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Angiographic localization of spinal cord blood supply and its relationship to postoperative paraplegia
LITERATURE REVIEW Fredetick W. Campbell, MD, Editor
SCIENTIFIC
ARTICLES
Crawford EF, Svensson LG, Hess KR, et al: A prospective randomized study of cerebral spinal fluid drainage to prevent paraplegia after high risk surgery on the thoraco-abdominal aorta. J Thorac Cardiovast Surg 13:36-46,199O In this prospective clinical study, 98 patients undergoing repair of thoracoabdominal aortic aneurysms were randomized to spinal fluid drainage or control groups. Aortic reconstructive techniques including intercostal and lumbar artery reattachment and atriofemoral pump bypass were applied variably within both patient groups in a nonrandomized manner as clinically indicated. Cerebrospinal fluid (CSF) pressure was continuously monitored in the drainage group and pressure maintained I 10 mm Hg in 20 patients, 5 15 mm Hg in 20, and > 15 mm Hg in 6 patients during the period of aortic clamping. CSF volume removed ranged from 24 to 120 mL (median, 52.5 mL). Surgical treatment, including intercostal and lumbar artery reattachment, temporary atriofemoral bypass, and spinal fluid drainage, was not statistically related to the incidence of postoperative neurological deficit. The relationship between neurological deficit and volume of CSF removed or pressure maintained is not reported. No complications related to CSF drainage occurred. Predictors of neurological complication included postoperative hypotension, aortic clamp time, age, and extent of aorta replaced.
Gregoretti F, Gelman S, Henderson T, Bradley EL: Hemodynamics and oxygen uptake below and above aortic occlusion during cross-clamping of the thoracic aorta and sodium nitroprusside infusion. J Thorac Cardiovasc Surg 100:830-836,199O The effects of nitroprusside-induced vasodilation on blood flow and oxygen consumption above and below the site of aortic occlusion during cross-clamping of the thoracic aorta (at the diaphragm) were examined in this controlled, prospective canine study. Cross-clamping of the thoracic aorta produced marked decreases in blood flow and oxygen consumption below the occlusion in all animals. Above the occlusion, blood flow increased but oxygen uptake decreased. Sodium nitroprusside infusion exacerbated these changes. The authors relate the decrease in blood flow distal to the site of occlusion to the decrease in distal aortic blood pressure. Readers are referred toAnesthesiology 74:320-325, 1991 for results of an experimental evaluation of another modality, phlebotomy, to control systemic hypertension and improve organ perfusion below the level of clamping in a canine model.
Williams GM, Perler BA, Berdick JF, et al: Angiographic localization of spinal cord blood supply and its relationship to postoperative paraplegia. J Vast Surg 13:23-35,199l Forty-seven patients underwent catheterization of middle and lower thoracic intercostal and upper lumbar arteries to define the Journalof Cardiofhoracic and VascularAnesthesia,
Vol5,
No 4
origin of the great radicular artery of Adamkiewicz prior to thoracoabdominal aortic surgery. Two patients suffered complications related to angiography. The origin was found in 55% of studied patients. Twenty-one patients underwent thoracoabdominal aneurysm repair with this knowledge. When the critical lumbar or intercostal artery could be included as part of an anastomosis, all patients (n = 12) survived and 1 was paralyzed. If aneurysm repair mandated a midgraft anastomosis to intercostal arteries critical to spinal cord perfusion, 7 of 9 patients either died or were paralyzed. In the 19 patients undergoing operation without identification of spinal cord blood supply, surgical complications developed in 3, and death and paralysis developed in 1 each. Postoperatively, paresis developed in 2 patients. Paralysis was associated with aneurysm extent. The authors conclude that selective intercostal angiography requires further refinement and offers the promise of understanding risks of spinal cord complications after thoracoabdominal aneurysm repair.
Isaacson IJ, Lowdon JD, Berry AJ, et al: The value of pulmonary artery and central venous monitoring in patients undergoing abdominal aortic reconstructive surgery: A comparative study of two selected, randomized groups. J Vast Surg 12:754-760,199O One hundred two healthy patients undergoing abdominal aortic reconstructive surgery were prospectively and randomly allocated to monitoring with a central venous or a pulmonary artery catheter. Patients with uncompensated congestive heart failure, cardiomyopathy, left ventricular ejection fraction less than 40%, symptomatic valvular heart disease, and significant chronic lung disease were excluded. No statistically significant differences occurred between the two patient groups with regard to cardiac, pulmonary, or renal morbidity, mortality, duration of intensive care, postoperative hospital stay, or cost of hospitalization. Professional fee for anesthetic care was significantly higher in patients monitored with pulmonary artery catheters.
