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Online ISSN 1827-1847
Zanetti P. P., Loddo P.
From the "Heart" Department, Division of Thoracovascular Surgery, “G. Brotzu” Specialised Surgery Hospital - Cagliari
Background. The aim of this paper is to set out the guidelines we have adopted for the reattachment of the intercostal arteries for the prevention of paraplegia-paraparesis (P/P) in 94 operated cases of thoracoabdominal aneurysm (TAA). More precisely, the study concerns 59 cases, given that 33 Crawford type IV cases were excluded in whom the problem of intercostal artery was of secondary importance, and there were 2 intraoperative deaths.
Methods. Patients were divided using Crawford’s classification, depending on the presence or otherwise of tares (arterial hypertension in 80% of cases), the method of protection used (Bio-pump, clamp and go, F/F ECC), and the site of proximal and distal clamping. With regard to the treatment of intercostal arteries, subdivided into high (T3-T8) and low (T9-T12) and the lumbar arteries (L1-L4), our attitude was adapted case by case and decisions were always taken after the aneurysm had been opened, depending on vessel calibre, the degree of run-off, the quality of the aortic wall and, lastly, whether the surgery was emergency or elective.
Results. Overall, we observed 6 cases of P/P in 59 patients (10.1%). Ligature of the intercostal arteries at the level of T9-T12 (16 cases) was catastrophic, with 4 cases of P/P out of 6 (66.66%), whereas there was only case of P/P in 33 cases of reattachment in the same site. The ligation of vessels at a lumbar level was unimportant. Crawfords’s type 1 and 2 were statistically significant for the onset of P/P (p=0.002), as well the dissecting type (p=0.001).
Conclusions. The correct treatment of intercostal arteries may significantly influence of P/P. In particular, it is considered good practice at the level of T3-T8 to attach 1 or more vessels with a proximal suture, whereas in the rest it is possible, except in rare cases, to ligate these arteries without risk. In segment T9-T12, the reattachment of the intercostal arteries is imperative, especially if it is large calibre with scarce run-off. Only calcific aortic walls or on the contrary fragile walls after acute dissection makes ligation necessary. The approach used for L1-L4 is absolutely irrelevant in our experience. Cases of intraoperative arterial hypotension, especially if prolonged (AP ≤50-60 mmHg for 20-30 min) are worth noting, since they can annul any form of spinal cord protection, including reattachment.
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