Update on current management of aortic aneurysms with special emphasis on descending aortic aneurysms.

1. Thoracic Aortic
Aneurysm
Ashraf banoub, MD, MBA
09/30/2016

2. Thoracic Aortic
Aneurysm
• Thoracic aortic aneurysm is a permanent localized thoracic aortic
dilatation that has at least a 50% diameter increase and three aortic wall
• Pseudoaneurysm or a false aneurysm is a localized dilation of the aorta
that does not contain all three layers of the vessel wall and instead
consists of connective tissue and clot
• Thoracic aortic aneurysms are common and are the 15th most common
cause of death in people older than 65
H.L. Lazar, M. McDonnell, S.R. Chipkin, et al.: The Society of Thoracic Surgeons practice guideline series: Blood glucose management during adult cardiac surgery. Ann Thorac Surg.
87:663 2009 19161815

3. Risk Factors
• Hypertension
• Hypercholesterolemia
• Smoking
• Genetic inheritance

4. Genetic Factors
• Thoracic aortic aneurysms divide into two groups at the
level of the ligamentum arteriosum.
• Above the ligamentum arteriosum, the disease is not
related to typical arterial risk factors and has a smooth,
noncalcified wall accompanied by no debris or clot.
• Below the ligamentum arteriosum, the disease process
primarily is atherosclerotic, with an irregular calcified
wall accompanied by copious debris and clot
G. Albornoz, M.A. Coady, M. Roberts, et al.: Familial thoracic aortic aneurysms and dissections—incidence, modes of inheritance, and phenotypic patterns. Ann Thorac Surg. 82:1400 2006
16996941

5. Inflammatory Causes
• Syphilis
• Mycotic aneurysm from endocarditis
• Giant-cell arteritis
• Takayasu arteritis.

6. Complications of Thoracic
Aortic Aneurysms
• Aortic rupture
• Aortic regurgitation
• Tracheobronchial and esophageal compression
• Right pulmonary artery or right ventricular outflow tract obstruction
• Systemic embolism from mural thrombus

7. Classifications of Aortic
Aneurysms
Safi modification of Crawford TAA classification
Safi HJ, Winnerkvist A, Miller CC 3rd, et al. Effect of extended cross-clamp time during thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 1998;
66:1204.

8. The shape of thoracic
aortic aneurysms
• Fusiform aneurysms are
more common
• Associated with
atherosclerotic or
collagen vascular
disease, and usually
affect a longer segment
of the aorta
• Saccular aneurysms are
more localized, confined to
an isolated segment of the
aorta

9. Symptoms
• Chest and back pain caused by aneurysmal dissection, rupture, or bony erosion.
• Mass effect from a large thoracic aortic aneurysm
• Hoarseness (recurrent laryngeal nerve)
• Dyspnea (trachea, mainstem bronchus, pulmonary artery)
• Central venous hypertension (superior vena cava syndrome)
• Dysphagia (esophagus).
• Rupture of thoracic aortic aneurysms is a surgical emergency and is often accompanied with
• Acute pain with or without hypotension
• Rupture of an ascending aortic aneurysm may cause cardiac tamponade
• Rupture in the descending thoracic aorta may cause hemothorax, aortobronchial fistula, or
aortoesophageal fistula.

10. Diagnostic Imaging for
Thoracic Aortic
• Typically, transthoracic echocardiography can
provide a reasonable examination of the
thoracic aorta
• The contemporary imaging modalities of
choice are CT, MRI, and TEE.

11. CTA Imaging for
Thoracic Aortic
• Computed tomographic angiography (CTA) images the thoracic aorta
during the arterial phase of an intravenous radiocontrast agent injection.
• Advantages include high resolution, wide availability, rapid acquisition,
imaging in patients with metallic implants, and generation of volumetric
aortic images for stent design.
• CTA requires iodinated contrast agents, it carries a risk for contrast
nephropathy that can be attenuated by administration of acetylcysteine and
sodium bicarbonate.
J.R. Brown, C.A. Block, D.J. Malenka, et al.: Sodium bicarbonate plus N-acetylcysteine prophylaxis: A meta-analysis. JACC Cardiovasc Interv. 2:1116 2009
19926054

