Intercostal Artery Management in

Thoracoabdominal Aortic Surgery: To

reattach or not to reattach? Rana O. Afifi, MD

Department of Cardiothoracic and Vascular Surgery

McGovern Medical School

The University of Texas Science Center at Houston

Memorial Hermann Heart & Vascular Institute

Assistant Professor

No Disclosures

SCI - Clamp & Go Era

1993

Extent <0.0001

Aortic Clamp Time <0.0001

Rupture 0.0073

Age 0.025 Proximal Aneurysm 0.034

Renal Dysfunction 0.040

SCI - Clamp and Go

Spinal Cord Protection

Rationale for

Spinal Cord Protection

1. Distal aortic pressure

2. Moderate hypothermia

3. CSF pressure

Spinal Cord Protection

CSF Drainage

ICA reattachment is of the

utmost importance for

preventing paraplegia

following TAAA repair.

Reattachment of ICA T11 -T12

significantly reduces the risk of

overall paraplegia

Reattachment of ICA T9 - T10

significantly decreases the risk

for delayed paraplegia.

Neuromonitoring

Timeline of Advancements and Modification in Surgical Approach

to TAAA Repairs from 1991 to 2014.

SCI – Modern Era

Collateral Network Concept

Endovascular Era

Methods

We reviewed all cases of open D/TAAA repair between 2001-2014.

We retrospectively reviewed

Patient characteristics

Intraoperative variables and complications

Intraoperative data to ascertain the status of thoracic

ICAs 3-12 and lumbar arteries 1-4.

Postoperative paraplegia was evaluated for this

cohort.

Methods

ICA Status Determination:

Not manipulated

Natively occluded

Not exposed in the surgical field

Ligated

Reattached into the aortic circulation

Table1:PreoperativePatientDemographics

PatientVariable Overall(N=1,096)

ICAasFound(N=315)

ICALigatedOnly(N=273)

ICAReattached(N=508)

P-value

Age,years 67(56-74) 70(63-76) 62(50-72) 66(56-74) <.001Female 409(37.3) 118(37.5) 110(40.3) 181(35.6) 0.437Hypertension 973(88.8) 281(89.2) 234(85.7) 458(90.1) 0.165

Diabetes 132(12.0) 40(12.7) 33(12.1) 59(11.6) 0.897CAD 313(28.6) 118(37.5) 46(16.9) 149(29.3) <.001COPD 450(41.1) 157(49.8) 90(32.9) 203(39.9) <.001

Smoking 769(70.2) 253(80.3) 168(61.5) 348(68.5) <.001PVD 223(20.4) 94(29.8) 40(14.7) 89(17.5) <.001PriorStroke 98(8.9) 32(10.2) 21(7.7) 45(8.9) 0.577Rupture 136(12.4) 53(16.8) 42(15.4) 41(8.1) <.001

CKDStage1–eGFR>902–eGFR60-893a–eGFR44-593b–eGFR30-43

4–eGFR15-295–eGFR<15

376(35.2)280(26.2)191(17.9)127(11.9)

71(6.7)22(2.1)

72(23.6)62(20.3)70(22.9)51(16.7)

39(12.8)11(3.6)

123(46.1)76(28.5)26(9.7)23(8.6)

15(5.6)4(1.5)

181(36.6)142(28.7)95(19.2)53(10.7)

17(3.4)7(1.4)

<.0010.018<.0010.007

<.0010.084

Connectivetissuedisorder 205(18.7) 43(13.7) 62(22.7) 100(19.7) 0.014Marfan 82(7.5) 14(4.4) 19(6.9) 49(9.7) 0.021Chronicdissection 379(34.6) 40(12.7) 111(40.7) 228(44.9) <.001

PriorProximalAorticRepair 253(23.1) 35(11.1) 66(24.2) 152(29.9) <.001PriorDistalAorticRepair 296(27.0) 123(39.1) 38(13.9) 135(26.6) <.001PriorAVR 135(12.3) 18(5.7) 39(14.3) 78(15.4) <.001Emergency 116(10.6) 49(15.6) 35(12.8) 32(6.3) <.001

Redo 196(17.9) 89(28.3) 29(10.6) 78(15.4) <.001Extentofaneurysm TAAAI 127(11.6) 16(5.1) 23(8.4) 88(17.3) <.001TAAAII 113(10.3) 10(3.2) 11(4.0) 92(18.1) <.001

TAAAIII 118(10.8) 24(7.6) 15(5.5) 79(15.6) <.001

TAAAIV 217(19.8) 186(59.2) 8(2.9) 23(4.5) <.001

TAAAV 75(6.9) 13(4.1) 15(5.5) 47(9.3) 0.011

DTAA 445(40.6) 65(20.7) 201(73.6) 179(35.2) <.001

AVR=aorticvalvereplacement;CABG=coronaryarterybypassgrafting;CAD=Coronaryarterydisease;COPD=chronicobstructivepulmonarydisease;eGFR=estimatedglomerularfiltrationrate;PVD=peripheralvasculardisease;Smoking=anysmokinghistory.Continuousvariablesareexpressedasmedian(interquartilerange);categoricalvariablesareexpressedasnumber(%).

