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| Staged Repair Significantly Reduces Paraplegia Rate after Extensive Thoracoabdominal Aortic Aneurysm Repair | |
Christian D. Etz, Stefano Zoli, Christoph S. Mueller, Carol A. Bodian, Gabriele Di Luozzo, Ricardo Lazalla, Konstadinos A. Plestis, Randall B. Griepp; Mount Sinai School of Medicine, New York, NY
Methods: 90 patients (pts) who underwent extensive SA sacrifice (median:13, range: 9-15; see figure) during open surgical repair from 06/94-12/07 were reviewed retrospectively. 55 pts—most with extensive TAAA / Crawford type II; mean age 65±12 yrs; 49% male—had a single procedure (1-stage group). 35 pts had two operations (2-stage-group): usually Crawford type III or IV repair after operation for descending thoracic aneurysm (DTA) / Crawford type I; mean age: 62±14 yrs; 57% male. The median interval between the 2-stage procedures was 5 yrs (3 months - 17 yrs). There were no significant differences between the groups with regard to age, gender, etiology of the aneurysm, hypertension, COPD, urgency, previous cerebrovascular accidents, year of procedure, or CSF drainage. In 1-stage procedures, hypothermic circulatory arrest (HCA) was used in 29%; left heart bypass in 40%, and distal aortic perfusion in 27%. Somato-sensory evoked potentials (SSEP) were monitored in all pts, and motor-evoked potentials in 39%. CSF was drained in 84%. Results: Overall hospital mortality was 11.1%. There were no significant differences in mortality, stroke, postoperative bleeding, infection, renal failure or pulmonary insufficiency between the groups. However, 15% (* in figure) in the 1-stage-group suffered permanent spinal cord injury vs. none in the 2-stage-group, p=.02. The significantly lower rate of paraplegia / paraparesis in the 2-stage group occurred despite a significantly higher number of SAs sacrificed in this group: a median of 14 (11-15) vs.12 (9-15), p<.0001. Pts with 1-stage procedures without HCA were more likely to develop spinal cord injury than pts with 1-stage procedures with HCA or 2-stage procedures (p=.02). Conclusion: A staged approach to repair of extensive TAAA may dramatically reduce the incidence of spinal cord injury: this is of particular importance in designing strategies involving hybrid or entirely endovascular procedures. If a staged approach is not possible, a single-stage procedure utilizing HCA protects the spinal cord better than a 1-stage procedure using other perfusion techniques. 
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