HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Marc Schepens Karl Dossche Robin Heijmen Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Schepens, M. Articles by Boezeman, E. Search for Related Content PubMed PubMed Citation Articles by Schepens, M. Articles by Boezeman, E. Related Collections Great vessels

Eur J Cardiothorac Surg 2004;25:701-707
© 2004 Elsevier Science NL

Introduction of adjuncts and their influence on changing results in 402 consecutive thoracoabdominal aortic aneurysm repairs

^a Department of Cardiothoracic Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
^b Department of Anesthesiology and Intensive Care, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
^c Department of Cardiology Research and Statistical Analysis, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
^d Department of Neurophysiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands

Received 21 October 2003; received in revised form 9 January 2004; accepted 14 January 2004.

^* Corresponding author. Tel.: +31-30-609-2104; fax: +31-30-609-2120
e-mail: m.schepens{at}antonius.net

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Objective: To assess the influence of adjuncts, cerebrospinal fluid drainage (CSFD) and evoked potentials, on morbidity and mortality after thoracoabdominal aortic aneurysm (TAAA) repair and to update our experience. Methods: Between February 1981 and February 2003, 402 consecutive patients underwent repair of their TAAA using simple cross-clamping between 1981 and 1994 (n=123; CC), left heart bypass (from 1987; n=254) or extracorporeal circulation (n=25; ADJ). Somatosensory evoked potentials were used in 264 patients and motor evoked potentials in 176 patients. CSFD was used in 202 patients (50.2%). Results: Overall hospital mortality was 10.9:14.1% in the CC-group versus 9.1% in the ADJ-group (P=0.07). The incidence of postoperative dialysis was 6.1%. Paraplegia and paraparesis together was found in 11.3%. Independent risk factors for hospital mortality were age (OR 1.1 per year, 95% CI 1.04–1.16), rupture (OR 3.8, 95% CI 1.7–8.8) and postoperative hemodialysis (OR 8.1, 95% CI 3.2–20.3). For postoperative hemodialysis the risk factors were age75 years (OR 3.2, 95% CI 1.1–9.7), a preoperative creatinine level higher than 150 µM/l (OR 6.5, 95% CI 2.6–16.2), and as a protective factor operation performed after 1995 (OR 0.2, 95% CI 0.06–0.6). For spinal cord dysfunction (paraplegia and paraparesis together) the protective factors were age75 years (OR 0.16, 95% CI 0.02–1.2), operation performed after 1995 (OR 0.31, 95% CI 0.15–0.65) and a previous aortic dissection (OR 0.38, 95% CI 0.15–0.9). Conclusions: The use of different adjuncts introduced over the years clearly influenced our results in a positive way.

Key Words: Aortic aneurysm • Thoracoabdominal aortic aneurysm • Evoked potentials • Cerebrospinal fluid drainage • Renal failure • Left heart bypass

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. Conference... References

 
It was the late Stanley Crawford who introduced the surgical technique of simple cross-clamping (CC) and the replacement by the so-called graft inclusion technique with direct visceral reattachment to treat thoracoabdominal aortic aneurysms (TAAAs) [1]. It then became the mainstay of the surgical therapy of TAAAs. We have previously reported on our results using this technique [2]. Since then numerous adjuncts such as distal aortic perfusion, moderate hypothermia, cerebrospinal fluid drainage (CSFD), evoked potentials (EPs) have been introduced with the aim to reduce perioperative morbidity, especially renal failure and spinal cord dysfunction, and mortality. Over the past 10 years, numerous papers have shown the beneficial effects of these ‘assists’ [3–13].

The aim of this study was to review possible differences in the perioperative morbidity and mortality between the group of patients operated upon using simple cross-clamping (CC-group) and the group in which the left heart bypass or total extracorporeal circulation (ADJ-group) was used. Furthermore we wanted to assess the influence of CSFD and EP's and to update our institutional experience.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. Conference... References

 
2.1. Patients and time-related introduction of adjuncts
From February 1981 to February 2003, 402 consecutive TAAAs were repaired at the St. Antonius Hospital, Nieuwegein, The Netherlands.

