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TAAA / Spinal Cord Protection
Hazim J. Safi, MD
Department of Cardiothoracic and Vascular Surgery
McGovern Medical School
The University of Texas Science Center at Houston
Memorial Hermann Heart & Vascular Institute
Professor and Chair
International Cardiovascular Surgery Mini-Symposium 2018
January 1984
Uni P = 0.0001 Multi P = 0.007 H.R. 1.6
1993
Extent
Classification
15% 31% 7% 4%
Clamp and Go Era
All Aneurysm Types
Rationale for
Spinal Cord Protection
1. Distal aortic pressure
2. Moderate hypothermia
3. CSF pressure
Spinal Cord Protection
90° to table
60° hip rotation
patient’s back is near edge of table
CSF Drainage
1286 TAAA & DTAA Repairs:
(Jan 1991 – Aug 2006)
Median age: 67 (8-92)
64% 36%
Variable %
Smoking 32
Hypertension 73
Cerebrovascular Disease 11
Coronary Artery Disease 27
Renal Disease 19
Acute Dissection 4
Chronic Dissection 25
Pre-Operative Characteristics
Variable
Intercostal Artery Reattachment 39%
Pump time 44 min
Aortic Cross-Clamp Time 46 min
Adjunct use 74%
Operative Factors
Jan ‘91 –
Jan ‘95
Evolution of TAAA Surgery in Quartiles
Feb ’95 –
May 98 Jun ’98 –
Jul ‘01 Aug ‘01 –
Aug ‘04
Neurologic Deficit n %
Overall 36/1106 3.3
(-) Adjunct 16/283 5.7
(+) Adjunct 20/823 2.4
p=0.008
Results
35 sec/yr
p
p=0.02
All Aneurysm Extents
TAAA II
p=0.0001
Neurologic Deficit Multiple Logistic Regression Analysis
Variable OR p
TAAA Extent II 6.41 0.0001
Renal Dysfunction 2.28 0.03
(+) Adjunct 0.26 0.0004
Aortic Clamp Time 1.01 0.11
Neurologic Deficit X-Clamp and Go Era
No Adjunct
Neurologic Deficit Adjunct Era
Despite increased aortic cross-clamp times, adjunct has reduced overall risk of neurologic deficit
Adjunct use has blunted effect of aortic cross-clamp time
Adjunct may allow surgeon to operate without pressure of time
Conclusions
Median Age: 67 (8 – 85)
Adjunct 246/300* (82%)
64% 36%
*Now 394
Classification
Classification DTAAA
30-day mortality 8.0% (24/310)
(In-hospital mortality) 8.7% (26/310)
Neurological Deficit 2.3% (7/300)
Overall
Results
*Neurologic Deficit
Adjunct Group 1.2% (3/238)
Non-Adjunct 6.4% (4/62)
* p=0.02
Results
Adjunct Group
Immediate 0.8% (2)
Delayed 0.4% (1)
Non-Adjunct
Immediate 4.7% (3)
Delayed 1.6% (1)
Neurologic Deficit
Results
TAAA
AAA
Fistula
Freedom From Reoperation
DAP & CSFD can be performed with acceptable
morbidity and mortality significantly reducing the
incidence of neurological deficits during repair of
DTAA
Open Repair appears durable
Classification - prognostic significance
Results
Delayed Neurological
Complication
+CSFD -CSFD
Immediate 20.1% 21.2%
Delayed 8.3% 11.5%
1990
Extent II 3.12
Results
75%
43% 0%
Delayed
Improved
Cases Controls OR P
Hemoglobin
Results*
OR 95% CI P
MAP
Correctly Classified
N GFR / Ab Cr
N Cr / Ab GFR
1106 TAAA & DTAA Repairs:
(1991 –2004)
Median age: 67 (8-92)
64% 36%
30-Day Mortality
p = 0.0001
Patients
Deaths
27% 18% 10% 5%
30-Day Mortality
Patients
Deaths
Conclusion
Subclinical pre-existing renal disease is
prevalent in TAAA patients
GFR versus serum creatinine
More sensitive index of renal function
Better predictor of mortality
Neuromonitoring
Jan 2000 - Jan 2006
444 SSEP in DTA/TAA repair
Data collected prospectively &
reviewed retrospectively
68 years (20 - 87 years)
158 (36%) 286 (64%)
Methods
Right & left PTN alternatively stimulated at the ankle to get a sustained waveform
SSEP Monitoring
Rate = 4.7 Hz
Stimulus Duration = 0.05 – 0.7 sec
Intensity = 0.3 Amp
Sensory
10%
50%
SSEP Monitoring
Group 1
Normal SSEP
Group 2
Transient Change Group 3
Persistent Change
SSEP changes classified into three groups
Sensitivity for immediate ND: 62.5
Specificity for immediate ND: 81.2
NPV of SSEP for immediate ND: 99.2%
Results
Motor
Overall ND: 8/233 (3.1%)
Permanent SSEP Change: 9/233 (3.8%)
Permanent MEP Change: 11/233 (4.7%)
Sensitivity:
37.5% SSEP
62.5% MEP
Specificity and negative predictive value
>97% for both
‘Any’ Change (Transient and permanent)
Sensitivity
Specificity
False Positive
Conclusion
If there is no change at the end of
operation, > 97% awakening with no ND
MEP have not added any additional
benefit in detecting ND
Thank You