Operativecharacteristicscomparingintercostalarterymanagementstrategiesbyaneurysmextent

Variable ICALigated ICAReattach:

Island

ICAReattach:

Bypass

ICAReattach:

LoopTAAAI

Pumptime(minutes/artery) -0.9(0.149) 1.2(<.001) 1.1(0.147) 1.2(0.018)

Clamptime(minutes/artery) -1.0(0.964) 1.1(<.001) 1.0(0.997) 1.1(0.052)

Cellssaved(Units/artery) 1.0(0.484) 1.0(0.908) 1.1(0.501) 1.5(0.053)

Packedredbloodcells(Units/artery) -0.9(0.201) 1.2(0.039) -0.7(0.055) -0.9(0.776)

Freshfrozenplasma(Units/artery) 1.2(0.061) 1.4(0.019) -0.9(0.864) 1.9(0.029)

Platelets(Units/artery) 1.1(0.269) 1.3(0.084) -0.9(0.819) 2.2(0.029)

Intraoperativecoagulopathy(OR/artery) 1.1(0.596) 0.8(0.314) 1.4(0.137) 2.0(0.010)

Intraoperativecomplications(OR/artery) 1.0(0.727) 0.9(0.354) 1.3(0.196) 1.9(0.014)

TAAAII

Pumptime(minutes/artery) 1.0(0.001) 1.1(<.001) 1.2(<.001) 1.1(<.001)

Clamptime(minutes/artery) 1.0(0.001) 1.1(<.001) 1.1(0.009) 1.1(<.001)

Cellssaved(Units/artery) 1.1(0.035) 1.2(0.005) 1.2(0.172) 1.3(0.002)

Packedredbloodcells(Units/artery) -0.9(0.215) 1.1(0.189) -0.9(0.339) 1.2(0.015)

Freshfrozenplasma(Units/artery) -0.9(0.459) -0.9(0.569) 1.2(0.391) 1.3(0.059)

Platelets(Units/artery) 1.0(0.659) 1.0(0.755) 1.1(0.752) 1.4(0.065)

Intraoperativecoagulopathy(OR/artery) 1.1(0.097) 0.8(0.120) 1.4(0.125) 1.9(0.011)

Intraoperativecomplications(OR/artery) 1.1(0.146) 0.8(0.073) 1.4(0.159) 1.8(0.014)

TAAAIII

Pumptime(minutes/artery) -1.0(0.704) 1.2(<.001) 1.1(0.053) 1.0(0.732)

Clamptime(minutes/artery) -1.0(0.926) 1.1(<.001) 1.0(0.480) -1.0(0.532)

Cellssaved(Units/artery) 1.1(0.483) 1.3(0.033) -0.7(0.233) 1.5(0.094)

Packedredbloodcells(Units/artery) -0.9(0.399) 1.1(0.194) -0.5(0.002) 1.2(0.237)

Freshfrozenplasma(Units/artery) -0.9(0.685) 1.1(0.644) -0.3(0.001) 2.0(0.046)

Platelets(Units/artery) 1.2(0.535) -0.8(0.422) -0.2(0.001) 1.8(0.175)

Intraoperativecoagulopathy(OR/artery) 1.6(0.045) 1.1(0.674) 0.4(0.285) 2.0(0.039)

Intraoperativecomplications(OR/artery) 1.5(0.102) 1.0(0.909) 0.4(0.238) 1.7(0.075)

Results

Early paraplegia : 35/1,096 (3.2%) patients.

Delayed paraplegia : 77/1,061 (7.3%) patients.

Results

MEPs were available for only 660/1,096 (60%) of the cohort.

MEPs were lost in 370/660 (56%) of cases during surgery

332 of these (90%) recovered in the operating room.

13 (3.5%) did so after anesthesia maneuvers

74 (20%) following distal aortic perfusion

112 (31%) after restoration of distal pulsatile flow

133 (36%) after segmental artery reattachment

(p<0.0001; Cochran-Armitage test for trend)

Study Limitations

A retrospective study.

MEP monitoring began only after 2004. Therefore, data on

MEPs were available for only (60%) of the cohort.

The analysis focused mainly on ICAs T8-12

The lack anatomical information regarding collateral

circulation status .

Conclusions

Increased risk of delayed paraplegia :

Loss of intraoperative MEPs.

Ligation of T8-12 ICA (even with intact MEPs).

These findings support reattachment of T8-12 ICA,

whenever feasible, to improve spinal cord perfusion and

prevent delayed paraplegia.

1998 2017

Thank You