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Philippe Gailloud - One of the best experts on this subject based on the ideXlab platform.
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removal of antiscatter grids for spinal digital subtraction angiography dose reduction without loss of diagnostic value
Radiology, 2020Co-Authors: Emanuele Orru, Amgad El Mekabaty, Diego San Millan, Monica S Pearl, Philippe GailloudAbstract:Background Spinal digital subtraction angiography (DSA) exposes patients and operators to substantial amounts of radiation. Antiscatter grid (ASG) removal is used to decrease radiation exposure but may reduce image quality. Purpose To determine whether ASG removal during spinal DSA in adults reduces radiation dose while maintaining diagnostic image quality and whether dose reduction is related to body mass index (BMI). Materials and Methods This Health Insurance Portability and Accountability Act-compliant prospective study included adults undergoing spinal DSA between January and December 2016. Each procedure included an additional angiographic acquisition performed twice, once with and once without ASG, either documenting the Artery of Adamkiewicz (no pathology group) or the condition leading to the procedure (pathology group). Dose differences between study acquisitions and the influence of BMI were evaluated via paired t test. Two neurointerventionalists blinded to acquisition protocols were asked to independently evaluate a sample of 40 study acquisitions (20 with ASG, 20 without ASG) from 20 randomly selected participants to (a) rate image quality, (b) categorize findings, and (c) determine whether images had been obtained with or without ASG. Percentage agreement on image quality, findings categorization, and ability to correctly identify the acquisition protocol was calculated for both readers. Results Fifty-three participants (mean age ± standard deviation, 51 years ± 15.2; 32 men) were evaluated. ASG removal reduced the mean dose per acquisition by approximately 33% (mean dose-area product and air kerma decreased from 202 to 135.6 µGy/m2 and from 35.3 to 24 mGy, respectively; P < .001) independently of BMI (P = .3). Both readers evaluated all images (40 of 40) as being of diagnostic quality and correctly categorized findings in 19 of 20 (95%) cases. Overall percentage agreement for correct protocol identification was 60% (12 of 20) for grid-in and 45% (nine of 20) for grid-out images. Conclusion Antiscatter grid removal during spinal digital subtraction angiography decreased participants' radiation exposure while preserving diagnostic image quality. © RSNA, 2020.
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spinal dural arteriovenous fistula sdavf variant with dual perimedullary and epidural drainage
European Spine Journal, 2018Co-Authors: Philippe GailloudAbstract:A spinal dural arteriovenous fistula (SDAVF) is an abnormal connection between a radiculomeningeal Artery and a radiculomedullary vein (RMV) characteristically draining into the perimedullary venous system. We present an observation of SDAVF draining simultaneously into the perimedullary and epidural venous systems. A 67-year-old man presented with lower extremity weakness and sphincter dysfunction. MRI documented a longitudinally extensive myelopathy with parenchymal enhancement and flow-voids on T2-weighted images. Spinal angiography revealed the presence of two SDAVFs, at left T9 and right L1. The right L1 SDAVF was treated endovascularly. Superselective angiography of the main feeder, a right T12 radiculomeningeal branch, documented an unusual drainage pattern, with contrast flowing both retrogradely towards the perimedullary venous system and antegradely into the epidural plexus. The meningeal branch was embolized using a liquid embolic agent with adequate penetration of the embolic material into the proximal segment of the draining vein. The left T9 SDAVF was surgically resected, as the radicular Artery supplying the fistula also provided the Artery of Adamkiewicz. Dual drainage of the right L1 SDAVF into the perimedullary and epidural venous systems allowed to locate the site of the arteriovenous shunt at the point of transdural passage of the RMV, a narrowed segment also known to represent an anti-reflux mechanism. The potential role played by the topographical relationship between the shunt and the anti-reflux mechanism of the RMV in the formation and clinical expression of SDAVFs is discussed.