12. Contrast-enhanced magnetic
resonance angiography with
gadolinium
• Advantages are
• Avoidance of ionizing radiation
• Lack of renal toxicity
• Allows for degrees of tissue and fluid characterization.
• Disadvantages include
• Limited availability
• Lack of imaging in patients with metallic implants
• Imaging difficulty in the setting of need for continuous
hemodynamic monitoring
• Time required for image acquisition

13. TEE
• TEE can image the thoracic aorta from the aortic valve to the distal
ascending aorta and from the distal aortic arch to the proximal
abdominal aorta. The distal ascending aorta and proximal aortic arch
cannot be reliably imaged by TEE because the intervening trachea and
left mainstem bronchus obstruct the acoustic window
• The advantages of TEE include its portability, its real-time
interpretation, its compatibility at the bedside and in the OR, and its
multiple imaging modalities for complete aortic and cardiac
assessment.
• Its disadvantages include the requirement for sedation or general
anesthesia and the risks for upper gastrointestinal injury.

14. Indications for Surgical Repair
of Thoracic Aortic Aneurysms
Atherosclerotic aneurysm diameter
Ascending aorta >/=5.5 cm
Descending aorta >/=6.5 cm
Marfan’s or familial thoracic aneurysm diameter
Ascending aorta >/=5.0 cm
Descending aorta >/=6.0cm
Severe aortic regurgitation
Aortoannular ectasia with aortic root aneurysm
Rupture
Refractory pain
J.A. Elefteriades, E.A. Farkas: Thoracic aortic aneurysm. J Am Coll Cardiol. 55:841 2010 20185035
J.G. Augoustides, T. Plappert, J.E. Bavaria: Aortic decision-making in the Loeys-Dietz syndrome: Aortic root aneurysm and a normal-caliber ascending aorta and
aortic arch. J Thorac Cardiovasc Surg. 138:502 2009 19619806
R.R. Davies, A. Gallo, M.A. Coady, et al.: Novel measurement of relative aortic size predicts rupture of thoracic aortic aneurysms. Ann Thorac Surg. 81:169 2006
16368358

15. Surgical Repair of Ascending
Aortic and Arch Aneurysms
• The type of surgical repair
depends on aortic valve
function and the aneurysm
extent.
• Perioperative TEE can evaluate
the aortic valve structure and
function to guide and assess
the surgical intervention
(reimplantation, repair,
replacement).

16. If the aortic valve and aortic root are normal, a simple tube graft can be used to replace the ascending aorta
If the aortic valve is diseased but the sinuses of Valsalva are normal, an aortic valve replacement combined with a tube
graft for the ascending aorta without need for reimplantation of the coronary arteries can be performed (Wheat
procedure

17. Dilated Aortic Root

18. Aortic Root
Replacement
(modified Bentall
Procedure)

19. Repairing aortic aneurysms that extend
into or involve the aortic arch
requires CPB with DHCA with or
without perfusion adjuncts
Elephant Trunk Repair

20. The trifurcated graft technique for
replacing the aortic arch.

21. Anesthetic Management for Ascending
Aorta and Arch Aneurysms
• The imaging studies should be reviewed for aneurysm compression of
mediastinal structures such as the right pulmonary artery and left
mainstem bronchus
• Prevention of hypertension increases forward flow in AR and
minimizes the risk for aneurysm rupture
• A right radial arterial catheter is preferred for most cases
• If arterial cannulation of the right axillary, subclavian, or innominate
artery is planned for CPB and ACP, bilateral radial arterial catheters
often are required to measure cerebral and systemic perfusion pressures
• Nasopharyngeal, tympanic, and bladder temperatures are important for
estimating brain and core temperatures for monitoring the conduct of
DHCA

22. • Intraoperative TEE is essential to guide and assess the surgical
interventions
• In patients with AR, TEE can assist in the conduct of CPB by guiding
placement of cannulae such as the retrograde cardioplegia cannula
(coronary sinus) and by monitoring left ventricular (LV) volume
• Intraoperative TEE is reasonable in thoracic aortic procedures,
including endovascular interventions, in which it assists in
hemodynamic monitoring, procedural guidance, and endoleak
detection
1L.F. Hiratzka, G.L. Bakris, J.A. Beckman, et al.: ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and
management of patients with thoracic aortic disease: Executive summary. A report of the American College of Cardiology Foundation, American
Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke
Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society for Vascular
Medicine. J Am Coll Cardiol. 55:1509 2010

