- Email: [email protected]
Transcatheter Aortic Valve Replacement via Left Anterior Thoracotomy in a Patient With Severe Pectus Excavatum
FEATURE ARTICLES
344
CASE REPORT LOBERMAN ET AL TAVR IN PECTUS, LEFT THORACOTOMY
surrounding vessel might be suspected. Magnetic resonance imaging can provide information to distinguish the tumor from the surrounding structures. Surgical intervention is indispensable in the case of clinically suspected malignant neoplasm, especially lung cancer or probably metastases from distant organs. Surgical resection followed by histopathologic analysis is the diagnostic and therapeutic method of choice [5]. In our case, video-assisted thoracoscopic surgery for tumor resection was not possible because of the broad-based tumor mass on the central pulmonary artery. Interestingly and despite their vascular origin, significant bleeding during surgical resection is rarely seen [6]. Preoperative embolization of the highly vascularized leiomyoma has been described in the literature to achieve tumor shrinking and to minimize intraoperative bleeding complications [7]. Leiomyoma represents a benign tumor that derives from the smooth muscle cells. Vascular leiomyoma can be correctly diagnosed using conventional hematoxylin and eosin staining [6]. Immunohistochemical staining for smooth muscle cells, for example, actin, myosin, and desmin, as well as CD31 for vascular endothelium, can differentiate vascular leiomyoma from other spindle cell tumors such as hemangioma, angiofibroma, amgiomyolipoma, and angiomyosarcoma [5]. Moreover, the lack of malignancy is characterized by a very low Ki67 expression. Missing expression of estrogen and progesterone helps to differentiate primary leiomyoma of the lung and metastases of leiomyoma of the uterus [2]. Neoplasms in the thoracic cavity represent many different histopathologic entities, and differential diagnosis is difficult with radiologic tools alone. Vascular leiomyoma of the pulmonary artery represents a rarity, but must be included in the differential diagnosis. Therefore, surgical opportunities such as video-assisted thoracoscopy should be considered early. Surgical resection of these benign tumors represents the treatment of choice.
References 1. Agnos JW, Starkey GW. Primary leiomyosarcoma and leiomyoma of the lung; review of the literature and report of two cases of leiomyosarcoma. N Engl J Med 1958;258:12–7. 2. Terada T. Vascular leiomyoma of the lung arising from pulmonary artery. Int J Clin Exp Pathol 2013;6:97–9. 3. Orlowski TM, Stasiak K, Kolodziej J. Leiomyoma of the lung. J Thorac Cardiovasc Surg 1978;76:257–61. 4. Rodríguez PM, Freixinet JL, Plaza ML, Camacho R. Unusual primary pleural leiomyoma. Interact Cardiovasc Thorac Surg 2010;10:441–2. 5. Yoon TM, Yang HC, Choi YD, Lee DH, Lee JK, Lim SC. Vascular leiomyoma in the head and neck region: 11 years experience in one institution. Clin Exp Otorhinolaryngol 2013;6:171–5. 6. Wang CP, Chang YL, Sheen TS. Vascular leiomyoma of the head and neck. Laryngoscope 2004;114:661–5. 7. Bald o X, Sureda C, Gimferrer JM, Belda J. Primary mediastinal leiomyoma: an angiographic study and embolisation of the feeding vessels to improve the surgical approach. Eur J Cardiothorac Surg 1997;11:574–6. Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2016;101:344–6
Transcatheter Aortic Valve Replacement via Left Anterior Thoracotomy in a Patient With Severe Pectus Excavatum Dan Loberman, MD, Taufiek Konrad Rajab, MD, Maroun Yammine, MD, Frederick G. Welt, MD, Andrew C. Eisenhauer, MD, and Michael J. Davidson, MD Division of Cardiac Surgery and the Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts
With the development of the transcatheter aortic valve replacement, innovative approaches can be geared to atypical and challenging cases. We describe a case of transcatheter aortic valve replacement via a left anterior thoracotomy in a patient with pectus excavatum and unusual intrathoracic anatomy where surgical and traditional transcatheter aortic valve replacement approaches were deemed inapplicable. (Ann Thorac Surg 2016;101:344–6) Ó 2016 by The Society of Thoracic Surgeons
T
