A simple method to reduce ischemic time of the spinal cord in extensive thoracoabdominal aneurysm operations

Although the incidence of paraplegia from surgery of extensive thoracoabdominal aneurysms Crawford type I - Ill.could be reduced to about 10 % in more recent series, development of additional measures to avoid this disastrous complication seems worthwhile. One of of the major determinants of preventing ischemia is obviously keeping ischemic time of the spinal cord below 30'. In this regard, we introduced a surgical technique that allowed reperfusing the intercostal arteries within 30 min.

In a consecutive series 17 Patients with thoracoabdominal aneurysms (9 Crawford type II, 7 type I and one type III) underwent thoracoabdominal aortic replacement using either fem.-fem.-or left atrio-fem. bypass with selective perfusion of the visceral vessels. To keep the ischemic time of the spinal cord as short as possible, the first step of aortic replacement consisted of reattachement of the intercostal arteries of the segments Th 10-L 1 followed by immediate reperfusion via a side branch of the prostheses with the aid of the heart and lung machine.

Mean ischemic time was 25 min. The mean number of reperfused intercostal arteries was five. One patient died of bleeding complications and could not be evaluated for paraplegia. There was no further hospital mortality. One patient developed paraplegia. With the exception of two patients, all had a very fast recovery and limited stay on the ICU.

Compared to our former experience, we were able to reduce the incidence of paraplegia dramatically. Our observations to date strongly support the hypothesis that an ischemic period of less than 30' is fairly well tolerated by the spinal cord.