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Novel approaches to spinal cord protection during thoracoabdominal aortic interventions

Augoustides, John G.T.a; Stone, Marc E.b; Drenger, Benjaminc

Current Opinion in Anaesthesiology: February 2014 - Volume 27 - Issue 1 - p 98–105
doi: 10.1097/ACO.0000000000000033
CARDIOVASCULAR ANESTHESIA: Edited by Alina M. Grigore
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Purpose of review Spinal cord ischemia after thoracoabdominal aortic interventions is a devastating complication because it significantly worsens the perioperative morbidity and mortality. Long-term outcome is also affected because of medical complications which are directly related to the neural deficits. Paraplegia has significant medical, social, and financial aspects. Limited mobility, the need for assistance in activities of daily living, makes paraplegia an important target for prevention. An understanding of spinal cord blood supply, risk factors for spinal ischemia, and strategies for spinal cord rescue in this setting can help minimize the negative outcome effects of this important complication.

Recent findings The vascular supply of the spinal cord is via an extensive collateral arterial network with multiple auxiliary arterial supplies. Risk factors for spinal cord ischemia include extensive aortic repair, prior aortic repair, spinal cord malperfusion on clinical presentation, systemic hypotension, acute anemia, prolonged aortic clamping, and vascular steal. Spinal rescue strategies include systemic hypothermia, endovascular aortic repair, permissive systemic hypertension, cerebrospinal fluid drainage, pharmacologic neuroprotection, and intensive neuromonitoring.

Summary The progression of spinal cord ischemia after thoracoabdominal aortic interventions can frequently be arrested before irreversible infarction results. This spinal cord rescue depends on the early detection and immediate multimodal intervention to maximize spinal cord oxygen supply. The devastating outcomes associated with spinal infarction in this setting offset the risks and knowledge gaps currently associated with contemporary interventions.

aDepartment of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania

bDepartment of Anesthesiology, Icahn School of Medicine, Mount Sinai Medical Center, New York, New York, USA

cDepartment of Anesthesiology and Critical Care Medicine, Hadassah-Hebrew University Medical Centers, Jerusalem, Israel

Correspondence to John G.T. Augoustides, MD, FASE, FAHA, Associate Professor, Cardiothoracic Section, Anesthesiology and Critical Care, Dulles 680, HUP, 3400 Spruce Street, Philadelphia, PA 19104-4283, USA. Tel: +1 215 662 7631; fax: +1 215 349 8133; e-mail: yiandoc@hotmail.com

© 2014 Lippincott Williams & Wilkins, Inc.