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intraoperative spinal digital subtraction angiography indications technique safety and clinical impact
Journal of NeuroInterventional Surgery, 2017Co-Authors: Emanuele Orru, Danielle Eckart Sorte, Lydia Gregg, Jean Paul Wolinsky, George I Jallo, Ali Bydon, Rafael J Tamargo, Philippe GailloudAbstract:Background Cerebral intraoperative DSA (IODSA) is a well-described, routinely performed procedure that allows the effectiveness of cerebrovascular interventions to be evaluated in the operating room. Spinal IODSA, on the other hand, is infrequently obtained and has received less attention. Objective To discuss the indications, technique, safety, and clinical impact of spinal IODSA. Materials and methods Twenty-three patients underwent 45 thoracic and/or lumbar spinal IODSA between 2005 and 2016, either immediately before surgery for lesion localization or after the intervention to evaluate its effectiveness. Indications included 21 vascular malformations and 2 diaphragmatic crus compression syndromes. A long femoral arterial sheath with its hub positioned on the lateral surface of the thigh was used to allow catheter manipulations in the prone position. Results All targeted intersegmental arteries (ISAs) were successfully catheterized. The course of surgery was changed in 6 instances (26.1%). In 4 cases of epidural or perimedullary arteriovenous fistulae (AVFs), a residual lesion required additional intervention. In one case of epidural AVF, initial IODSA revealed spontaneous resolution of the lesion, preventing unnecessary surgery. Finally, angiography performed in a case of diaphragmatic crus syndrome showed thrombosis of the ISA and non-visualization of the Artery of Adamkiewicz. Recanalization was obtained by IA thrombolysis, with excellent clinical outcome. No intraprocedural or postprocedural complication was noted. Conclusions Spinal IODSA is a safe technique that offers an immediate assessment of the effectiveness of a spinovascular surgical procedure, notably epidural and perimedullary AVFs. Spinal IODSA was technically successful in all cases, influencing the surgical strategy in 6 of 23 patients, including one patient who benefited from intraoperative endovascular therapy.
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normal venous phase documented during angiography in patients with spinal vascular malformations incidence and clinical implications
American Journal of Neuroradiology, 2016Co-Authors: Eckart D Sorte, M Obrzut, Emily Wyse, Philippe GailloudAbstract:BACKGROUND AND PURPOSE: A key angiographic sign observed in patients with spinal vascular malformations is the absence of a normal venous phase. While this finding alone is often believed to rule out a lesion impacting the perimedullary venous drainage, the observation of a venous phase in several patients with vascular malformations led us to reconsider the validity of that sign. MATERIALS AND METHODS: Eighty-one patients with 6 spinal arteriovenous malformations, 16 perimedullary arteriovenous fistulas, 61 spinal epidural or dural AVFs, and 1 paravertebral AVF (2 patients had multiple lesions) were reviewed. The venous phase was defined as normal, absent, or indeterminate. The venous phase timing was analyzed in patients with spinal dural or epidural AVFs. RESULTS: The existence of a venous phase could not be determined for technical reasons in 23 patients. A venous phase was documented in 25 of 58 patients (43%), including 16 of 49 vascular malformations (40.0%) with perimedullary venous drainage. Twelve of the 30 patients (40.0%) with dural or epidural AVFs had a normal venous phase, appearing, on average, 10.1 seconds and best visualized 15.0 seconds after opacification of the Artery of Adamkiewicz. CONCLUSIONS: A normal venous phase was observed in 43% of patients with spinal vascular malformations, and within an acceptable delay (
Nobuyoshi Kawaharada - One of the best experts on this subject based on the ideXlab platform.
