Asian Cardiovasc Thorac Ann 2001;9:221-222
© 2001 Asia Publishing EXchange Pte Ltd
Repair of Intercostal Arteries in Thoracoabdominal Aneurysm
Yukifusa Yokoyama, MD,
Shuji Tamaki, MD,
Masao Ito, MD,
Noriyuki Kato, MD,
June Yokote, MD,
Masato Mutsuga, MD,
Masaho Okada, MD
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Department of Thoracic and Cardiovascular Surgery Ogaki Municipal Hospital Ogaki, Gifu, Japan
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For reprint information contact: Yukifusa Yokoyama, MD Tel: 81 584 81 3341 Fax: 81 584 75 5715 email: MHB02003{at}nifty.com Department of Thoracic and Cardiovascular Surgery, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu 503-8502, Japan.
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Abstract
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A parallel aortic graft composed of a 20-mm graft with two 10-mm accessory grafts was used in the repair of a large thoracoabdominal aneurysm in a 50-year-old man. The graft was attached to 6 intercostal arteries and used immediately for spinal cord perfusion before repairing the aneurysm. The patient recovered quickly without paraplegia.
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INTRODUCTION
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The threat of spinal cord ischemia and postoperative paraplegia remains an unsolved problem in the repair of thoracoabdominal aneurysms. Reattachment of particular intercostal and lumbar arteries is important in preserving spinal cord function. It would seem prudent to minimize the spinal cord ischemic time by rapid surgery as well as elective bypass.
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CASE REPORT
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A 50-year-old hypertensive man was referred with back pain. An enhanced computed tomography scan showed a large aneurysm involving the lower half of the thoracic aorta and the entire abdominal aorta (Crawford type III), with broad aortic dissection.1 No evidence of rupture of the aneurysm was detected, and calcification of the false lumen suggested a chronic state of dissection. Magnetic resonance imaging showed that the visceral vessels emerged from the false lumen. The patient underwent an elective operation with somatosensory evoked potential monitoring. Surgical exposure was through a left postero-lateral thoracoabdominal incision. Cardiopulmonary bypass was established via a 22F catheter in the left femoral artery and a 28F catheter in the femoral vein. Moderate hypothermia (32°C nasopharyngeal) was maintained until all anastomoses were completed. After partial cardiopulmonary bypass was instituted, the aorta was clamped proximally and the entire aneurysm was opened. Each visceral vessel, except the inferior mesenteric artery, was perfused via a balloon catheter connected to the cardiopulmonary bypass system. The intercostal and lumbar arteries were reconstructed with a parallel aortic graft before repairing the aneurysm with the main aortic graft. The parallel aortic graft was composed of a 20-mm graft with two 10-mm accessory grafts connected obliquely (Figure 1A2
). The parallel graft was trimmed (6 x 4 cm) to adjust to the posterior tongue of aortic wall that included 6 large intercostal and lumbar arteries, over the level of the 11th intercostal and 1st lumbar spaces. Immediately after suturing the trimmed graft to the aortic wall (Figure 1B), blood supply was restored to the spinal cord via one of the accessory grafts, using the cardiopulmonary bypass system (Figure 1C). Somatosensory evoked potential monitoring revealed ischemic changes and recovery following reperfusion via the accessory grafts. The time for sewing the parallel aortic graft was 17 minutes, and the spinal cord ischemic time was 32 minutes. The thoracoabdominal aneurysm was then repaired with the main aortic graft. Each visceral artery was reconstructed using a 10-mm graft interposition technique. Finally, both accessory grafts were connected to the main aortic graft (Figure 2). The patient recovered quickly without postoperative paraplegia. Angiography 6 months postoperatively revealed that both accessory grafts were patent and there was downward blood flow in the parallel aortic graft.
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Figure 1. (A) Technique of repairing the intercostal arteries using a parallel aortic graft of 10 cm in length. (B) The trimmed graft was attached to the posterior aortic wall to repair 6 intercostal arteries simultaneously. (C) Blood flow to the spinal cord was restored via the accessory graft before repairing the aneurysm.
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Figure 2. Thoracoabdominal aortic repair was completed by connecting both accessory grafts to the main aortic graft.
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DISCUSSION
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Numerous strategies and techniques to protect the spinal cord during aortic aneurysm repair have been reported, but no consensus has been reached on a standard method of preventing spinal cord ischemia.2–4 Total hypothermic circulatory arrest may induce a bleeding tendency. The inclusion technique seems to require much experience and skill to prevent bleeding from the suture line. In contrast, the technique devised for this case does not require deep hypothermia, and could be performed readily elsewhere because of the easy handling of the graft.
The main feature of this method is the prior reconstruction of the intercostal and lumbar arteries in advance of aneurysm repair. This improved operative exposure and shortened the ischemic time. A 20-mm graft was chosen to cover as many intercostal and lumbar arteries as possible. However, a graft of this size may not always be necessary and it can be trimmed to adjust to the size of the area at risk, as in this case. Another feature of this method is the use of accessory grafts connected to the parallel aortic graft. The accessory grafts were used to restore blood supply to the spinal cord immediately after attachment of the parallel aortic graft. The use of 2 accessory grafts connected to the parallel aortic graft would be advantageous in the event of obstruction of either accessory graft. This method of repairing intercostal and lumbar arteries is recommended as a means of reducing the spinal cord ischemic time and preventing paraplegia.
Presented at the 8th Annual Meeting of The Asian Society for Cardiovascular Surgery, Fukuoka, Japan, September 6–8, 2000.
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REFERENCES
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Crawford ES, Crawford JL, Safi HJ, Coselli JS, Hess KR, Brooks B, et al. Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operation in 605 patients. J Vasc Surg 1986;3:389–404.[Medline]
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Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thoraco-abdominal aortic operations. J Vasc Surg 1993;17:357–70.[Medline]
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Frank SM, Parker SD, Rock P, Gorman RB, Kelly S, Beattie C, et al. Moderate hypothermia with partial bypass and segmental sequential repair for thoracoabdominal aortic aneurysm. J Vasc Surg 1994;19:687–97.[Medline]
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Kouchoukos NT, Daily BB, Rokkas CK, Murphy SF, Bauer S, Abboud N. Hypothermic bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg 1995;60:67–7.[Abstract/Free Full Text]
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Abstract
INTRODUCTION
