Original article: cardiovascular
Interventions for reversing delayed-onset postoperative paraplegia after thoracic aortic reconstruction

Presented at the Thirty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2002.
https://doi.org/10.1016/S0003-4975(02)03714-1Get rights and content

Abstract

Background. Delayed postoperative paraplegia is a recognized complication of thoracic (TAA) or thoracoabdominal aortic aneurysm (TAAA) repair. The purpose of this study was to evaluate the effectiveness of interventions to treat delayed-onset paraplegia.

Methods. Between January 1, 2000 and August 31, 2001, 99 patients underwent surgical repair of TAA, Crawford type I, II, or III TAAA. Standard intraoperative management included distal aortic perfusion and cerebrospinal fluid (CSF) drainage unless contraindicated. Therapeutic interventions to treat delayed paraplegia included lumbar CSF drainage and vasopressor therapy.

Results. Three of the 99 patients had paraplegia upon awakening. Delayed-onset paraplegia occurred in 8 patients, 2 of whom had recurrent episodes. In those 8 patients, the initial episode occurred at a median of 21.6 hours (range 6.4 to 110.0 hours) after surgery and the second episode averaged 176 hours after surgery. At the onset of paraplegia, the average mean arterial pressure was 74 mm Hg and CSF pressure was 14 mm Hg. Three of the 8 patients had a functioning CSF catheter at the onset and the other 5 patients had catheters subsequently placed. Therapeutic interventions increased blood pressure to a mean arterial pressure of 95 mm Hg and decreased CSF pressure to 10 mm Hg. Five of the 8 patients with delayed-onset paraplegia made a full neurologic recovery and 3 had partial recovery.

Conclusions. Patients with delayed-onset paraplegia had an increased chance of recovery as compared with those patients in whom paraplegia was diagnosed upon emergence from anesthesia. Acute interventions directed to increase spinal cord perfusion by increasing systemic blood pressure and decreasing CSF pressure were effective for the reversal of delayed onset of paraplegia after TAA or TAAA repair, resulting in an overall 3% incidence of permanent paraplegia and 3% incidence of residual paraparesis.

Section snippets

Material and methods

All patients undergoing TAA or TAAA repair from January 1, 2000 to August 31, 2001 were prospectively entered into a clinical database. Patients in this database with postoperative paraplegia were identified and analyzed. TAAA were classified according to Crawford type I to IV. In addition, aneurysms isolated to the thoracic aorta (TAA) were included. Descending aneurysms with concomitant distal arch extension were also included (Table 1). Patients with Crawford type IV aortic aneurysms

Results

During the study period, 99 patients underwent thoracic or thoracoabdominal aortic replacement. This cohort was 55% male and had a mean age of 68 ± 15 years (Table 1). Included in the cohort were 19 patients with combined thoracic and thoracoabdominal aneurysms with distal arch extension requiring an “open proximal anastomosis” utilizing HCA techniques. Intercostal artery implantation rate was near 100% in patients with dissecting aortic aneurysms, but only 25% in patients with atherosclerotic

Comment

Postoperative paraplegia has been a well-recognized complication of operations to replace the descending thoracic or abdominal aorta and has an estimated incidence that ranges between 2.7% and 20% 3, 7. Spinal cord ischemia and subsequent infarction as a consequence of temporary or permanent interruption of the vascular supply to the spinal cord during operation has been believed to be the major cause of postoperative paraplegia in this patient population. Distal aortic perfusion, deliberate

Acknowledgements

We acknowledge Elizabeth Hoel and William Moser for their assistance in managing the aortic surgical database used in this study. We also wish to acknowledge the nursing staff of the Cardiothoracic Surgical Intensive Care Unit for their dedication to the project and attention to the early identification of patients with postoperative paraplegia. The study was unfunded.

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