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spinal cord protection with selective spinal perfusion during descending thoracic and thoracoabdominal aortic surgery
Interactive Cardiovascular and Thoracic Surgery, 2010Co-Authors: Nobuyoshi Kawaharada, Tetsuya Koyanagi, Yoshihiko Kurimoto, Toshiro Ito, Ryo Harada, Hideki Hyodoh, Atsushi Watanabe, Tetsuya HigamiAbstract:Open repair of aortic aneurysm causes spinal cord perfusion pressure to decrease due to the steal phenomenon from the bleeding of intercostal arteries and cross-clamping of the aorta. We attempted to perfuse the intercostal arteries for preoperative detection of the Artery of Adamkiewicz using newly developed catheters. Fifteen patients underwent selective spinal perfusion with our original catheter as spinal protection during the procedure of distal descending thoracic aneurysm (DTA) or thoracoabdominal aortic aneurysm (TAAA) repair. Seven patients had distal DTA and eight had TAAA. Monitoring of motor evoked potential (MEP) was performed in all patients throughout the operation. The perfusion flow was 30-40 ml/min for each intercostal Artery and was adjusted to keep the proximal circuit pressure at 150-200 mmHg. The average number of perfused intercostal arteries was 2.3 per patient and the number of intercostal arteries reimplanted per patient was 2.5. Intercostal arteries were reimplanted using an interpositional graft. MEPs were still observable after graft replacement in all patients and there were no cases of paraparesis/paraplegia. All patients were discharged ambulatory. Selective spinal perfusion maintains the quantity of total blood flow in the spinal cord and is very useful for reducing the incidence of ischemic injury of the spinal cord during operation.
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institutional report vascular thoracic spinal cord protection with selective spinal perfusion during descending thoracic and thoracoabdominal aortic surgery
2010Co-Authors: Nobuyoshi Kawaharada, Tetsuya Koyanagi, Yoshihiko Kurimoto, Toshiro Ito, Ryo Harada, Hideki Hyodoh, Atsushi Watanabe, Tetsuya HigamiAbstract:Open repair of aortic aneurysm causes spinal cord perfusion pressure to decrease due to the steal phenomenon from the bleeding of intercostal arteries and cross-clamping of the aorta. We attempted to perfuse the intercostal arteries for preoperative detection of the Artery of Adamkiewicz using newly developed catheters. Fifteen patients underwent selective spinal perfusion with our original catheter as spinal protection during the procedure of distal descending thoracic aneurysm (DTA) or thoracoabdominal aortic aneurysm (TAAA) repair. Seven patients had distal DTA and eight had TAAA. Monitoring of motor evoked potential (MEP) was performed in all patients throughout the operation. The perfusion flow was 30–40 mlymin for each intercostal Artery and was adjusted to keep the proximal circuit pressure at 150–200 mmHg. The average number of perfused intercostal arteries was 2.3 per patient and the number of intercostal arteries reimplanted per patient was 2.5. Intercostal arteries were reimplanted using an interpositional graft. MEPs were still observable after graft replacement in all patients and there were no cases of paraparesisyparaplegia. All patients were discharged ambulatory. Selective spinal perfusion maintains the quantity of total blood flow in the spinal cord and is very useful for reducing the incidence of ischemic injury of the spinal cord during operation. 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
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spinal cord ischemia after elective endovascular stent graft repair of the thoracic aorta
European Journal of Cardio-Thoracic Surgery, 2007Co-Authors: Nobuyoshi Kawaharada, Yoshihiko Kurimoto, Toshiro Ito, Ryo Harada, Hideki Hyodoh, Kiyofumi Morishita, Kenji Kuwaki, Tetsuya HigamiAbstract:Background: We reviewed our experience to investigate the determinants of paraplegia/paraparesis after endovascular stent-graft repair of the thoracic aorta, to assess the influence of the Artery of Adamkiewicz (ARM) detected by preoperative magnetic resonance angiography (MRA) and to identify patients at risk. Methods: Over a 5-year period (March 2001—June 2006), 149 patients underwent elective endovascular stentgraft repair of the descending thoracic aorta. Patient