumbar arteries, including those within the T8 to L1 vertebral level, are that some of the arteries may not need to be reattached and that reattachment of all of the arteries from the T8 to L1 prolongs clamp time and operation time. A long clamp time may result in spinal cord injury, and a long operation time may result in other postoperative complications.
We have been using the sequential clamping technique for operations on thoracoabdominal aortic aneurysms, and no cases in which the deep hypothermia method was used are included in these groups. We now reconstruct intercostal arteries with 8-mm tube grafts using the interposition method, and the distal perfusion time and clamp time vary depending on the number of reconstructions of arm grafts. Therefore, the reconstruction time differs depending on whether or not we have information on ARM before the operation. Obviously, an accurate and reliable technique for identifying arteries that need to be reattached is needed.
Selective angiographic procedures to demonstrate the spinal cord blood supply using high-resolution digital subtraction angiography have been reported [14,15]. The only reliable method for identifying the spinal cord blood supply before the operation was the invasive and often time-consuming technique of selective spinal angiography. This procedure has been shown to result in arteriography-related complications, including retroperitoneal bleeding, temporary cerebral ischemia, and transient paresis of the lower extremities from spinal ischemia, in 4.6% of patients [16].
The recent development in MRA, which is a non-invasive technique, has enabled detection of the ARM before an operation for descending or thoacoabdominal aortic repair [17]. To prevent ischemic injury of the spinal cord, preoperative detection of an intercostal artery that may be related with the ARM is very useful for establishing the best strategy of an operation for descending aortic aneurysm or thoracoabdominal aortic aneurysm repair, because surgical repair can be performed with intensive care to revascularize the intercostal and lumbar arteries at or near the level of the ARM.
Considering the lower rates than degenerative aortic aneurysm in identification of the ARM with MRA (Table 2), it seems that the ARM is difficult to detect in dissection cases due to complicated blood flow in the dissecting aneurysm with eventually slow flow in the false lumen feeding the ARM.
In conclusion, preoperative detection of the Adamkiewicz artery is possible by MRA, and detection of this artery is very useful for reducing the incidence of ischemic injury of the spinal cord and for reducing the time of an operation for repair of an aneurysm of the thoracoabdominal or descending aorta.
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Footnotes
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Presented at the joint 15th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 9th Annual Meeting of the European Society of Thoracic Surgeons, Lisbon, Portugal, September 16–19, 2001.
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Top
Abstract
1. Introduction