ranscatheter aortic valve replacement (TAVR) is an established treatment strategy for high-risk patients with aortic valve stenosis. In cases where transapical, femoral, or subclavian access is denied, direct aortic access, first described in 2010, is an alternative [1, 2]. This access strategy typically involves a right anterior thoracotomy to expose the ascending aorta [3]. Here we describe transcatheter aortic valve replacement via a left anterior thoracotomy in a patient with severe pectus excavatum. An 86-year-old man presented with progressive dyspnea on exertion. His medical history was notable for hypertension, hyperlipidemia, atrial fibrillation, carotid artery stenosis, and chronic anemia. Physical examination demonstrated severe pectus excavatum, a late-peaking systolic murmur, and delayed carotid impulse. Echocardiography, left heart catheterization, and computed tomography (CT) of the chest showed a calculated aortic valve area of 0.6 cm2, left ventricular ejection fraction of 0.75, a 70% left anterior descending stenosis, and severe pectus excavatum with deflection of the heart and the great vessels to the left of the midline (Fig 1). Owing to this anatomy, TAVR was suggested. Because the heart apex was not in the usual position, a transapical approach was not appropriate. The CT study demonstrated bilateral iliac artery aneurysms and calcification, making his iliac anatomy inappropriate for a
Accepted for publication March 6, 2015. Address correspondence to Dr Loberman, Division of Cardiac Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115; email: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.03.081
Ann Thorac Surg 2016;101:344–6
CASE REPORT LOBERMAN ET AL TAVR IN PECTUS, LEFT THORACOTOMY
345
Fig 1. Computed tomography image shows severe pectus excavatum and the location of the heart and great vessels entirely to the left of the midline.
Fig 2. A minithoracotomy over the second intercostal space was used to expose the distal ascending aorta. The Ascendra sheath (Edwards Lifesciences Corp, Irvine, CA) is seen passing retrograde over a wire.
Aortic balloon valvuloplasty was performed during rapid ventricular pacing. The valvuloplasty balloon was exchanged for the Edwards 29-mm SAPIEN valve (Edwards Lifesciences) on its delivery system. This was positioned within the native aortic valve and its position confirmed with root aortography. Rapid ventricular pacing was again used to suspend cardiac output, and the prosthetic valve was deployed within the native valve (Fig 3, Fig 4). Transesophageal echocardiography demonstrated a small paravalvular leak that was treated by a second inflation of the delivery balloon with an additional volume of 1 mL. This reduced the paravalvular leak to
Fig 4. Postdeployment image shows the Edwards SAPIEN (Edwards Lifesciences Corp, Irvine, CA) valve is in adequate position.
FEATURE ARTICLES
transfemoral approach. Therefore, a direct transaortic technique was used for valve replacement. Initially, percutaneous left femoral artery access was obtained and 2 bare-metal stents were placed in the left anterior descending coronary artery. A minithoracotomy was performed in the left second intercostal space directly over the distal ascending aorta (Fig 2). Through 2 concentric purse-string sutures, a 6F sheath, Berenstein catheter (Boston Scientific, Boston, MA), and a 0.035-inch straight wire were used to cross the aortic valve retrograde. After transvalvular pressure measurements were obtained, the catheter was exchanged for a superstiff Amplatz wire (Cook Medical, Bloomington, IN), and the Edwards Ascendra sheath (Edwards Lifesciences Corp, Irvine, CA) was passed over this wire and into the aorta.
Fig 3. Fluoroscopic image of the new valve deploying with balloon inflation. The Ascendra sheath (Edwards Lifesciences Corp, Irvine, CA) is seen in the aorta.
346
CASE REPORT BOUTROUS ET AL NEUROLOGIC DEFICIT AFTER THORACOABDOMINAL AORTIC OPERATION
trivial. The Ascendra sheath was removed, the arteriotomy was closed, and hemostasis was achieved.
Comment TAVR via direct aortic access is an alternative when access through the peripheral arteries is not available, as was the case in our patient with a shifted mediastinum. Previous descriptions of the transthoracic technique have included right minithoracotomy and ministernotomy to obtain access to the ascending aorta. The hemisternotomy approach has the advantage of avoiding violation of the pleura, but the thoracotomy approach facilitates easier dissection and allows future refinements that could lead to a port-access approach [4]. The anatomy of the mediastinum may be distorted due to congenital, acquired, or iatrogenic reasons. In our patient, the heart and the great vessels were entirely located to the left of the midline due to severe pectus excavatum. In cases like this, a left minithoracotomy can be used for direct aortic access. The usual landmarks could not be used because of the distorted anatomy, and the dissection was guided by preoperative CT imaging. A specific contraindication for this approach includes patients who have had bypass procedures with a left internal mammary artery graft. The left anterior thoracotomy approach we describe offers patients with severe pectus excavatum and poor transarterial access an important avenue for transcatheter valve replacement.