demographics and perioperative factors relating to the endovascular procedure were evaluated by using univariate statistical analyses. To assess the influence of the ARM in the thoracolumbar region, patients in whom ARM was detectedbypreoperativeMRAweredividedintotwogroups:patientswhohadocclusionoftheintercostalArteryforARMduetostent-graft(group A, n = 33) and patients who had patency of the intercostal Artery for ARM following stent-graft (group B, n = 38). Results: Five (3.6%) of the 144 patients had paraparesis/paraplegia. Two of these five patients had previously undergone operation for total arch replacement with elephant trunk and one had surgery for descending aortic repair. Univariate analyses identified only prior aortic surgery as a significant risk factor (p = 0.04). Paraparesis/paraplegia rates were 10% (three patients) in group A and 0% in group B (p = 0.09). Conclusion: Prior thoracic aortic replacement was found to be a significant predictor of spinal cord ischemia, and therefore vigilance is needed regarding occlusion of the intercostal Artery for ARM detected prior to stent-graft repair. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
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usefulness of preoperative detection of Artery of Adamkiewicz with dynamic contrast enhanced mr angiography
Radiology, 2005Co-Authors: Hideki Hyodoh, Nobuyoshi Kawaharada, Kiyofumi Morishita, Hidenari Akiba, Mitsuharu Tamakawa, Kazusa Hyodoh, Johji Fukada, Masato HareyamaAbstract:PURPOSE: To prospectively evaluate the detection of the Artery of Adamkiewicz at magnetic resonance (MR) angiography and the effect such detection has on outcome after surgical graft placement in a series of patients with thoracoabdominal aortic disease. MATERIALS AND METHODS: This study had ethics committee approval, and written informed consent was obtained from all patients. Fifty patients (38 men, 12 women; age range, 47–83 years; mean age, 67.2 years) who were scheduled to undergo thoracoabdominal aortic surgery for treatment of thoracoabdominal aortic aneurysm (n = 42) or thoracoabdominal aortic dissection (n = 8) were enrolled in the study. MR angiography was performed with a 1.5-T system by using dynamic three-dimensional fast spoiled gradient-recalled acquisition in the steady state with a bolus of contrast material and saline injection (4 mL/sec). Differences in the cross-clamping time, bypass time, total surgery time, and spinal complication rate between patients in whom the Artery of Adamkiewi...
Hideki Hyodoh - One of the best experts on this subject based on the ideXlab platform.
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spinal cord protection with selective spinal perfusion during descending thoracic and thoracoabdominal aortic surgery
Interactive Cardiovascular and Thoracic Surgery, 2010Co-Authors: Nobuyoshi Kawaharada, Tetsuya Koyanagi, Yoshihiko Kurimoto, Toshiro Ito, Ryo Harada, Hideki Hyodoh, Atsushi Watanabe, Tetsuya HigamiAbstract:Open repair of aortic aneurysm causes spinal cord perfusion pressure to decrease due to the steal phenomenon from the bleeding of intercostal arteries and cross-clamping of the aorta. We attempted to perfuse the intercostal arteries for preoperative detection of the Artery of Adamkiewicz using newly developed catheters. Fifteen patients underwent selective spinal perfusion with our original catheter as spinal protection during the procedure of distal descending thoracic aneurysm (DTA) or thoracoabdominal aortic aneurysm (TAAA) repair. Seven patients had distal DTA and eight had TAAA. Monitoring of motor evoked potential (MEP) was performed in all patients throughout the operation. The perfusion flow was 30-40 ml/min for each intercostal Artery and was adjusted to keep the proximal circuit pressure at 150-200 mmHg. The average number of perfused intercostal arteries was 2.3 per patient and the number of intercostal arteries reimplanted per patient was 2.5. Intercostal arteries were reimplanted using an interpositional graft. MEPs were still observable after graft replacement in all patients and there were no cases of paraparesis/paraplegia. All patients were discharged ambulatory. Selective spinal perfusion maintains the quantity of total blood flow in the spinal cord and is very useful for reducing the incidence of ischemic injury of the spinal cord during operation.
