Eur J Cardiothorac Surg 2007;32:684-685. doi:10.1016/j.ejcts.2007.07.001
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Is preoperative demonstration of Adamkiewicz's artery a clinical reality in acute aortic dissection?
Efstratios Apostolakisa,
Karolina Akinosogloub,*
a Department of Cardiothoracic Surgery, University Hospital of Rion Patras, 26500 Patras, Greece
b Faculty of Life Sciences, Imperial College London, United Kingdom
Received 27 April 2007;
accepted 2 July 2007.
* Corresponding author. Address: 2A Butler Road, West Harrow, Middlesex, London HA1 4DR, United Kingdom. Tel.: +44 7864958573; Mob.: 306977762897. (Email: stratisapostolakis{at}yahoo.gr; k.akinosoglou07{at}imperial.ac.uk; karolakinosoglou{at}yahoo.gr).
Key Words: Artery of Adamkiewicz • Acute aortic dissection CT • Postoperative paraplegia: Angiography
We read the excellent article by Nojiri et al. with great interest [1]. The authors examined the effectiveness of intra-arterial CT angiography to demonstrate preoperatively the Adamkiewicz's artery (AA) in 27 patients with acute or chronic thoracic aortic disease. The authors showed the continuity of artery in 61% of cases, and in all cases they gathered enough information concerning its origin. Indeed, in comparison to MRI and intravenous CT-angiography efficiency to demonstrate the AA (70–85% and 90%, respectively) [2,3], the presented method seems to be superior. However, the study also showed some of the method's drawbacks that should not routinely be performed in aortic dissection.
- (A) Although there were not any cases of aorta rupture in the cohort of patients with aortic dissection (14 patients), the patient's discomfort and pain may increase the vessel's pressure and thus the potential risk of rupture as well.
- (B) The introduction of a catheter tip into the false lumen, or the occlusion of some radical arteries could cause an incomplete demonstration of origin or of its course. Indeed, they failed to demonstrate the continuity down from innate origin in up to 39% of cases. In addition, in their Fig. 1D it was evident that, although the left intercostals are well demonstrated as they originate from true lumen, the right intercostals appear faintly. It means that in this case, if the AA is structured by some of the right radicals, it will appear faint, interrupted, or even absent (Fig. 2). In fact, they observed an absence of the artery's origin in three cases due to technical reasons (all in patients with dissection), an absence of continuity of course of artery in 10 cases (39%), and patients with dissection in 50% of the cases (i.e. 36% of cases of dissection) (see Table 1). However, in about 35% of patients with dissection, two arteries have been found.
- (C) Toxicity of contrast media or ischemia due to macro-embolism is a substantial problem. Neuro-toxicity of contrast media (alone or in combination with ischemia) to the spinal cord, although rare, may cause severe spinal injury with poor prognosis [4].
- (D) Failure to demonstrate the continuity of arteries in about 36% of cases (see B) means that surgeons cannot be sure of their potential intraoperative decision to exclude any radical arteries. Furthermore, the operative strategy of the surgeon remains largely unaffected by the findings of preoperative angiography, and the number of segmental arteries that are finally preserved are not significantly different between the groups undertaking or not undertaking angiography [5].
- (E) Avoidance of surgery in five of the patients with aortic dissection did not give us the real risk of paraplegia. In fact, it may mean that judgment based on an angiography's findings may lead to a wrong decision.
Finally, although this interventional method seems to be highly effective in non-emergency cases, in cases of aortic dissection it cannot demonstrate the complete course of AA in a significant number of cases.
Footnotes
\#9734; The authors of the original paper [1] were invited to reply to this Letter to the Editor but they did not respond.
References
- Nojiri J, Matsumoto K, Kato A, Miho T, Furukawa K, Ohtsubo S, Itoh T, Kudo S. The Adamkiewicz artery: demonstration by intra-arterial computed tomographic angiography. Eur J Cardiothorac Surg 2007;31(2):249-255.[Abstract/Free Full Text]
- Takase K, Akasaka J, Sawamura Y, Ota H, Sato A, Yamada T, Higano S, Igarashi K, Chiba Y, Takahashi S. Preoperative MDCT evaluation of the artery of Adamkiewicz and its origin. J Comp Assist Tomogr 2006;30:716-722.[CrossRef][Medline]
- Hyodoh H, Kawaharada N, Akiba H, Tamakawa M, Hyodoh K, Fukada J, Moridhita K, Hareyama M. Usefulness of preoperative detection of artery of Adamkiewicz with dynamic contrast-enhanced MR angiography. Radiology 2005;236:1004-1009.[Abstract/Free Full Text]
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- Minatoya K, Karck M, Hagl C, Meyer A, Brassel F, Harringer W, Haverich A. Impact of spinal angiography on the neurological outcome after surgery on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg 2002;74:S1870-S1872.[Abstract/Free Full Text]
