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729Ann Thorac Surg ZOLI ET AL2010;90:722–30 STAGED APPROACH FOR TAAA REPAIR

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ut. It may also be possible to devise an attractive optionor extensive endovascular TAAA repair with some sortf temporary landing zone in the peridiaphragmatic area.his site may not be suitable for a long-lasting anasto-osis, but could be used transiently as a bridge to

btaining a more robust collateral network by the timehe resection is completed a few days later, either surgi-ally or by stent grafting. It is of note that preliminaryxperimental observations suggest that the order of SAacrifice (intercostal first followed by lumbar artery re-ection, or vice versa) does not seem to alter the impactn spinal cord protection, and therefore creative hybridolutions may be designed to suit each patient dependingn the specific anatomy of each aneurysm.In conclusion, complete elimination of the risk of

araplegia after repair of TAA or TAAA no longer seemsn unachievable goal. We think spinal cord injury willecome increasingly rare with the routine use of ade-uate adjuncts, the progressive reduction of surgicalttrition, the increased availability and reliability of en-ovascular strategies, and the ability to exploit the re-ources offered by the collateral network.

eferences

1. Strauch JT, Lauten A, Spielvogel D, et al. Mild hypothermiaprotects the spinal cord from ischemic injury in a chronicporcine model. Eur J Cardiothorac Surg 2004;25:708–15.

2. Coselli JS, Lemaire SA, Koksoy C, Schmittling ZC, CurlingPE. Cerebrospinal fluid drainage reduces paraplegia afterthoracoabdominal aortic aneurysm repair: results of a ran-domized clinical trial. J Vasc Surg 2002;35:631–9.

3. Cina CS, Abouzahr L, Arena GO, Lagana A, Devereaux PJ,Farrokhyar F. Cerebrospinal fluid drainage to prevent para-plegia during thoracic and thoracoabdominal aortic aneu-rysm surgery: a systematic review and meta-analysis. J VascSurg 2004;40:36–44.

4. Amabile P, Grisoli D, Giorgi R, Bartoli JM, Piquet P. Inci-dence and determinants of spinal cord ischaemia in stent-graft repair of the thoracic aorta. Eur J Vasc Endovasc Surg2008;35:455–61.

5. Hnath JC, Mehta M, Taggert JB, et al. Strategies to improvespinal cord ischemia in endovascular thoracic aortic repair:outcomes of a prospective cerebrospinal fluid drainage pro-tocol. J Vasc Surg 2008;48:836–40.

6. Kouchoukos NT, Masetti P, Murphy SF. Hypothermic car-diopulmonary bypass and circulatory arrest in the manage-ment of extensive thoracic and thoracoabdominal aorticaneurysms. Semin Thorac Cardiovasc Surg 2003;15:333–9.

7. Coselli JS, LeMaire SA. Left heart bypass reduces paraplegiarates after thoracoabdominal aortic aneurysm repair. AnnThorac Surg 1999;67:1931–4; discussion 1953–8.

8. Coselli JS, Bozinovski J, LeMaire SA. Open surgical repair of2286 thoracoabdominal aortic aneurysms. Ann Thorac Surg2007;83(Suppl):S862–4; discussion S90–2.

9. Safi HJ, Miller CC 3rd, Carr C, Iliopoulos DC, Dorsay DA,Baldwin JC. Importance of intercostal artery reattachmentduring thoracoabdominal aortic aneurysm repair. J Vasc

Surg 1998;27:58–68.

1) ischemia during aortic cross clamping, (2) segmental

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2010 by The Society of Thoracic Surgeonsublished by Elsevier Inc

0. Griepp RB, Ergin MA, Galla JD, et al. Looking for the arteryof Adamkiewicz: a quest to minimize paraplegia after opera-tions for aneurysms of the descending thoracic and thoracoab-dominal aorta. J Thorac Cardiovasc Surg 1996;112:1202–15.

1. Etz CD, Homann TM, Plestis KA, et al. Spinal cord perfusionafter extensive segmental artery sacrifice: can paraplegia beprevented? Eur J Cardiothorac Surg 2007;31:643–8.

2. Etz CD, Luehr M, Kari FA, et al. Selective cerebral perfusionat 28 degrees C—is the spinal cord safe? Eur J CardiothoracSurg 2009;36:946–55.

3. Etz CD, Zoli S, Kari FA, et al. Redo lateral thoracotomy forreoperative descending and thoracoabdominal aortic repair:a consecutive series of 60 patients. Ann Thorac Surg 2009;88:758–67.

4. Schlosser FJ, Mojibian H, Verhagen HJ, Moll FL, Muhs BE.Open thoracic or thoracoabdominal aortic aneurysm repairafter previous abdominal aortic aneurysm surgery. J VascSurg 2008;48:761–8.

5. Lombardi JV, Carpenter JP, Pochettino A, Sonnad SS, Ba-varia JE. Thoracoabdominal aortic aneurysm repair afterprior aortic surgery. J Vasc Surg 2003;38:1185–90.