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institutional report vascular thoracic spinal cord protection with selective spinal perfusion during descending thoracic and thoracoabdominal aortic surgery
2010Co-Authors: Nobuyoshi Kawaharada, Tetsuya Koyanagi, Yoshihiko Kurimoto, Toshiro Ito, Ryo Harada, Hideki Hyodoh, Atsushi Watanabe, Tetsuya HigamiAbstract:Open repair of aortic aneurysm causes spinal cord perfusion pressure to decrease due to the steal phenomenon from the bleeding of intercostal arteries and cross-clamping of the aorta. We attempted to perfuse the intercostal arteries for preoperative detection of the Artery of Adamkiewicz using newly developed catheters. Fifteen patients underwent selective spinal perfusion with our original catheter as spinal protection during the procedure of distal descending thoracic aneurysm (DTA) or thoracoabdominal aortic aneurysm (TAAA) repair. Seven patients had distal DTA and eight had TAAA. Monitoring of motor evoked potential (MEP) was performed in all patients throughout the operation. The perfusion flow was 30–40 mlymin for each intercostal Artery and was adjusted to keep the proximal circuit pressure at 150–200 mmHg. The average number of perfused intercostal arteries was 2.3 per patient and the number of intercostal arteries reimplanted per patient was 2.5. Intercostal arteries were reimplanted using an interpositional graft. MEPs were still observable after graft replacement in all patients and there were no cases of paraparesisyparaplegia. All patients were discharged ambulatory. Selective spinal perfusion maintains the quantity of total blood flow in the spinal cord and is very useful for reducing the incidence of ischemic injury of the spinal cord during operation. 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
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spinal cord ischemia after elective endovascular stent graft repair of the thoracic aorta
European Journal of Cardio-Thoracic Surgery, 2007Co-Authors: Nobuyoshi Kawaharada, Yoshihiko Kurimoto, Toshiro Ito, Ryo Harada, Hideki Hyodoh, Kiyofumi Morishita, Kenji Kuwaki, Tetsuya HigamiAbstract:Background: We reviewed our experience to investigate the determinants of paraplegia/paraparesis after endovascular stent-graft repair of the thoracic aorta, to assess the influence of the Artery of Adamkiewicz (ARM) detected by preoperative magnetic resonance angiography (MRA) and to identify patients at risk. Methods: Over a 5-year period (March 2001—June 2006), 149 patients underwent elective endovascular stentgraft repair of the descending thoracic aorta. Patient demographics and perioperative factors relating to the endovascular procedure were evaluated by using univariate statistical analyses. To assess the influence of the ARM in the thoracolumbar region, patients in whom ARM was detectedbypreoperativeMRAweredividedintotwogroups:patientswhohadocclusionoftheintercostalArteryforARMduetostent-graft(group A, n = 33) and patients who had patency of the intercostal Artery for ARM following stent-graft (group B, n = 38). Results: Five (3.6%) of the 144 patients had paraparesis/paraplegia. Two of these five patients had previously undergone operation for total arch replacement with elephant trunk and one had surgery for descending aortic repair. Univariate analyses identified only prior aortic surgery as a significant risk factor (p = 0.04). Paraparesis/paraplegia rates were 10% (three patients) in group A and 0% in group B (p = 0.09). Conclusion: Prior thoracic aortic replacement was found to be a significant predictor of spinal cord ischemia, and therefore vigilance is needed regarding occlusion of the intercostal Artery for ARM detected prior to stent-graft repair. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
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usefulness of preoperative detection of Artery of Adamkiewicz with dynamic contrast enhanced mr angiography
Radiology, 2005Co-Authors: Hideki Hyodoh, Nobuyoshi Kawaharada, Kiyofumi Morishita, Hidenari Akiba, Mitsuharu Tamakawa, Kazusa Hyodoh, Johji Fukada, Masato HareyamaAbstract:PURPOSE: To prospectively evaluate the detection of the Artery of Adamkiewicz at magnetic resonance (MR) angiography and the effect such detection has on outcome after surgical graft placement in a series of patients with thoracoabdominal aortic disease. MATERIALS AND METHODS: This study had ethics committee approval, and written informed consent was obtained from all patients. Fifty patients (38 men, 12 women; age range, 47–83 years; mean age, 67.2 years) who were scheduled to undergo thoracoabdominal aortic surgery for treatment of thoracoabdominal aortic aneurysm (n = 42) or thoracoabdominal aortic dissection (n = 8) were enrolled in the study. MR angiography was performed with a 1.5-T system by using dynamic three-dimensional fast spoiled gradient-recalled acquisition in the steady state with a bolus of contrast material and saline injection (4 mL/sec). Differences in the cross-clamping time, bypass time, total surgery time, and spinal complication rate between patients in whom the Artery of Adamkiewi...