23. Neuroprotection Strategies for
Temporary Interruption of
Cerebral Blood Flow
• Hypoperfusion or temporary circulatory arrest during aortic arch
repair.
• Cerebral ischemia due to embolization secondary to CPB and atheroma
• Air
• Atherosclerotic particulate debris
• CPB may result in the microparticulate aggregates of platelets and
fat
• Retrograde blood flow through a diseased descending thoracic aorta
L.H. Stein, J.A. Elefteriades: Protecting the brain during aortic surgery: An enduring debate with unanswered questions. J Cardiothorac Vasc Anesth. 24:316-321
2010 19646900

24. Brain Protection for Aortic
Arch Reconstruction
• Deep systemic hypothermia
• Topical cerebral cooling
• Retrograde cerebral perfusion
• Selective antegrade cerebral perfusion
• Cerebral hyperthermia prevention during rewarming

25. Deep Hypothermic
Circulatory Arrest
• The physiologic basis for deep hypothermia as
a neuroprotection strategy is to decrease
cerebral metabolic rate and oxygen demands
to increase the period that the brain can
tolerate circulatory arrest
• Autoregulation of cerebral blood flow is
maintained during deliberate hypothermia
with alpha-stat blood gas management
without compromise of clinical outcome
D.K. Harrington, F. Fragomeni, R.S. Bonser: Cerebral perfusion. Ann Thorac Surg. 83:S799 2007 17257930
K.A. Abdul Aziz, A. Meduoye: Is pH-stat or alpha-stat the best technique to follow in patients undergoing deep hypothermic circulatory arrest?. Interact
Cardiovasc Thorac Surg. 10:271 2010 19914925

26. Adapted from Cheung AT, Bavaria JE,
Pochettino A, et al: Oxygen delivery
during retrograde cerebral perfusion
in humans. Anesth Analg 88:14, 1999

27. • The median nasopharyngeal temperature for
electrocortical silence was 18° C
• A nasopharyngeal temperature of 12.5° C or
cooling on CPB for at least 50 minutes
achieved electrocortical silence in 99.5% of
cases
M.M. Stecker, A.T. Cheung, A. Pochettino, et al.: Deep hypothermic circulatory arrest: I. Effects
of cooling on electroencephalogram and evoked potentials. Ann Thorac Surg. 71:14 2001
11216734

28. (A) The cumulative probability of electrocerebral silence on
electroencephalogram (EEG) as a function of cooling time. (B)
The cumulative probability that electrocerebral silence (ECS) is
not achieved for temperatures above that indicated.
Stecker MM, Cheung AT, Pochettino A, et al: Deep hypothermic circulatory arrest: I. Effects of cooling on electroencephalogram and evoked potentials. Ann Thorac Surg 71:19, 2001, by
permission of the Society of Thoracic Surgeons

29. Retrograde Cerebral
Perfusion
• RCP is performed
by infusing cold
oxygenated blood
into the superior
vena cava cannula
at a temperature of
8° C to 14° C via
CPB
A. Pochettino, A.T. Cheung: Pro: Retrograde cerebral perfusion is useful for deep hypothermic circulatory arrest. J Cardiothorac Vasc Anesth. 17:764 2003
14689421

30. Retrograde Cerebral
Perfusion
• The internal jugular venous pressure is
maintained at less than 25 mm Hg to prevent
cerebral edema
• The patient is positioned in 10 degrees of
Trendelenburg to decrease the risk for cerebral
air embolism and prevent trapping of air
within the cerebral circulation in the presence
of an open aortic arch. RCP flow rates of 200 to
600 mL/min usually can be achieved
A. Pochettino, A.T. Cheung: Pro: Retrograde cerebral perfusion is useful for deep hypothermic circulatory arrest. J Cardiothorac Vasc Anesth. 17:764 2003 14689421

31. Retrograde Cerebral
Perfusion
• The potential benefits of RCP include
• partial supply of cerebral metabolic
substrate
• cerebral embolic washout
• maintenance of cerebral hypothermia
A. Pochettino, A.T. Cheung: Pro: Retrograde cerebral perfusion is useful for deep hypothermic circulatory arrest. J Cardiothorac Vasc Anesth. 17:764 2003
14689421