Mangano DT, Browner WS, Hollenberg M, et al: Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. N Engl J Med 323:1781-1788, 1990 The authors prospectively studied 474 men with coronary artery disease (n = 243) or at high risk for it (n = 231) undergoing elective noncardiac surgery and general anesthesia. Historical, clinical, laboratory, and physiological data during hospitalization and up to 24 months after surgery were collected. Myocardial ischemia was assessed by continuous electrocardiographic monitoring beginning 2 days before surgery and continuing for 2 days after. Eighty-three patients (18%) had postoperative cardiac events in the hospital: 1.5 patients had ischemic events (cardiac death, myocardial infarction, unstable angina), 30 had congestive heart failure, and 38 had ventricular tachycardia. Postoperative myocardial ischemia was associated with a 2.8-fold increase in the odds of
(August), 1991: pp 409-411
409
SCIENTIFIC
ARTICLES
Crawford EF, Svensson LG, Hess KR, et al: A prospective randomized study of cerebral spinal fluid drainage to prevent paraplegia after high risk surgery on the thoraco-abdominal aorta. J Thorac Cardiovast Surg 13:36-46,199O In this prospective clinical study, 98 patients undergoing repair of thoracoabdominal aortic aneurysms were randomized to spinal fluid drainage or control groups. Aortic reconstructive techniques including intercostal and lumbar artery reattachment and atriofemoral pump bypass were applied variably within both patient groups in a nonrandomized manner as clinically indicated. Cerebrospinal fluid (CSF) pressure was continuously monitored in the drainage group and pressure maintained I 10 mm Hg in 20 patients, 5 15 mm Hg in 20, and > 15 mm Hg in 6 patients during the period of aortic clamping. CSF volume removed ranged from 24 to 120 mL (median, 52.5 mL). Surgical treatment, including intercostal and lumbar artery reattachment, temporary atriofemoral bypass, and spinal fluid drainage, was not statistically related to the incidence of postoperative neurological deficit. The relationship between neurological deficit and volume of CSF removed or pressure maintained is not reported. No complications related to CSF drainage occurred. Predictors of neurological complication included postoperative hypotension, aortic clamp time, age, and extent of aorta replaced.
Gregoretti F, Gelman S, Henderson T, Bradley EL: Hemodynamics and oxygen uptake below and above aortic occlusion during cross-clamping of the thoracic aorta and sodium nitroprusside infusion. J Thorac Cardiovasc Surg 100:830-836,199O The effects of nitroprusside-induced vasodilation on blood flow and oxygen consumption above and below the site of aortic occlusion during cross-clamping of the thoracic aorta (at the diaphragm) were examined in this controlled, prospective canine study. Cross-clamping of the thoracic aorta produced marked decreases in blood flow and oxygen consumption below the occlusion in all animals. Above the occlusion, blood flow increased but oxygen uptake decreased. Sodium nitroprusside infusion exacerbated these changes. The authors relate the decrease in blood flow distal to the site of occlusion to the decrease in distal aortic blood pressure. Readers are referred toAnesthesiology 74:320-325, 1991 for results of an experimental evaluation of another modality, phlebotomy, to control systemic hypertension and improve organ perfusion below the level of clamping in a canine model.
Williams GM, Perler BA, Berdick JF, et al: Angiographic localization of spinal cord blood supply and its relationship to postoperative paraplegia. J Vast Surg 13:23-35,199l Forty-seven patients underwent catheterization of middle and lower thoracic intercostal and upper lumbar arteries to define the Journalof Cardiofhoracic and VascularAnesthesia,
Vol5,
No 4
origin of the great radicular artery of Adamkiewicz prior to thoracoabdominal aortic surgery. Two patients suffered complications related to angiography. The origin was found in 55% of studied patients. Twenty-one patients underwent thoracoabdominal aneurysm repair with this knowledge. When the critical lumbar or intercostal artery could be included as part of an anastomosis, all patients (n = 12) survived and 1 was paralyzed. If aneurysm repair mandated a midgraft anastomosis to intercostal arteries critical to spinal cord perfusion, 7 of 9 patients either died or were paralyzed. In the 19 patients undergoing operation without identification of spinal cord blood supply, surgical complications developed in 3, and death and paralysis developed in 1 each. Postoperatively, paresis developed in 2 patients. Paralysis was associated with aneurysm extent. The authors conclude that selective intercostal angiography requires further refinement and offers the promise of understanding risks of spinal cord complications after thoracoabdominal aneurysm repair.
Isaacson IJ, Lowdon JD, Berry AJ, et al: The value of pulmonary artery and central venous monitoring in patients undergoing abdominal aortic reconstructive surgery: A comparative study of two selected, randomized groups. J Vast Surg 12:754-760,199O One hundred two healthy patients undergoing abdominal aortic reconstructive surgery were prospectively and randomly allocated to monitoring with a central venous or a pulmonary artery catheter. Patients with uncompensated congestive heart failure, cardiomyopathy, left ventricular ejection fraction less than 40%, symptomatic valvular heart disease, and significant chronic lung disease were excluded. No statistically significant differences occurred between the two patient groups with regard to cardiac, pulmonary, or renal morbidity, mortality, duration of intensive care, postoperative hospital stay, or cost of hospitalization. Professional fee for anesthetic care was significantly higher in patients monitored with pulmonary artery catheters.
Mangano DT, Browner WS, Hollenberg M, et al: Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. N Engl J Med 323:1781-1788, 1990 The authors prospectively studied 474 men with coronary artery disease (n = 243) or at high risk for it (n = 231) undergoing elective noncardiac surgery and general anesthesia. Historical, clinical, laboratory, and physiological data during hospitalization and up to 24 months after surgery were collected. Myocardial ischemia was assessed by continuous electrocardiographic monitoring beginning 2 days before surgery and continuing for 2 days after. Eighty-three patients (18%) had postoperative cardiac events in the hospital: 1.5 patients had ischemic events (cardiac death, myocardial infarction, unstable angina), 30 had congestive heart failure, and 38 had ventricular tachycardia. Postoperative myocardial ischemia was associated with a 2.8-fold increase in the odds of
(August), 1991: pp 409-411
409