Tetsuya Higami - One of the best experts on this subject based on the ideXlab platform.
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spinal cord protection with selective spinal perfusion during descending thoracic and thoracoabdominal aortic surgery
Interactive Cardiovascular and Thoracic Surgery, 2010Co-Authors: Nobuyoshi Kawaharada, Tetsuya Koyanagi, Yoshihiko Kurimoto, Toshiro Ito, Ryo Harada, Hideki Hyodoh, Atsushi Watanabe, Tetsuya HigamiAbstract:Open repair of aortic aneurysm causes spinal cord perfusion pressure to decrease due to the steal phenomenon from the bleeding of intercostal arteries and cross-clamping of the aorta. We attempted to perfuse the intercostal arteries for preoperative detection of the Artery of Adamkiewicz using newly developed catheters. Fifteen patients underwent selective spinal perfusion with our original catheter as spinal protection during the procedure of distal descending thoracic aneurysm (DTA) or thoracoabdominal aortic aneurysm (TAAA) repair. Seven patients had distal DTA and eight had TAAA. Monitoring of motor evoked potential (MEP) was performed in all patients throughout the operation. The perfusion flow was 30-40 ml/min for each intercostal Artery and was adjusted to keep the proximal circuit pressure at 150-200 mmHg. The average number of perfused intercostal arteries was 2.3 per patient and the number of intercostal arteries reimplanted per patient was 2.5. Intercostal arteries were reimplanted using an interpositional graft. MEPs were still observable after graft replacement in all patients and there were no cases of paraparesis/paraplegia. All patients were discharged ambulatory. Selective spinal perfusion maintains the quantity of total blood flow in the spinal cord and is very useful for reducing the incidence of ischemic injury of the spinal cord during operation.
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institutional report vascular thoracic spinal cord protection with selective spinal perfusion during descending thoracic and thoracoabdominal aortic surgery
2010Co-Authors: Nobuyoshi Kawaharada, Tetsuya Koyanagi, Yoshihiko Kurimoto, Toshiro Ito, Ryo Harada, Hideki Hyodoh, Atsushi Watanabe, Tetsuya HigamiAbstract:Open repair of aortic aneurysm causes spinal cord perfusion pressure to decrease due to the steal phenomenon from the bleeding of intercostal arteries and cross-clamping of the aorta. We attempted to perfuse the intercostal arteries for preoperative detection of the Artery of Adamkiewicz using newly developed catheters. Fifteen patients underwent selective spinal perfusion with our original catheter as spinal protection during the procedure of distal descending thoracic aneurysm (DTA) or thoracoabdominal aortic aneurysm (TAAA) repair. Seven patients had distal DTA and eight had TAAA. Monitoring of motor evoked potential (MEP) was performed in all patients throughout the operation. The perfusion flow was 30–40 mlymin for each intercostal Artery and was adjusted to keep the proximal circuit pressure at 150–200 mmHg. The average number of perfused intercostal arteries was 2.3 per patient and the number of intercostal arteries reimplanted per patient was 2.5. Intercostal arteries were reimplanted using an interpositional graft. MEPs were still observable after graft replacement in all patients and there were no cases of paraparesisyparaplegia. All patients were discharged ambulatory. Selective spinal perfusion maintains the quantity of total blood flow in the spinal cord and is very useful for reducing the incidence of ischemic injury of the spinal cord during operation. 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
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spinal cord ischemia after elective endovascular stent graft repair of the thoracic aorta