During the first years we used only simple CC (n=123). In 1987 the left heart bypass was introduced for distal aortic perfusion (n=254), initially for types I and II, and later also for types III and IV. Simple CC was completely abandoned in 1994. Only occasionally extracorporeal circulation was used, mostly when clamping of the aortic arch between the left subclavian artery and the left common carotid artery was not feasible or when the aneurysm was so large that a safe entry in the thorax was judged unsafe (n=25). The total number of patients in the ADJ-group was 279. CSFD was used since 1989 in 202 patients. Intraoperative EPs were applied since 1987 (somatosensory evoked potentials in 264 patients) and combined somatosensory and motor evoked potentials in 176 patients since 1994. Motor evoked potentials cannot be applied in patients who were operated upon using simple CC due to the ischemia of the legs. Contra-indications for this technique were known neuromuscular disorders of any kind, epilepsy, implanted pacemaker or cardiodefibrillator.

The mean age was 65.2±10.4 years; 64.8±10.2 years in the patient group operated upon before 1996 and 65.8±10.5 years in the group operated on since 1996 (P=0.35). There were 269 men (66.7%). The cause of the aneurysm was degenerative in 285 (70.9%) and it was a chronic postdissection TAAA in 112 (27.9%). Rupture was present in 57 patients (16%). Aneurysmal extent was classified as described by Crawford [1] (Fig. 1) : 19.9% type I (n=80; from the left subclavian to or opposite to the superior mesenteric artery but above the renal arteries), 46.5% type II (n=187; from the left subclavian artery to the level of the aortic bifurcation or more distally), 23.1% type III (n=93; from the level of the sixth intercostal space to the infrarenal aorta) and 10.4% type IV (n=42; from the 12th intercostal space tapering to above the iliac bifurcation). Fourteen patients had proven Marfan syndrome according to the Gent nosology [14].

View larger version (71K): [in this window] [in a new window]   Fig. 1. Different types of TAAAs.

The distal aortic perfusion was typically conducted from the left atrium to the left common femoral artery. The left hemidiaphragm was always divided circumferentially keeping a rim of 1.5 cm of diaphragmatic tissue intact on the chest wall (for closure) and the aorta was exposed using median rotation of the viscera (either transperitoneally or using the extraperitoneal route). Priming of the left heart bypass was done with 500 ml normal saline solution, 5000 units of heparin, and 100 ml (20%) albumin. All tubings and cannulas were heparin-coated except the heat-exchanger. The mean proximal arterial pressure was kept well above 80 mmHg if possible and the distal perfusion pressure (measured in the right femoral artery) above 70 mmHg by adjusting bypass flow, intravascular volume and vasopressors if necessary. During the intervention rectal temperature was permitted to decrease spontaneously to 32 °C. When aneurysm contours allowed doing so, we used staged or sequential clamping in a cranio-caudal fashion to maximize the beneficial effect of the distal perfusion. A woven prosthesis was sewn to the completely transsected proximal aortic stump with prolene 4x0. Reimplantation of intercostal or lumbar arteries directly into the prosthesis through an oval, circular or square opening (very rarely via an interposed 6 or 8 mm dacron or ptfe tube) was started. When opening the aortic segment containing intestinal and renal arteries, a renal cooling solution (nonoxygenated 4 °C Ringer's acetate with 12 g mannitol per l, 100 ml per min, no heparin) was administered through both renal artery ostia and repeated every 30 min if appropriate with the intention to keep the renal temperature at 15 °C during the period of renal artery occlusion. The celiac trunk and superior mesenteric artery were occluded with a balloon catheter. Direct reimplantation of these vessels into the vascular prosthesis was performed, usually the right renal artery in a separate opening in the dorsal aspect of the prosthesis and the left renal together with the celiac trunk and superior mesenteric artery in one island in the anterolateral side of the prosthesis. Finally the graft was anastomosed above or on the aortic bifurcation, if necessary an aorto mono- or biiliac or aorto mono- or bifemoral prosthesis was added. Sometimes the left heart bypass was stopped in order to make an open distal anastomosis. Rewarming to a rectal temperature of 34 °C was started when the visceral vessels and most important intercostal or lumbar arteries were reperfused in the antegrade (normal) way. Bypass was then discontinued and the blood in the circuit was retransfused through the left atrial cannula. Finally the cleaned aneurysmal sac was closed over the prosthesis. During the procedure a cell saver was used and the autotransfused blood was further supplemented by red cells, fresh frozen plasma and platelets.