32. Retrograde Cerebral
Perfusion
• The perioperative rates for mortality
and stroke in this series were 10.4% and
2.8%, respectively. The application of
RCP was significantly protective
against mortality (odds ratio, 0.42; 95%
confidence interval, 0.25-0.70; P =
0.0009) and stroke (odds ratio, 0.35; 95%
confidence interval, 0.15-0.81; P = 0.02
A.L. Estrera, C.C. Miller, T.Y. Lee, et al.: Ascending and transverse aortic arch repair: The impact of retrograde cerebral perfusion. Circulation. 118:S160
2008 18824749

33. Selective Antegrade
Cerebral Perfusion
• Selective ACP should be
considered for aortic arch
repairs longer than 45 minutes
• ACP typically is initiated
during DHCA by selective
cannulation of the right axillary
artery, right subclavian artery,
innominate artery, or left
common carotid artery
L.H. Stein, J.A. Elefteriades: Protecting the brain during aortic surgery: An enduring debate with unanswered questions. J Cardiothorac Vasc Anesth. 24:316-321
2010

34. Selective Antegrade
Cerebral Perfusion
• In transverse aortic
arch reconstruction
procedures, ACP
can be
accomplished by
inserting individual
perfusion cannulae
into the open end of
the aortic branch
vessels after

35. Selective Antegrade
Cerebral Perfusion
• Unilateral ACP via right
axillary arterial cannulation is a
popular technique for adult
aortic repair
• This technique assumes an
adequate circle of Willis;
however, the anatomic
completeness of the circle of
Willis does not guarantee
adequate cerebral cross-
perfusion during aortic arch
repair
C.D. Etz, K.A. Plestis, F.A. Kan, et al.: Axillary cannulation significantly improves survival and neurologic outcome after atherosclerotic aneurysm repair of
the aortic root and ascending aorta. Ann Thorac Surg. 86:441 2008

36. Selective Antegrade
Cerebral Perfusion
• Safe ACP was significantly
prolonged with bilateral ACP
(86–164 minutes) compared
with unilateral ACP (30–50
minutes). The evidence favors
bilateral ACP in the setting of
aortic arch repair times longer
than 60 minutes
• ACP with oxygenated blood at
10° C to 14° C at flow rates in
the range of 250 to 1000 mL/
min typically achieves a
cerebral perfusion pressure in
the range of 50 to 80 mm Hg
P.G. Malvindi, G. Scrascia, N. Vitale: Is unilateral antegrade cerebral perfusion equivalent to bilateral cerebral perfusion for patients undergoing aortic arch
surgery?. Interact Cardiovasc Thorac Surg. 7:891 2008

37. Pharmacologic Neuroprotection Strategies
for Deep Hypothermic Circulatory Arrest
• Neuroprotective effects of such drugs may
decrease any cerebral metabolic activity that
remains at temperatures less than 18°C
• When thiopental was available, doses of 20
mg/kg were administered prior to DHCA to
provide EEG silence.
• Propofol in DHCA has not demonstrated
neuroprotective effects, but do show effect
EEG burst suppression
Woodcock TE, Murkin JM, Farrar JK Tweed WA, Guiraudon GM, McKenzie FN. Pharmacologic EEG
suppression during cardiopulmonary bypass: cerebral hemodynamic and metabolic effects of thiopental or
isoflurane during hypothermia and normothermia. Anesthesiology 1987;67:218-24

38. Pharmacologic Neuroprotection Strategies
for Deep Hypothermic Circulatory Arrest
• Steroids do provide anti-inflammatory and spinal cord protection
during CPB, but neuroprotection during DHCA has not been proven
• Mechanisms include anti-oxidant effects, cytoprotective effects, reduced
release of excitatory amino acids, inhibition of proinflammatory
pathways activated by CPB and ischemia, and attenuation of altered
CBF resulting from hypothermic arrest
• Support for the clinical use of corticosteroids for neuroprotection
during DHCA is in part based on the positive effects of large doses of
methylprednisolone (30 mg/kg) after spinal cord injury, although these
data are controversial
• Corticosteroid may lead to hyperglycemia. Even mild glucose elevation
(i.e., >140 mg/dL) is associated with poor outcome after stroke
mandating close monitoring of glucose during surgery
Shine TSJ, Uchikado M, Crawford CC, Murray MJ. Importance of perioperative blood glucose management
in cardiac surgical patients. Asian Cardiovasc Thorac Ann 2007;15:534-538

