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Cardiac index trumps both age and acuity, but as age increases cardiac index declines Figure 4 , which may explain why younger patients are at significantly less risk of paralysis with aortic replacement Table 3.

Original Research

There has been a significant decline in paraplegia risk in clinical reports of thoracoabdominal surgery in the last 27 years and this decline is defined by two distinct eras: before and after Figure 5. We studied the world literature 16, patients in approximately reports to understand why outcomes improved over time and between eras We categorized patients by surgical technique: assisted circulation AC , hypothermic arrest HA and cross clamp without assisted circulation XCL.


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Surgeons learned how to use AC in a way that was not as deleterious to spinal cord perfusion, metabolism and oxygen delivery. This has been brought into sharper focus by the results of TEVAR and branched endograft use where the anatomic paradigm for spinal cord circulation is ignored and reliance on physiologic factors that affect spinal cord perfusion MAP, SFD , metabolism and ischemic tolerance steroids, naloxone, hypothermia , and oxygen delivery hemoglobin, MAP, oxygen saturation, cardiac index are the only tools to prevent paralysis. It is also apparent that patients treated with endografts are as vulnerable to paraplegia as patients having open surgery when extensive aortic coverage occurs and that this risk is predictable as is the effect of preventative interventions Table 4.

It is also evident that there is a range of effectiveness of applied strategies among treatment centers Figure 6. What this variation tells us is that it is not enough to go through the motions in using hypothermia, draining spinal fluid, managing perfusion pressure and cardiac function, and applying neurochemical manipulation, but rather treatment protocols to optimize these factors must be followed consistently to achieve the best results.

This lack of understanding is demonstrated in a recent paper by Greiner that focuses on using motor evoked potentials to selectively re-implant intercostal arteries In their multicenter effort they indicate mean perfusion pressures of 60mmHg with no mention of hypothermia, and although they use SFD there is no detail about controlling spinal fluid pressure.

Unfortunately and indeed unnecessarily there continues to be confusion about paraplegia risk and prevention in the surgical treatment of the thoracoabdominal aorta.


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This confusion arises primarily from a perceived conflict between two paradigms of causation: the purely anatomic paradigm which postulates that paraplegia can only be prevented by reattaching the correct and specific intercostal arteries and a more complex paradigm of collateral blood flow and physiologic factors such as perfusion pressure, temperature, neurotransmitters, spinal fluid pressure, and cardiac function that is much more supported by the experimental literature and clinical observation.

Equally distracting is the focus on surgical technique when equally good outcomes are possible with the application of physiologic principles, regardless of whether AC, HA or XCL is used for repair. The fact that TEVAR carries the same risk of paraplegia as open procedures supports the observation that spinal cord ischemia is primarily a matter of collateral blood flow and ischemic tolerance, rather than assisted circulation and selective intercostal reattachment.

INTRODUCTION

Figure 1 Diagram of factors that are critical in spinal cord ischemia illustrating possible points of intervention to prevent paralysis. Table 1 Results in patients treated for thoracic and thoracoabdominal aneurysms. Hypothermic arrest was used when anatomy precluded aortic cross clamping and had higher mortality. Intercostal re-implantation was started in as was TEVAR, leading to lower paralysis risk and mortality Full table.

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The incorporation of spinal fluid drainage SFD reduced paraplegia risk by about half. Table 2 Increased cardiac index and spinal fluid drainage with naloxone were protective against paralysis. Crawford type 2 aneurysm, acute presentation and the presence of dissection increase the risk of paralysis. Factors such as age and temperature, significant by univariate analysis, were not as important as the other factors but when placed in a larger model with these factors cardiac index remained significant, while acute presentation was not significant Full table.

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Table 3 Younger patients have less risk for paralysis and mortality but in a multivariate model age is less significant than cardiac index Table 2 , which may indicate that a good cardiac index is important in collateral perfusion dynamics Full table. Assisted Circulation is a standard technology in cardiac surgery and especially in cardiac transplantation. Description Reviews. Detaily Assisted Circulation 4 is an authoritative review of the progress which has been achieved in the last 5 years since the publication of Assisted Circulation 3 in Be the first to review this product.

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