6. Coselli JS, Poli de Figueiredo LF, LeMaire SA. Impact ofprevious thoracic aneurysm repair on thoracoabdominalaortic aneurysm management. Ann Thorac Surg 1997;64:639–50.

7. Heil M, Eitenmuller I, Schmitz-Rixen T, Schaper W. Arterio-genesis versus angiogenesis: similarities and differences.J Cell Mol Med 2006;10:45–55.

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9. Etz CD, Di Luozzo G, Zoli S, et al. Direct spinal cordperfusion pressure monitoring in extensive distal aorticaneurysm repair. Ann Thorac Surg 2009;87:1764–74.

0. Calligaro KD, Dougherty MJ. Correlation of carotid arterystump pressure and neurologic changes during 474 carotidendarterectomies performed in awake patients. J Vasc Surg2005;42:684–9.

1. Kato K, Tomura N, Takahashi S, et al. Balloon occlusion testof the internal carotid artery: correlation with stump pres-sure and 99mTc-HMPAO SPECT. Acta Radiol 2006;47:1073–8.

2. Etz CD, Homann TM, Luehr M, et al. Spinal cord blood flowand ischemic injury after experimental sacrifice of thoracicand abdominal segmental arteries. Eur J Cardiothorac Surg2008;33:1030–8.

3. Etz CD, Luehr M, Kari FA, et al. Paraplegia after extensivethoracic and thoracoabdominal aortic aneurysm repair: doescritical spinal cord ischemia occur postoperatively? J ThoracCardiovasc Surg 2008;135:324–30.

4. Toumpoulis IK, Anagnostopoulos CE, Drossos GE,Malamou-Mitsi VD, Pappa LS, Katritsis DG. Early ischemicpreconditioning without hypotension prevents spinal cordinjury caused by descending thoracic aortic occlusion. J Tho-rac Cardiovasc Surg 2003;125:1030–6.

5. Etz CD, Zoli S, Mueller CS, et al. Staged repair significantlyreduces paraplegia rate after extensive thoracoabdominalaortic aneurysm repair. J Thorac Cardiovasc Surg 2010;139:1464–72.

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Neurochir (Wien) 2009;151:497–505.

NVITED COMMENTARY

he reasons for the occurrence of paralysis after openescending and thoracoabdominal aneurysm repairs are

rtery related reduction of perfusion of the spinal cordfter the operation, (3) postoperative events, including

educed collateral flow from low blood pressure and a

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ascade of complex biochemical pathways activated dur-ng reperfusion (including reperfusion injury and apo-tosis). For endovascular grafting, paralysis is largelyelated to loss of segmental arteries, and to a lessxtent, embolic material in segmental arteries. In thistudy by Zoli and colleagues [1], the authors used twoechniques to reduce the risk of paralysis, cooling to2°C (a method we have reported previously), and stag-ng the sacrifice of segmental arteries. Cooling has beenound to be effective in previous animal studies androspective human studies that have used active cooling

o the low 30s and upper 20s. This is also as effective aseep hypothermia and circulatory arrest to protect thepinal cord during the period of ischemia; clearly coolings important in mitigating ischemic effects.

The issue of segmental artery sacrifice is more com-lex. Interestingly, this study supports our observedlinical experience, particularly in those patients withhronic dissection that the approach of staged sacrificesf segmental arteries results in a lower risk of paralysis.ence, for second-stage elephant trunk procedures (inhich the first-stage elephant trunk typically causes

xtensive thrombosis of the upper segmental arteries),he risk of paralysis is lowered, whether done openly orndovascularly. Second, we have found that while per-orming extensive thoracoabdominal aneurysm endovas-ular grafting procedures, it is better to place proximalescending thoracic stent grafts as a first stage procedureown to approximately the celiac artery and complete theest of the visceral and infrarenal stenting at a later stage.his allows occlusion of the upper segmental arteries toreate new collaterals that open up through other path-

ays to the spinal cord as an interim measure. The

urrent animal study by Zoli and associates [1] is furthervidence to support using this approach. For open de-cending aortic repairs, we advocate that it is safe toacrifice segmental arteries down to T8 based on pro-pective and retrospective studies, but not below T8. Forpen thoracoabdominal repairs, also based on prospec-ive and randomized studies, it is safe to sacrifice seg-

ental arteries to T6, but then between T6 and including2 the segmental arteries need to be re-attached andeperfused. For some of the complex patients, particu-arly with chronic dissection, in whom there are anxtensive number of intercostal and lumber arteries, weill create a separate tube from the posterior residual

orta to maintain perfusion of the intercostal and lumberrteries. This allows for the tube to be sacrificed later,nce a more effective circulation has been established byhe collaterals.

The authors are to be congratulated for adding sup-orting evidence for the staged repair of aneurysms.

ars G. Svensson, MD, PhD

arfan and Connective Tissue Disorder Cliniche Cleveland Clinic Foundation500 Euclid Ave, F25leveland, OH 44195-mail: svenssl@ccf.org

eference

. Zoli S, Etz CD, Roder F, et al. Experimental two-stage simu-lated repair of extensive thoracoabdominal aneurysms re-

duces paraplegia risk. Ann Thorac Surg 2010;90:722–30.