40. Aortic Dissection
• Aortic dissection results from
an intimal tear that exposes the
media to the pulsatile force of
blood within the aortic lumen
• The aortic dissection may
remain localized at the primary
entry site at the original intimal
tear, or it may extend
proximally, distally, or both

41. Aortic Dissection
• DeBakey Classification
• Type I: The entire aorta is involved (ascending, arch,
and descending)
• Type II: Confined to the ascending aorta
• Type III: Intimal tear originating in the descending aorta
with either distal or retrograde extension
• Type IIIA: Intimal tear originating in the descending
aorta with extension distally to the diaphragm or
proximally into the aortic arch
• Type IIIB: Intimal tear originating in the descending
aorta with extension below the diaphragm or
proximally into the aortic arch
• Stanford Classification
• Type A: Involvement of the ascending aorta or aortic
arch regardless of the site of origin or distal extent
• Type B: Confined to the descending aorta distal to the
origin of the left subclavian artery

42. Type A Aortic Dissection
• Aortic dissections that involve the ascending
aorta (Stanford type A) are considered surgical
emergencies
• The mortality rate without emergency surgery
is about 1% per hour for the first 48 hours, 60%
by about 1 week, 74% by 2 weeks, and 91% by
6 months

43. Potential Complications of
Acute Type a Aortic Dissection
• Cardiac tamponade
• Aortic regurgitation
• Myocardial infarction
• Stroke
• Limb ischemia
• Mesenteric ischemia

44. Mortality in Acute Aortic Dissection
According to Dissection Type and
Management
Hagan PG, Nienaber CA, Isselbacher EM, et al: The International Registry of Acute Aortic Dissection (IRAD). New insights into an old disease. JAMA
283:897, 2000
Dissection Type N Hospital Mortality(%)
Stanford Type A 289 101 (34.9)
Medical Management 81 47 (58.0)
Surgical Management 208 54 (26.0)
Stanford Type B 175 26 (14.9)
Medical Management 140 15 (10.7)
Surgical Management 35 11 (31.4)

45. Modified Crawford
Classification

46. Descending Thoracic and Thoracoabdominal
Aortic Aneurysms
• Surgical therapy for thoracic and TAAAs is to
replace aneurysmal aorta with a prosthetic
tube graft
• Surgical access is via lateral thoracotomy or
thoracoabdominal incision
• The risks for spinal, mesenteric, renal, and
lower extremity ischemia are significant due to
thromboembolism, loss of collateral vascular
networks, temporary interruption of blood

47. Clinical Outcomes of Thoracoabdominal
Aortic Aneurysm (TAAA) Repair
Cowan JA, Dimick JB, Henke PK, et al: Surgical treatment of intact thoracoabdominal aortic aneurysms in the United States: Hospital and surgeon
volume-related outcomes. J Vasc Surg 37:1169, 2003; and Cowan JA, Dimick JB, Wainess RM, et al: Ruptured thoracoabdominal aortic aneurysm
treatment in the United States: 1988 to 1998. J Vasc Surg 38: 312, 2003.
. Yamauchi T, Takano H, Nishimura M, Matsumiya G, Sawa Y. Paraplegia and para- paresis after descending thoracic aortic aneurysm
repair: a risk factor analysis. Ann Thorac Cardiovasc Surg. 2006;12(3) 179-83
Complications Intact TAAA (n=1542) Ruptured TAAA (n=321)
Cardiac 14.8% 18.1%
Pulmonary 19% 12.7%
Hemorrhage 12.4% 10.9%
Acute renal failure 14.2% 28%
Paraplegia 2.7%-12% 3.4%-16%
In-hospital mortality 22.3% 53.8%

50. Operative techniques for repair of
thoracic or thoracoabdominal aortic
aneurysms
• (1) aortic cross-
clamping
• (2) aortic cross-
clamping with a
Gott shunt
• (3) aortic cross-
clamping with
PLHB or partial
CPB