2.3. Data collection and statistical analysis
Most important associated preoperative, intraoperative and postoperative variables used in the analysis are given in Table 1. Preoperative variables could not always be obtained in emergency cases. Throughout the 22-year experience the information was deduced from the patient records and entered in a prospectively maintained database.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. Conference... References

View larger version (13K): [in this window] [in a new window]   Fig. 2. Influence of age (in combination with rupture and dialysis) on hospital mortality (based on the multivariate equation).

The incidence of postoperative hemodialyis has decreased from 9.3% before 1996 to 2.7% since then (P=0.01). The incidence of postoperative dialysis for the total group was 6.1:10.9% in the CC-group versus 4.0% in the ADJ-group (P=0.01). For postoperative hemodialysis the independent risk factors after logistic regression were age higher than or equal to 75 years (OR 3.2, 95% CI 1.1–9.7), a preoperative serum creatinine level higher than 150 µM/l (OR 6.5, 95% CI 2.6–16.2), and as a protective factor emerged an operation performed later than 1995 (OR 0.2, 95% CI 0.06–0.6). If the renal arteries were contained in the TAAA (types II, II and IV), the appearance time of blue dye in the urine after reperfusion of the kidneys longer than 30 min was also a risk factor for postoperative hemodialysis (OR 22.5, 95% CI 6.3–80).

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Ten years ago surgical results of TAAA repair were less satisfactory than they are today. A downward trend in complication rates and mortality is generally observed. The introduction of several adjuncts is probably associated with this decrease. However, hospital mortality has remained fairly constant over time despite advances in postoperative care. This study shows that increasing age emerges as a major risk factor for hospital mortality. This was also reported by Coselli et al. [15]. The risk of dying in the hospital is 2.7 and 10.1% for a patient of 60 and 70 years, respectively. This risk becomes 3.0 and 11.1% for patients of 61 years and 71 years, respectively. Each added year in age increases the relative risk of hospital death by 10%. Although age alone should not be a reason to exclude patients from surgery, we should realize that in patients over 75, mortality is substantial.

The number of ruptured TAAAs operated upon by our team has decreased over time. This could be explained by several factors. First there is the growing shortage of intensive care unit capacity and the institutional pressure on the regular cardiac operative schedule which has forced us to refuse some patients with free rupture because there were simply no intensive care unit beds or operative rooms available at the time of contact with the referring hospital. These refusals might have introduced a selection bias which could have played an important role in the better outcome in recent years. On the other hand we appreciate that the results of ruptured TAAAs are bad, especially when the rupture is free [16]. We would like to underscore that it is of utmost importance that surgeons and anesthesiologists with experience in this kind of pathology are available 24 h a day so that not the youngest resident with no experience has to perform the intervention.

In our series we notice a lowering of the incidence of paraplegia and paraparesis from almost 17% before 1996 to 5.4% over the past 6 years. With regard to the interpretation of spinal cord problems it is important to stress that we have included patients with paraparesis because in many series these patients are excluded. Furthermore both early (on awakening) and delayed-onset (loss of peripheral neurologic function after initial normal function) problems are included while intraoperative or early postoperative deaths who could not be evaluated for neurologic deficit are excluded from the risk analysis. Our current strategy to prevent spinal damage in elective patients consists of the use of distal aortic perfusion (keeping the distal perfusion pressure at or higher than 70 mmHg) in combination with sequential aortic clamping, single or if possible double CSFD, moderate permissive hypothermia (32 °C), liberal reattachment of intercostal and/or lumbar arteries partially guided by EPs (especially those between T8 and L2). This multimodality approach is based on findings of other surgeons with a vast experience [3,6–9,11] and is supported by our own results. We do not identify preoperatively the artery of Adamkiewicz by angiography [17] neither intraoperatively nor by hydrogen injection [18] because this technique is not always succesfull and still has its own risks although they are low. Furthermore we think that this technique does not prevent spinal cord problems. It is not a surprise to us that a previous chronic dissection is a protecting factor against spinal cord deficit because in these patient categories more intercostal arteries are patent and as a consequence of our strategy, they are reimplanted in a higher number as compared to patients with atherosclerotic aneurysms (Table 5). This is completely in accordance with the conclusions of Coselli et al. [19]. A reduction of the amplitude of the motor evoked potentials of >50% of baseline is an intraoperative alarm sign showing that the motor horn cells of the spinal cord are at risk at that particular moment. This necessitates undelayed protective interventions such as the immediate increase of the proximal and distal perfusion pressure, accelerated drainage of spinal fluid and accelerated reimplantation and reperfusion of intercostal/lumbar vessels [5].