European Journal of Cardio-Thoracic Surgery, 2007Co-Authors: Nobuyoshi Kawaharada, Yoshihiko Kurimoto, Toshiro Ito, Ryo Harada, Hideki Hyodoh, Kiyofumi Morishita, Kenji Kuwaki, Tetsuya HigamiAbstract:Background: We reviewed our experience to investigate the determinants of paraplegia/paraparesis after endovascular stent-graft repair of the thoracic aorta, to assess the influence of the Artery of Adamkiewicz (ARM) detected by preoperative magnetic resonance angiography (MRA) and to identify patients at risk. Methods: Over a 5-year period (March 2001—June 2006), 149 patients underwent elective endovascular stentgraft repair of the descending thoracic aorta. Patient demographics and perioperative factors relating to the endovascular procedure were evaluated by using univariate statistical analyses. To assess the influence of the ARM in the thoracolumbar region, patients in whom ARM was detectedbypreoperativeMRAweredividedintotwogroups:patientswhohadocclusionoftheintercostalArteryforARMduetostent-graft(group A, n = 33) and patients who had patency of the intercostal Artery for ARM following stent-graft (group B, n = 38). Results: Five (3.6%) of the 144 patients had paraparesis/paraplegia. Two of these five patients had previously undergone operation for total arch replacement with elephant trunk and one had surgery for descending aortic repair. Univariate analyses identified only prior aortic surgery as a significant risk factor (p = 0.04). Paraparesis/paraplegia rates were 10% (three patients) in group A and 0% in group B (p = 0.09). Conclusion: Prior thoracic aortic replacement was found to be a significant predictor of spinal cord ischemia, and therefore vigilance is needed regarding occlusion of the intercostal Artery for ARM detected prior to stent-graft repair. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
Randall B Griepp - One of the best experts on this subject based on the ideXlab platform.
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the anatomy of the spinal cord collateral circulation
Annals of cardiothoracic surgery, 2012Co-Authors: Eva B Griepp, Gabriele Di Luozzo, Deborah Schray, Angelina Stefanovic, Sarah Geisbusch, Randall B GrieppAbstract:Spinal cord injury remains a devastating complication of the treatment of extensive thoracoabdominal aortic aneurysms (TAAA), whether by open surgery or endovascular strategies. Although the incidence and pattern of occurrence of spinal cord injury have been changing in recent years, the threat of possible paraplegia or paraparesis continues to deter patients from undergoing elective operations to prevent rupture of extensive TAAA. A better understanding of the anatomy and physiology of the spinal cord circulation have in recent years led to a reduction in the risk of postoperative spinal cord ischemia; further insights should soon enable us to make postoperative paraplegia and paraparesis a very rare complication of TAAA treatment. A number of clinical and experimental findings led us to question the traditional view that spinal cord perfusion is dependent principally upon a single prominent branch from the descending aorta with a distinctive hairpin configuration, the so-called Artery of Adamkiewicz (1). We proposed instead the existence of an extensive collateral network that supports spinal cord perfusion. This collateral network includes all the segmental arteries (SAs), both intercostal and lumbar: they send branches to the anterior spinal Artery (ASA), the major Artery within the spinal canal. In addition to multiple SA inputs, the ASA is also potentially fed by an extensive epidural arterial network, and by a dense array of small vessels which supply the paraspinal musculature. All these vessels are interconnected, and have major anastomoses with the subclavian arteries cranially, and the hypogastric arteries caudally. This extensive collateral network allows compensatory flow to the spinal cord when some of the direct inputs to the ASA are compromised during repair
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thoracic and thoracoabdominal aneurysm repair is reimplantation of spinal cord arteries a waste of time