51. Spinal Cord Ischemia

52. Spinal Cord Ischemia
• The largest of the
radicular arteries is
the artery of
Adamkiewicz,
often given off at
the level of T10 but
it can vary in
position from T7 to
L4

53. Spinal Cord Ischemia
• Paraplegia/ paraparesis occurs in 2.7 to 12% in
thoracic and 3.6 to 16% in thoracoabdominal
open surgical procedures
• Paraplegia post thoracic stenting varies from 0
to 9.8%, with a permanent paraplegia risk of
5.5%.
• Isolated descending thoracic stents is 0.9%
• Complex procedures involving fenes- trated
and branched stents (7.1%) and visceral
hybrid procedures (11.3%)
. Yamauchi T, Takano H, Nishimura M, Matsumiya G, Sawa Y. Paraplegia and para- paresis after descending thoracic aortic aneurysm
repair: a risk factor analysis. Ann Thorac Cardiovasc Surg. 2006;12(3) 179-83
. Drinkwater SL, Goebells A, Haydar A, Bourke P, Brown L, Hamady M, Gibbs RG; Regional Vascular Unit, St Mary's Hospital, Imperial
College NHS Trust. The inci- dence of spinal cord ischaemia following thoracic and thoracoabdominal aortic endo- vascular intervention. Eur J Vasc
Endovasc Surg. 2010;40(6) 729-35

54. Spinal Cord Ischemia
• Spinal cord perfusion pressure is a balance
between the inflow and outflow pressures
within the closed confines of the spinal canal,
calculated as mean arterial pressure (MAP)
minus CSF pressure
• Theoretically therefore, decreasing the CSF
pressure or increasing the blood pressure/
MAP will improve spinal cord perfusion
pressure

55. Risk factors for spinal
cord ischemia
• Blood Supply
• Perfusion Pressure
• Reperfusion Injury
• Critical Intercostal Artey Coverage
• Collateral Circulation
• Hypotension

56. Blood Supply
• Spinal cord blood supply is often segmental
and dependent upon contribution from
collateral arteries
• The need for more extensive aortic
replacement requires interruption of an
increasing number of intercostal arteries
providing spinal cord perfusion, thereby
posing a higher risk of SCI
. Carroccio A, Marin ML, Ellozy S, Hollier LH. Pathophysiology of paraplegia follow- ing endovascular thoracic aortic aneurysm repair. J Card Surg.
2003;18(4) 359-66.

57. Blood Supply
• Proximal aortic clamp interferes with the
autoregulatory response controlling cerebral
perfusion with resulting fluctuations in
cerebral blood flow
• Lowering proximal pressure decreases distal
mean arterial pressure, which in the presence
of an unchanged or possibly increased CSF
pressure, results in decreased perfusion
pressure of the distal cord
. Carroccio A, Marin ML, Ellozy S, Hollier LH. Pathophysiology of paraplegia follow- ing endovascular thoracic aortic aneurysm repair. J Card Surg. 2003;18(4) 359-66.

58. Reperfusion Injury
• Ischemia and reperfusion initiate
neurochemical cellular responses that can
exacerbate ischemia
• Lipid peroxidation with cell membrane
destruction
• Inflammatory cells including leukocytes
adhere to the microvasculature and release
cytotoxic mediators
. Acher C, Wynn M. Paraplegia after thoracoabdominal aortic surgery: not just assist- ed circulation, hypothermic arrest, clamp and sew, or TEVAR. Ann Cardiothorac Surg.
2012;1(3) 365-72

59. Critical intercostal artery
coverage
• Stent-graft coverage of the critical thoracic
intercostal arteries results in reduced perfusion
of the thoracic spinal cord and watershed
infarction.
• Loss of the artery of Adamkiewitz in prior
abdominal aortic repairs may explain why
patients with prior repair are at higher risk of
SCI during subsequent TAA repair
. McGarvey ML, Mullen MT, Woo EY, Bavaria JE, Augoustides YG, Messé SR, Cheung AT. The treatment of spinal cord ischemia following thoracic endovascular aortic re-
pair. Neurocrit Care. 2007;6(1) 35-9.