Theoretically the introduction of two catheters instead of one submits the patient to a doubled risk with regard to bleeding, infection, etc. On the other hand having two functional catheters offers a lot of benefits. First, one can drain twice the amount in a given time period and this might be crucial at the moment when the spinal cord is at risk (e.g. when the MEPs decrease): it allows for draining the doubled amount of fluid in a short time interval. It is also possible to drain CSF and to measure the pressure simultaneously (using a single system one can either drain or measure). One catheter can be used to fix an upper and lower threshold while the other system can be used for draining: this allows for optimal control of the CSF-pressure within a certain fixed range. In addition, in case of catheter failure due to e.g. kinking or clotting, which occurs often, there is always another functional catheter in place.

The incidence of postoperative hemodialysis has dropped from almost 10% before 1996 to 2.7% in recent years. Our results clearly show the benefits of distal aortic perfusion in order to reduce renal ischemic time. After multivariate analysis separate renal perfusion with a cooling solution did not emerge as a protective factor although we still apply this technique to reduce the metabolic demands of the kidneys during ischemia. We would like to stress again the importance to try to avoid renal problems since hemodialysis is clearly related to a very high hospital mortality; this is not only concluded by our analysis but has also been accentuated by several other authors [20–22]. Age above 75, a preoperative diminished renal function and an operation performed before 1996 were all risk factors for developing renal problems after surgery.

We have to assume that the changing results are the effect of the increased experience of the complete team and of the use of a standardized technique based on a multimodality approach. The introduction of all the adjuncts has certainly made the repair more complex. Therefore we have moved far away from ‘simple’ cross-clamping and the word simple does not fit anymore in this context. It is not a surprise that institutes with their diminishing resources cannot continue to offer this complete service although it offers the best chances to the patient to survive the intervention.

A major drawback of this study is that it is a retrospective, nonrandomized analysis. Furthermore, the compared groups showed major differences but this was statistically solved by adjusting for the known confounders. Introduction of several new adjuncts over the years in the surgical technique of TAAAs makes analysis difficult; this was worked out by using multivariate logistic regression. On the other hand this is a large single-center experience with similar data collection and a more or less uniform operative and anesthesiological approach.

The current analysis clearly demonstrates that surgical treatment of TAAA remains a major surgical challenge. Morbidity, more particular spinal and renal dysfunctions as well as mortality continue to be significant. Major progress has been achieved over the past years and results are encouraging. Although our analysis has established important risk factors, we think that selection of surgical candidates should be made individually and care must be taken not to interpret these data as endorsement to pursue surgical treatment in all patients despite high age or other comorbidities.

	Footnotes

 
Presented at the joint 17th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 11th Annual Meeting of the European Society of Thoracic Surgeons, Vienna, Austria, October 12–15, 2003.

	Appendix A. Conference discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Dr J. Bachet (Paris, France): You have confirmed what we all assume now, that surgery of thoracoabdominal aneurysms should be done always with adjuncts such as distal perfusion, cerebral fluid drainage, etc.

I think that despite the enormous progress shown by Stanley Crawford 40 years ago, the kind of surgery that he proposed is over, definitely. But all those adjuncts that you showed are, let's say, mechanical adjuncts.