FEATURE ARTICLES
References 1. Latsios G, Gerckens U, Grube E. Transaortic transcatheter aortic valve implantation: a novel approach for the truly “noaccess option” patients. Catheter Cardiovasc Interv 2010;75: 1129–36. 2. Bapat V, Thomas M, Hancock J, Wilson K. First successful trans-catheter aortic valve implantation through ascending aorta using Edwards SAPIEN THV system. Eur J Cardiothorac Surg 2010;38:811–3. 3. Bruschi G, De Marco F, Fratto P, et al. Direct aortic access through right minithoracotomy for implantation of selfexpanding aortic bioprosthetic valves. J Thorac Cardiovasc Surg 2010;140:715–7. 4. Ramlawi B, Anaya-Ayala JE, Reardon MJ. Transcatheter aortic valve replacement (TAVR): access planning and strategies. Methodist DeBakey Cardiovasc J 2012;8:22–5.
Management of Recurrent Delayed Neurologic Deficit After Thoracoabdominal Aortic Operation Mina L. Boutrous, MD, Rana O. Afifi, MD, Hazim J. Safi, MD, and Anthony L. Estrera, MD University of Texas Medical at Houston, Health Science Center at Houston, Texas
Ann Thorac Surg 2016;101:346–8
repair. Multiple adjuncts have been devised to counteract the development of DND, most notably cerebrospinal fluid (CSF) drainage. We report a case of a 63-year-old woman in whom DND developed four times during the first 10 days after her thoracoabdominal aortic operation. This necessitated lumbar drain “weaning” to allow for a slowly rising CSF pressure and preservation of lower extremity motor function. (Ann Thorac Surg 2016;101:346–8) Ó 2016 by The Society of Thoracic Surgeons
N
eurologic deficits after thoracoabdominal aortic operations have long been among the most catastrophic adverse events. Although their incidence has considerably declined over the past 2 decades with the use of several adjuncts, such as cerebrospinal fluid (CSF) drainage, distal aortic perfusion, and intercostal artery reattachment, neurologic deficit can still cause significant disabilities [1, 2]. We report the case of a 63-year-old woman with an extensive aortic aneurysm who experienced four consecutive episodes of paraplegia after the operation. This prompted us to wean her from a lumbar drain (LD) to allow its safe removal with no residual neurologic deficit. A 63-year-old woman with hypertension, hyperlipidemia, and paroxysmal atrial fibrillation was referred for repair of an extensive thoracic aortic aneurysm involving the ascending and transverse arch and entire thoracoabdominal aorta. She underwent ascending and transverse arch repair by use of the first-stage elephant trunk technique. The patient did well and was discharged. Three months later, she returned for completion of the second-stage repair, which required repair of the extent II thoracoabdominal aortic aneurysm (TAAA). Left-sided partial bypass was established by cannulation of the left lower pulmonary vein and the femoral artery, with sequential clamping of the aorta distal to the left subclavian artery implemented for the full repair of the extent II TAAA. The total bypass time was 76 minutes, and aortic cross-clamp time was 32 minutes. The case was complicated by coagulopathy and bowel ischemia, necessitating delayed closure and performance of a colostomy with planned return. The patient experienced delayed neurologic deficit (DND), which presented as left lower extremity weakness, 6 hours after her arrival at the cardiovascular intensive care unit. Peripheral pulses were confirmed. Our protocol for addressing DND was initiated, which included optimizing CSF drainage, delivering oxygen, managing pressure, and rectifying the patient’s status (COPS protocol) [3]. With these measures, the patient regained baseline neurologic function within 4 hours. Despite the COPS protocol, on postoperative day (POD) 2, the patient experienced a second episode of
Accepted for publication March 16, 2015.