The Annals of Thoracic Surgery, 2006Co-Authors: Christian D Etz, James C Halstead, David Spielvogel, Rohit Shahani, Ricardo Lazala, Tobias M Homann, Donald Weisz, Konstadinos A Plestis, Randall B GrieppAbstract:Background The impact of different strategies for management of intercostal and lumbar arteries during repair of thoracic and thoracoabdominal aortic aneurysms (TAA/A) on the prevention of paraplegia remains poorly understood. Methods One hundred consecutive patients with intraoperative monitoring of motor evoked potentials (MEP) and somatosensory evoked potentials (SSEP) during TAA/A repair involving serial segmental Artery sacrifice (October 2002 to December 2004) were reviewed. Results Operative mortality was 6%. The median intensive care unit stay was 2.5 days (IQ range: 1–4 days), and the median hospital stay 10.0 days (IQ range: 8–17 days). Potentials remained unchanged during the course of serial segmental Artery sacrifice, or could be returned to baseline levels by anesthetic and blood pressure manipulation, in 99 of 100 cases. An average of 8.0 ± 2.6 segmental Artery pairs were sacrificed overall, with an average of 4.5 ± 2.1 segmental pairs sacrificed between T7 and L1, where the Artery of Adamkiewicz is presumed to arise. Postoperative paraplegia occurred in 2 patients. In 1, immediate paraplegia was precipitated by an intraoperative dissection, resulting in 6 hours of lower body ischemia. A second ambulatory patient had severe paraparesis albeit normal cerebral function after resuscitation from a respiratory arrest. Conclusions With monitoring of MEP and SSEP, sacrifice—without reimplantation—of as many as 15 intercostal and lumbar arteries during TAA/A repair is safe, resulting in acceptably low rates of immediate and delayed paraplegia. This experience suggests that routine surgical implantation of segmental vessels is not indicated, and that, with evolving understanding of spinal cord perfusion, endovascular repair of the entire thoracic aorta should ultimately be possible without spinal cord injury.
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surgery for acquired heart disease looking for the Artery of Adamkiewicz a quest to minimize paraplegia after operations for aneurysms of the descending thoracic and thoracoabdominal aorta
The Journal of Thoracic and Cardiovascular Surgery, 1996Co-Authors: Randall B Griepp, Arisan M Ergin, Jan D Galla, Steven L Lansman, Nguyen Khan, Cid S Quintana, Jock N Mccollough, Carol A BodianAbstract:Abstract All patients undergoing resection of thoracic or thoracoabdominal aneurysms at Mount Sinai Hospital since November 1993 had spinal cord function monitored with somatosensory-evoked potentials as part of a multimodality approach to reducing spinal cord injury. In the segment to be resected, each pair of intersegmental vessels was sequentially clamped, and they were subsequently sacrificed only if no change in somatosensory evoked potentials occurred within 8 to 10 minutes after occlusion. Adjunctive protective measures included mild hypothermia (31° to 33° C), distal perfusion, corticosteroids, maintenance of high normal blood pressures, avoidance of nitroprusside, and cerebrospinal fluid drainage. Ninety-five consecutive patients operated on since 1993 (group II) were compared with 138 earlier patients (group I). Preoperative characteristics such as age, sex, etiology of aneurysm, emergency operation, and reoperation did not differ between groups, nor did operative variables such as incidence of rupture and extent of resection. Group I had slightly more smokers and slightly fewer hypertensive individuals. Group II patients had a significantly better outcome with respect to in-hospital mortality (10.5% vs 18%, p = 0.045) and paraplegia (2% vs 8%, p = 0.008). By multivariate analysis, rupture and diabetes were associated with significantly higher in-hospital mortality, and smoking greatly increased the incidence of paraplegia. The extent of the aneurysm was a major determinant of mortality and paraplegia. The low paraplegia rate in group II was achieved without reattachment of a single intercostal or lumbar Artery. No patient with fewer than 10 intersegmental arteries severed had paraplegia, and spinal cord ischemia was reversible in three patients after adjunctive maneuvers were performed to improve perfusion, suggesting that spinal cord blood supply is unlikely to depend on a single "Artery of Adamkiewicz." (J THORAC CARDIOVASC SURG 1996;112:1202-15)