Did you ever think of entering the era of pharmacological adjuncts? My colleague, Loic Lang-Lazdunski, has made a huge work about using several adjuncts like magnesium sulfate for instance, which blocks the NMDP receptors, and we have obtained in our last 13 patients very good results with this. There are also molecules like riluzole, which has been proven to be extremely useful in this field. I would like to know your opinion about that.

Secondly, a slight word of criticism. In many papers, renal failure is considered as an independent factor of gravity, but in my opinion, or in my observation, renal failure in those patients is not an independent disease. It is only the reflection that the patient has multiorgan failure. So don't you think that we should say multiorgan failure instead of dialysis, since they are not patients on dialysis like during chronic renal failure, they are patients in very bad condition.

Dr Schepens: Let me respond to your first comment. I think you are completely right, cross-clamping in this kind of surgery is history. That should be made clear once and for all.

Concerning the pharmacological protection, we have never used any medication that potentially could avoid spinal cord dysfunction, and we did this because there is a very nice study of a Dutch surgeon, Peter De Haan, who wrote his medical thesis about this subject, and one of the chapters is a very deep and thorough review of the literature concerning this topic. He has compared all the studies and made a risk score analysis, and from his study none of the used medications, whatever it might be, seems to be protective for the spinal cord. But I agree that in the future this might become a very important topic, I expect a lot from this.

Concerning your second remark about renal failure is the question of what comes first, renal failure or multiorgan failure? And indeed, you can discuss this, because very often it starts by the impossibility of weaning from the ventilator and then you see gradual increasing of the creatinine, and finally you decide to start hemodialysis or ultrafiltration, and after two weeks the patient gets into a spiral which is going downwards and which we all know the end of, and that is multiorgan failure and often death. So, indeed, I agree, you could discuss if it is not multiorgan failure that comes first.

Dr P. Mortensen (Odense, Denmark): I have two questions. You didn't tell us the demographics of your patients. Did they change over time, I mean, did you get better in sorting out which patients were worthwhile operating on?

Second, did you sort out which kind of adjuvant was better than the other? I mean, was it some specific adjuvant that was better than one of the others?

Dr Schepens: Concerning the demographics of our patients, there has been a change, indeed, and I said clearly, and this is a very important point in the analysis, that both groups were not completely comparable, since in the cross-clamp group we operated upon much more patients with rupture, but we adjusted for these confounders within the analysis, and that is a very important point, because otherwise I am telling you lies.

To go more deeply in it, rupture is I think a very negative point, and actually we will always try to postpone patients with rupture until the intervention can be done during the daytime with the team which is convenient in this kind of surgery, and probably this is also related to one of the previous topics that there is indeed a relation between the outcome and the volume of the surgeons, or the team, because this is not only one surgeon who is doing this kind of intervention. It is a complete team.

We haven't looked at the second aspect of your question, if one particular adjunct was better than another. We have looked at combinations but not specifically if one was better than another. And to be honest, I think that the left heart bypass or the distal perfusion is the best. If we can omit another one, because the patient has taken in Coumadin and the anesthesiologist is not able to puncture the cerebrospinal fluid because he is afraid from bleeding, then we will not do this, but we will use distal aortic perfusion.

Dr H. Dasmahapatra (Calcutta, India): It is nice to see that some of the work which I used to do in the Hospital For Sick Children in Toronto from ‘86 to ‘88, I did a lot of experiments about evoked potential measurement during coarctation of aorta repair, and I was involved in the experimental research in draining the cerebrospinal fluid and measured the evoked potential. I am glad to see that the data we produced, I think it has been used still in clinical practice and in the surgery of thoracoabdominal aneurysm.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion Appendix A. Conference... References

 