Delayed neurologic deficit (DND) is a devastating adverse event after thoracoabdominal aortic aneurysm Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
Address correspondence to Dr Boutrous, 6400 Fannin St, Ste 2850, Houston, TX 77030; email: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.03.052
344
CASE REPORT LOBERMAN ET AL TAVR IN PECTUS, LEFT THORACOTOMY
surrounding vessel might be suspected. Magnetic resonance imaging can provide information to distinguish the tumor from the surrounding structures. Surgical intervention is indispensable in the case of clinically suspected malignant neoplasm, especially lung cancer or probably metastases from distant organs. Surgical resection followed by histopathologic analysis is the diagnostic and therapeutic method of choice [5]. In our case, video-assisted thoracoscopic surgery for tumor resection was not possible because of the broad-based tumor mass on the central pulmonary artery. Interestingly and despite their vascular origin, significant bleeding during surgical resection is rarely seen [6]. Preoperative embolization of the highly vascularized leiomyoma has been described in the literature to achieve tumor shrinking and to minimize intraoperative bleeding complications [7]. Leiomyoma represents a benign tumor that derives from the smooth muscle cells. Vascular leiomyoma can be correctly diagnosed using conventional hematoxylin and eosin staining [6]. Immunohistochemical staining for smooth muscle cells, for example, actin, myosin, and desmin, as well as CD31 for vascular endothelium, can differentiate vascular leiomyoma from other spindle cell tumors such as hemangioma, angiofibroma, amgiomyolipoma, and angiomyosarcoma [5]. Moreover, the lack of malignancy is characterized by a very low Ki67 expression. Missing expression of estrogen and progesterone helps to differentiate primary leiomyoma of the lung and metastases of leiomyoma of the uterus [2]. Neoplasms in the thoracic cavity represent many different histopathologic entities, and differential diagnosis is difficult with radiologic tools alone. Vascular leiomyoma of the pulmonary artery represents a rarity, but must be included in the differential diagnosis. Therefore, surgical opportunities such as video-assisted thoracoscopy should be considered early. Surgical resection of these benign tumors represents the treatment of choice.
References 1. Agnos JW, Starkey GW. Primary leiomyosarcoma and leiomyoma of the lung; review of the literature and report of two cases of leiomyosarcoma. N Engl J Med 1958;258:12–7. 2. Terada T. Vascular leiomyoma of the lung arising from pulmonary artery. Int J Clin Exp Pathol 2013;6:97–9. 3. Orlowski TM, Stasiak K, Kolodziej J. Leiomyoma of the lung. J Thorac Cardiovasc Surg 1978;76:257–61. 4. Rodríguez PM, Freixinet JL, Plaza ML, Camacho R. Unusual primary pleural leiomyoma. Interact Cardiovasc Thorac Surg 2010;10:441–2. 5. Yoon TM, Yang HC, Choi YD, Lee DH, Lee JK, Lim SC. Vascular leiomyoma in the head and neck region: 11 years experience in one institution. Clin Exp Otorhinolaryngol 2013;6:171–5. 6. Wang CP, Chang YL, Sheen TS. Vascular leiomyoma of the head and neck. Laryngoscope 2004;114:661–5. 7. Bald o X, Sureda C, Gimferrer JM, Belda J. Primary mediastinal leiomyoma: an angiographic study and embolisation of the feeding vessels to improve the surgical approach. Eur J Cardiothorac Surg 1997;11:574–6. Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2016;101:344–6
Transcatheter Aortic Valve Replacement via Left Anterior Thoracotomy in a Patient With Severe Pectus Excavatum Dan Loberman, MD, Taufiek Konrad Rajab, MD, Maroun Yammine, MD, Frederick G. Welt, MD, Andrew C. Eisenhauer, MD, and Michael J. Davidson, MD Division of Cardiac Surgery and the Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts
With the development of the transcatheter aortic valve replacement, innovative approaches can be geared to atypical and challenging cases. We describe a case of transcatheter aortic valve replacement via a left anterior thoracotomy in a patient with pectus excavatum and unusual intrathoracic anatomy where surgical and traditional transcatheter aortic valve replacement approaches were deemed inapplicable. (Ann Thorac Surg 2016;101:344–6) Ó 2016 by The Society of Thoracic Surgeons
T