60. Collateral circulation
• SCI following stent-
graft deployment
can also be
dependent upon
the extent of
existing collateral
circulation

61. Real-time Monitoring of the Paraspinous Collateral Network
Oxygenation by Near Infrared Spectroscopy During and After
Open and Endovascular Descending and Thoracoabdominal Aortic
Repair
Real-time Monitoring of the Paraspinous Collateral Network Oxygenation by Near Infrared Spectroscopy During and After Open and
Endovascular Descending and Thoracoabdominal Aortic Repair
M. Luehr1, K. von Aspern1, A. Hoyer1, C. Mukherjee2, J. Banusch2, J. Ender2, F. Mohr1, C. D. Etz1. 1Cardiac Surgery, Leipzig Heart Center,
Leipzig, Germany, 2Anesthesiology, Leipzig Heart Center, Leipzig, Germany

62. Hypotension
• Hypotension that precipitates spinal cord
injury within the first 48 hours after open
surgical intervention is quite subtle
• Maintaining blood pressures at high levels not
only intraoperatively but for at least 48 hours
postoperatively

63. Hypotension
• Following TEVAR, MAP should be
maintained at greater than 80mmHg
with the use of vasopressors when
required
. Etz CD, Luehr M, Kari FA, Bodian CA, Smego D, Plestis KA, Griepp RB. Paraplegia after extensive thoracic and thoracoabdominal aortic aneurysm repair: does critical spinal
cord ischemia occur postoperatively? J Thorac Cardiovasc Surg. 2008;135(2) 324-30.

64. Adjuncts for the prevention of
paraplegia
• Intercostal artery re-implantation
• Internal iliac revascularization
• Left subclavian artery revascularization
• Elective sac perfusion via temporary controlled
endoleak
• Cerebrospinal fluid drainage

65. Intercostal artery re-
implantation or presevation
• Reduced paraplegia risk index
by 75%
• Based on magnetic resonance
angiography identification of
intercostal arteries that
supplied radicular arteries
• The incidence of paralysis after
TAAA repair decreased from
4.83% to 0.88%
Acher CW, Wynn MM, Mell MW, Tefera G, Hoch JR. A quantitative assessment of the impact of intercostal artery reimplantation on paralysis risk in thoracoabdominal aortic aneurysm repair.
Ann Surg. 2008 Oct;248(4):529-40

66. Adjuncts for the prevention of
paraplegia
• Internal iliac
revascularization
• Left subclavian
artery
revascularization
Bicknell CD, Riga CV, Wolfe JH. Prevention of paraplegia during thoracoabdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg. 2009 Jun;37(6) 654-60
Peterson BG, Eskandari MK, Gleason TG, Morasch MD. Utility of left subclavian artery revascularization in association with endoluminal repair of acute and chronic thoracic aortic
pathology. J Vasc Surg. 2006;43(3) 433-9
Left common carotid (CC) to left subclavian artery (LSCA,
arrow) bypass with Dacron graft (arrow head) performed
prior to endovascular stenting across origin of LSCA (star) to
createadequate landing zone for exclusion of thoracic aortic
aneurysm while maintaining flow to LSCA

67. Elective sac perfusion via
temporary controlled endoleak
• The perfusion
branches are left
open in order to
perfuse segmental
vessels.
• Five to ten days
postoperatively the
branches are then
closed with
Amplatzer plugs to
complete exclusion Harrison SC, Agu O, Harris PL, Ivancev K. Elective sac perfusion to reduce the risk
of neurologic events following endovascular repair of thoracoabdominal aneurysms.
J Vasc Surg. 2012;55(4) 1202-5.

68. Cerebrospinal fluid drainage
• Two meta-analyses concluded that CSFD
significantly reduces the risk of perioperative
paraplegia or paraparesis.
• A Cochrane review concluded CSFD may
increase the perfusion pressure to the spinal
cord and hence reduce the risk of ischemic
spinal cord injury
Cinà CS, Abouzahr L, Arena GO, Laganà A, Devereaux PJ, Farrokhyar F. Cerebrospinal
fluid drainage to prevent paraplegia during thoracic and thoracoabdominal aortic
aneurysm surgery: a systematic review and meta-analysis. J Vasc Surg. 2004;40

69. Cerebrospinal fluid
drainage
• CSF drainage
through insertion of
a spinal drain
(usually controlled
to maintain a CSF
pressure of less
than 10-12mmHg)
can reduce CSF
pressure, thereby
improving spinal
cord perfusion