1. Crawford S., Crawford J., Safi H., Coselli J., Hess K., Brooks B., Norton J., Glaeser D. Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients. J Vasc Surg 1986;3:389-404.[CrossRef][Medline]
2. Schepens M., Defauw J., Hamerlijnck R., De Geest R., Vermeulen F. Surgical treatment of thoracoabdominal aortic aneurysms by simple crossclamping. J Thorac Cardiovasc Surg 1994;107:134-142.[Abstract/Free Full Text]
3. Safi H., Miller C., Carr C., Iliopoulos D., Dorsay D., Baldwin J. Importance of intercostal artery reattachment during thoracoabdominal aortic aneurysm repair. J Vasc Surg 1998;27:58-68.[CrossRef][Medline]
4. Ballard J. Thoracoabdominal aortic aneurysm repair with sequential visceral perfusion: a technical note. Ann Vasc Surg 1999;13:216-221.[CrossRef][Medline]
5. van Dongen E., Schepens M., Morshuis W., ter Beek H., Aarts L., de Boer A., Boezeman E. Thoracic and thoracoabdominal aortic aneurysm repair: use of evoked potential monitoring in 118 patients. J Vasc Surg 2001;34:1035-1040.[CrossRef][Medline]
6. Coselli J., LeMaire S., Köksoy C., Schmittling Z., Curling P. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. J Vasc Surg 2002;35:631-639.[CrossRef][Medline]
7. Coselli J., LeMaire S. Left heart bypass reduces paraplegia rates after thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 1999;67:1931-1934.[Abstract/Free Full Text]
8. Safi H., Hess K., Randel M., Iliopoulos D., Baldwin J., Mootha R., Shenaq S., Sheinbaum R., Greene T. Cerebrospinal fluid drainage and distal aortic perfusion: reducing neurologic complications in repair of thoracoabdominal aortic aneurysm types I and II. J Vasc Surg 1996;23:223-229.[CrossRef][Medline]
9. Svensson L., Hess K., Coselli J., Safi H. Influence of segmental arteries, extent, and atriofemoral bypass on postoperative paraplegia after thoracoabdominal aortic operations. J Vasc Surg 1994;20:255-262.[Medline]
10. Schepens M., Vermeulen F., Morshuis W., Dossche K., van Dongen E., ter Beek H., Boezeman E. Impact of left heart bypass on the results of thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 1999;67:1963-1967.[Abstract/Free Full Text]
11. de Haan P., Kalkman C., de Mol B., Ubags L., Veldman D., Jacobs M. Efficacy of transcranial motor-evoked myogenic potentials to detect spinal cord ischemia during operations for thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg 1997;113:87-101.[Abstract/Free Full Text]
12. Schepens M., Defauw J., Hamerlijnck R., Vermeulen F. Use of a left heart bypass in the surgical repair of thoracoabdominal aortic aneurysms. Ann Vasc Surg 1995;9:327-338.[CrossRef][Medline]
13. van Dongen E., ter Beek H., Boezeman E., Schepens M., Langemeijer H., Aarts L. Normal serum concentrations of S-100 protein and changes in cerebrospinal fluid concentrations of S-100 protein during and after thoracoabdominal aortic aneurysm surgery: is S-100 protein a biochemical marker of clinical value in detecting spinal cord ischemia?. J Vasc Surg 1998;27:334-336.
14. De Paepe A., Devereux R., Dietz H., Hennekam R., Pyeritz R. Revised diagnostic criteria for the Marfan syndrome. Am J Med Genet 1996;62:417-426.[CrossRef][Medline]
15. Coselli J., LeMaire S., Conklin L., Köksoy C., Schmittling Z. Morbidity and mortality after extent II thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 2002;73:1107-1116.[Abstract/Free Full Text]
16. Cowan J., Dimick J., Wainess R., Henke P., Stanley J., Upchurch G. Ruptured thoracoabdominal aortic aneurysm treatment in the United States: 1988 to 1998. J Vasc Surg 2003;38:319-322.[CrossRef][Medline]
17. Kieffer E., Fukui S., Chiras J., Koskas F., Bahnini A., Cormier E. Spinal cord arteriography: a safe adjunct before descending thoracic or thoracoabdominal aortic aneurysmectomy. J Vasc Surg 2002;35:262-268.[CrossRef][Medline]
18. Svensson L. Intraoperative identification of spinal cord blood supply during repairs of descending aorta and thoracoabdominal aorta. J Thorac Cardiovasc Surg 1996;112:1455-1461.[Abstract/Free Full Text]
19. Coselli J., LeMaire S., Poli de Figueiredo L. Paraplegia after thoracoabdominal aortic aneurysm repair: is dissection a risk factor?. Ann Thorac Surg 1997;63:28-36.[Abstract/Free Full Text]
20. Schepens M., Defauw J., Hamerlijnck R., Vermeulen F. Risk assessment of acute renal failure after thoracoabdominal aortic aneurysm surgery. Ann Surg 1994;219:400-407.[Medline]
21. Safi H., Harlin S., Miller C., Iliopoulos D., Joshi A., Mohasci T., Zippel R., Letsou G., Tabor M. Predictive factors for acute renal failure in thoracic and thoracoabdominal aortic aneurysm surgery. J Vasc Surg 1996;24:338-344.[CrossRef][Medline]
22. Conklin L., LeMaire S., Chang S., Kreml S., Coselli J. Renal dysfunction scores are a valid surrogate measure of renal injury after thoracoabdominal aortic surgery. Heart Surg Forum 2003;6:208.