ranscatheter aortic valve replacement (TAVR) is an established treatment strategy for high-risk patients with aortic valve stenosis. In cases where transapical, femoral, or subclavian access is denied, direct aortic access, first described in 2010, is an alternative [1, 2]. This access strategy typically involves a right anterior thoracotomy to expose the ascending aorta [3]. Here we describe transcatheter aortic valve replacement via a left anterior thoracotomy in a patient with severe pectus excavatum. An 86-year-old man presented with progressive dyspnea on exertion. His medical history was notable for hypertension, hyperlipidemia, atrial fibrillation, carotid artery stenosis, and chronic anemia. Physical examination demonstrated severe pectus excavatum, a late-peaking systolic murmur, and delayed carotid impulse. Echocardiography, left heart catheterization, and computed tomography (CT) of the chest showed a calculated aortic valve area of 0.6 cm2, left ventricular ejection fraction of 0.75, a 70% left anterior descending stenosis, and severe pectus excavatum with deflection of the heart and the great vessels to the left of the midline (Fig 1). Owing to this anatomy, TAVR was suggested. Because the heart apex was not in the usual position, a transapical approach was not appropriate. The CT study demonstrated bilateral iliac artery aneurysms and calcification, making his iliac anatomy inappropriate for a
Accepted for publication March 6, 2015. Address correspondence to Dr Loberman, Division of Cardiac Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115; email: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.03.081
Ann Thorac Surg 2016;101:344–6
CASE REPORT LOBERMAN ET AL TAVR IN PECTUS, LEFT THORACOTOMY
345
Fig 1. Computed tomography image shows severe pectus excavatum and the location of the heart and great vessels entirely to the left of the midline.
Fig 2. A minithoracotomy over the second intercostal space was used to expose the distal ascending aorta. The Ascendra sheath (Edwards Lifesciences Corp, Irvine, CA) is seen passing retrograde over a wire.
Aortic balloon valvuloplasty was performed during rapid ventricular pacing. The valvuloplasty balloon was exchanged for the Edwards 29-mm SAPIEN valve (Edwards Lifesciences) on its delivery system. This was positioned within the native aortic valve and its position confirmed with root aortography. Rapid ventricular pacing was again used to suspend cardiac output, and the prosthetic valve was deployed within the native valve (Fig 3, Fig 4). Transesophageal echocardiography demonstrated a small paravalvular leak that was treated by a second inflation of the delivery balloon with an additional volume of 1 mL. This reduced the paravalvular leak to
Fig 4. Postdeployment image shows the Edwards SAPIEN (Edwards Lifesciences Corp, Irvine, CA) valve is in adequate position.
FEATURE ARTICLES
transfemoral approach. Therefore, a direct transaortic technique was used for valve replacement. Initially, percutaneous left femoral artery access was obtained and 2 bare-metal stents were placed in the left anterior descending coronary artery. A minithoracotomy was performed in the left second intercostal space directly over the distal ascending aorta (Fig 2). Through 2 concentric purse-string sutures, a 6F sheath, Berenstein catheter (Boston Scientific, Boston, MA), and a 0.035-inch straight wire were used to cross the aortic valve retrograde. After transvalvular pressure measurements were obtained, the catheter was exchanged for a superstiff Amplatz wire (Cook Medical, Bloomington, IN), and the Edwards Ascendra sheath (Edwards Lifesciences Corp, Irvine, CA) was passed over this wire and into the aorta.
Fig 3. Fluoroscopic image of the new valve deploying with balloon inflation. The Ascendra sheath (Edwards Lifesciences Corp, Irvine, CA) is seen in the aorta.
346
CASE REPORT BOUTROUS ET AL NEUROLOGIC DEFICIT AFTER THORACOABDOMINAL AORTIC OPERATION
trivial. The Ascendra sheath was removed, the arteriotomy was closed, and hemostasis was achieved.
Comment TAVR via direct aortic access is an alternative when access through the peripheral arteries is not available, as was the case in our patient with a shifted mediastinum. Previous descriptions of the transthoracic technique have included right minithoracotomy and ministernotomy to obtain access to the ascending aorta. The hemisternotomy approach has the advantage of avoiding violation of the pleura, but the thoracotomy approach facilitates easier dissection and allows future refinements that could lead to a port-access approach [4]. The anatomy of the mediastinum may be distorted due to congenital, acquired, or iatrogenic reasons. In our patient, the heart and the great vessels were entirely located to the left of the midline due to severe pectus excavatum. In cases like this, a left minithoracotomy can be used for direct aortic access. The usual landmarks could not be used because of the distorted anatomy, and the dissection was guided by preoperative CT imaging. A specific contraindication for this approach includes patients who have had bypass procedures with a left internal mammary artery graft. The left anterior thoracotomy approach we describe offers patients with severe pectus excavatum and poor transarterial access an important avenue for transcatheter valve replacement.
FEATURE ARTICLES
References 1. Latsios G, Gerckens U, Grube E. Transaortic transcatheter aortic valve implantation: a novel approach for the truly “noaccess option” patients. Catheter Cardiovasc Interv 2010;75: 1129–36. 2. Bapat V, Thomas M, Hancock J, Wilson K. First successful trans-catheter aortic valve implantation through ascending aorta using Edwards SAPIEN THV system. Eur J Cardiothorac Surg 2010;38:811–3. 3. Bruschi G, De Marco F, Fratto P, et al. Direct aortic access through right minithoracotomy for implantation of selfexpanding aortic bioprosthetic valves. J Thorac Cardiovasc Surg 2010;140:715–7. 4. Ramlawi B, Anaya-Ayala JE, Reardon MJ. Transcatheter aortic valve replacement (TAVR): access planning and strategies. Methodist DeBakey Cardiovasc J 2012;8:22–5.
Management of Recurrent Delayed Neurologic Deficit After Thoracoabdominal Aortic Operation Mina L. Boutrous, MD, Rana O. Afifi, MD, Hazim J. Safi, MD, and Anthony L. Estrera, MD University of Texas Medical at Houston, Health Science Center at Houston, Texas
Ann Thorac Surg 2016;101:346–8
repair. Multiple adjuncts have been devised to counteract the development of DND, most notably cerebrospinal fluid (CSF) drainage. We report a case of a 63-year-old woman in whom DND developed four times during the first 10 days after her thoracoabdominal aortic operation. This necessitated lumbar drain “weaning” to allow for a slowly rising CSF pressure and preservation of lower extremity motor function. (Ann Thorac Surg 2016;101:346–8) Ó 2016 by The Society of Thoracic Surgeons
N
eurologic deficits after thoracoabdominal aortic operations have long been among the most catastrophic adverse events. Although their incidence has considerably declined over the past 2 decades with the use of several adjuncts, such as cerebrospinal fluid (CSF) drainage, distal aortic perfusion, and intercostal artery reattachment, neurologic deficit can still cause significant disabilities [1, 2]. We report the case of a 63-year-old woman with an extensive aortic aneurysm who experienced four consecutive episodes of paraplegia after the operation. This prompted us to wean her from a lumbar drain (LD) to allow its safe removal with no residual neurologic deficit. A 63-year-old woman with hypertension, hyperlipidemia, and paroxysmal atrial fibrillation was referred for repair of an extensive thoracic aortic aneurysm involving the ascending and transverse arch and entire thoracoabdominal aorta. She underwent ascending and transverse arch repair by use of the first-stage elephant trunk technique. The patient did well and was discharged. Three months later, she returned for completion of the second-stage repair, which required repair of the extent II thoracoabdominal aortic aneurysm (TAAA). Left-sided partial bypass was established by cannulation of the left lower pulmonary vein and the femoral artery, with sequential clamping of the aorta distal to the left subclavian artery implemented for the full repair of the extent II TAAA. The total bypass time was 76 minutes, and aortic cross-clamp time was 32 minutes. The case was complicated by coagulopathy and bowel ischemia, necessitating delayed closure and performance of a colostomy with planned return. The patient experienced delayed neurologic deficit (DND), which presented as left lower extremity weakness, 6 hours after her arrival at the cardiovascular intensive care unit. Peripheral pulses were confirmed. Our protocol for addressing DND was initiated, which included optimizing CSF drainage, delivering oxygen, managing pressure, and rectifying the patient’s status (COPS protocol) [3]. With these measures, the patient regained baseline neurologic function within 4 hours. Despite the COPS protocol, on postoperative day (POD) 2, the patient experienced a second episode of
Accepted for publication March 16, 2015.
Delayed neurologic deficit (DND) is a devastating adverse event after thoracoabdominal aortic aneurysm Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
Address correspondence to Dr Boutrous, 6400 Fannin St, Ste 2850, Houston, TX 77030; email: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.03.052