This article has been cited by other articles:

				R. K. Greenberg, Q. Lu, E. E. Roselli, L. G. Svensson, M. C. Moon, A. V. Hernandez, J. Dowdall, M. Cury, C. Francis, K. Pfaff, et al. Contemporary Analysis of Descending Thoracic and Thoracoabdominal Aneurysm Repair: A Comparison of Endovascular and Open Techniques Circulation, August 19, 2008; 118(8): 808 - 817. [Abstract] [Full Text] [PDF]

				R. K. Greenberg and B. Lytle Endovascular Repair of Thoracoabdominal Aneurysms Circulation, April 29, 2008; 117(17): 2288 - 2296. [Abstract] [Full Text] [PDF]

				M. Hamaishi, K. Orihashi, S. Takahashi, M. Isaka, K. Okada, and T. Sueda Transcranial motor-evoked potentials following intra-aortic cold blood infusion facilitates detection of critical supplying artery of spinal cord Eur. J. Cardiothorac. Surg., April 1, 2008; 33(4): 695 - 699. [Abstract] [Full Text] [PDF]

				C. D. Etz, M. Luehr, F. A. Kari, C. A. Bodian, D. Smego, K. A. Plestis, and R. B. Griepp Paraplegia after extensive thoracic and thoracoabdominal aortic aneurysm repair: does critical spinal cord ischemia occur postoperatively? J. Thorac. Cardiovasc. Surg., February 1, 2008; 135(2): 324 - 330. [Abstract] [Full Text] [PDF]

				T. B. Reece, G. R. Green, and I. L. Kron Aortic Dissection Card. Surg. Adult, January 1, 2008; 3(2008): 1195 - 1222. [Full Text]

				E. E. Roselli, R. K. Greenberg, K. Pfaff, C. Francis, L. G. Svensson, and B. W. Lytle Endovascular treatment of thoracoabdominal aortic aneurysms J. Thorac. Cardiovasc. Surg., June 1, 2007; 133(6): 1474 - 1482. [Abstract] [Full Text] [PDF]

				C. D. Etz, T. M. Homann, K. A. Plestis, N. Zhang, M. Luehr, D. J. Weisz, G. Kleinman, and R. B. Griepp Spinal cord perfusion after extensive segmental artery sacrifice: can paraplegia be prevented? Eur. J. Cardiothorac. Surg., April 1, 2007; 31(4): 643 - 648. [Abstract] [Full Text] [PDF]

				E. C. Lases, M. A. Schepens, F. J. Haas, L. P. Aarts, H. T. ter Beek, E. P. van Dongen, H. P. Siegers, I. van der Tweel, and E. H. Boezeman Clinical prospective study of biochemical markers and evoked potentials for identifying adverse neurological outcome after thoracic and thoracoabdominal aortic aneurysm surgery Br. J. Anaesth., November 1, 2005; 95(5): 651 - 661. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Marc Schepens Karl Dossche Robin Heijmen Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Schepens, M. Articles by Boezeman, E. Search for Related Content PubMed PubMed Citation Articles by Schepens, M. Articles by Boezeman, E. Related Collections Great vessels