A transient spinal cord ischemia reveals a silent type A aortic dissection

Abstract Objective This study aimed to evaluate the prevalence of spinal cord injury in total arch replacement with frozen elephant trunk for acute type A aortic dissection using our spinal cord protection technique. Methods Between January 2013 and December 2017, 33 patients underwent total arch replacement with frozen elephant trunk for acute type A aortic dissection (mean age 67.9 ± 13.3 years). Our spinal cord protection technique involved maintaining extracorporeal circulation through the left subclavian artery in all procedures, using aortic occlusion balloon during distal anastomosis, and inserting frozen elephant trunk above Th 8 with transesophageal echocardiographic guidance. Computed tomography was performed within 1–2 weeks, 12 months, and 36 months postoperatively. We compared the degree of thrombosis of the descending aorta between preoperation and early postoperative period by Fisher’s exact test. Moreover, we evaluated postoperative mortality and mobility (including spinal cord injury) at follow-up. Results The operative mortality within 30 days was 6.1%. Neither paraplegia nor paraparesis was noted. We observed significant thrombosis of the false lumen at the distal arch and aortic valve level of the descending aorta in postoperative early term period (p < 0.01). At mid-term follow-up (mean 33.9 months), survival probability and 3-year freedom from reoperation rates were 93.9 ± 4.1% and 95.0 ± 4.9%, respectively. Conclusions The frozen elephant trunk technique with our spinal protection strategy provides good postoperative outcomes. Our strategy can maintain spinal cord perfusion without complete ischemia time even during lower body ischemia time. Implementation of our spinal protection strategy will help prevent spinal cord injury and dilated downstream aorta.

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Comparative study of the frozen elephant trunk and classical elephant trunk techniques to supplement total arch replacement for acute type A aortic dissection†

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezz104 ◽

2019 ◽

Vol 56 (3) ◽

pp. 579-586 ◽

Cited By ~ 4

Author(s):

Yosuke Inoue ◽

Hitoshi Matsuda ◽

Atsushi Omura ◽

Yoshimasa Seike ◽

Kyokun Uehara ◽

...

Keyword(s):

Spinal Cord ◽

Aortic Dissection ◽

Pulmonary Vein ◽

Type A ◽

Total Arch Replacement ◽

Acute Type ◽

Frozen Elephant Trunk ◽

Elephant Trunk ◽

Type A Aortic Dissection ◽

Cord Injury

Abstract OBJECTIVES In patients with acute type A aortic dissection, the use of the frozen elephant trunk (FET) procedure with total arch replacement (TAR) has been indicated for emergency operations to obtain thrombosis of the distal false lumen (FL). However, data comparing the FET and the classical elephant trunk (CET) procedures, including the incidences of mortality, morbidity, spinal cord injury and aortic remodelling, have not yet been reported. The goal of this study was to compare the early outcomes of TAR with the FET and the CET procedures. METHODS The past 7 years of medical records of 323 patients with type A aortic dissection who underwent emergency surgery were reviewed retrospectively, and 148 patients who underwent TAR were shortlisted for the study. First, the patients were divided into 2 groups, the CET group (n = 115; age 65 ± 12 years) and FET group (n = 33; 67 ± 11 years), to compare the early operative outcomes, including mortality and morbidity. Second, 86 patients (CET 56; FET 30) fulfilling the inclusive criteria (inserted length of elephant trunk ≥5 cm, involvement of dissection at the descending aorta and sufficient computed tomographic evaluation at ≥6 months after the operation) were compared to evaluate the patency and diameter of the FL at each segment of the downstream aorta. RESULTS The in-hospital mortality rate was 8.1% (12/148), without significant differences between the 2 groups (CET 8.7% vs FET 6.1%; P = 1). No spinal cord ischaemia was encountered in either group. The incidence of postoperative FL patency at the level of the left lower pulmonary vein was 30% in the FET group, which was significantly lower than that in the preoperative state (73%) and in the CET group (77%). The downsizing of the aortic diameter at the distal edge of the CET or the FET, the left lower pulmonary vein and the coeliac axis was significant in the FET group 6 months after TAR. CONCLUSIONS According to our initial experience, the FET compared to the CET procedure showed comparable early complications and an advantage concerning FL thrombosis and aortic remodelling at early follow-up examinations.

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Spinal Cord Ischemia Secondary to Aortic Dissection: Case Report with Literature Review for Different Clinical Presentations, Risk Factors, Radiological Findings, Therapeutic Modalities, and Outcome

Case Reports in Neurology ◽

10.1159/000518197 ◽

2021 ◽

pp. 634-655

Author(s):

Hosna Elshony ◽

Abdelrahman Idris ◽

Alaa Ahmed ◽

Murouj Almaghrabi ◽

Walaa Ahmed ◽

...

Keyword(s):

Spinal Cord ◽

Aortic Dissection ◽

Lower Limb ◽

Spinal Cord Ischemia ◽

Type A ◽

Therapeutic Modalities ◽

Anterior Spinal Artery Syndrome ◽

Clinical Presentations ◽

Increased Risk ◽

Left Lower Limb

Aortic dissection (AD) is a serious condition that causes transient or permanent neurological problems that include spinal cord ischemia (SCI), which occurs when AD extends into the descending aorta resulting in insufficient perfusion of segmental arteries that supplies the spinal cord. We report a 64-year-old male, presented with severe back pain, asymmetrical paresthesia, and weakness of both limbs, more in the left lower limb with loss of pinprick, temperature, and fine touch sensation on the lower left lower limb below the level of T5 with preserved proprioception and vibration and urine hesitancy. Computed tomography showed AD, Stanford type A, and spinal magnetic resonance imaging (MRI) showed hyperintense owl’s eye sign at T5. The patient was diagnosed as anterior spinal artery syndrome secondary to an AD and referred for aortic surgical repair with good functional outcome. In our review to cases of SCI due to AD, it was more common in males above 55 years, pain only found in 47.8% of patients, with anterior cord syndrome on top of the clinical presentations, and hypertension is the most common risk factor. MRI spine showed thoracic location predominance. Surgical or endovascular repair especially for type A and complicated type B should be considered to avoid complications, and cerebrospinal fluid drainage is a very useful tool in reversing SCI specially if done early with favorable outcome. Only the old age is associated with increased risk of mortality. Early diagnosis and appropriate management are crucial for better outcome.

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Repair of acute type A dissection with distal malperfusion using a novel hybrid arch device

10.1510/mmcts.2020.062 ◽

2020 ◽

Keyword(s):

Aortic Dissection ◽

Aortic Arch ◽

Circulatory Arrest ◽

Spinal Cord Ischemia ◽

False Lumen ◽

Type A ◽

Acute Type ◽

Type A Aortic Dissection ◽

Acute Type A Dissection ◽

Feasible Option

Acute type A aortic dissection remains a high-risk surgical condition, and mortality among those presenting with malperfusion is up to 3-fold higher. Despite the added technical challenge of distal aortic arch interventions in the acute setting, it may be necessary to resolve distal malperfusion in patients with this disorder. The ideal arch intervention to address acute type A aortic dissection complicated by malperfusion should address the following objectives: (1) to relieve distal malperfusion by expanding the distal true lumen and depressurizing the false lumen; (2) to avoid compromising arch branches without requiring additional arch branch interventions; (3) to minimize the risk of spinal cord ischemia; and (4) to minimize the operative duration and circulatory arrest time. The use of an uncovered aortic arch stent that is delivered in an antegrade manner during circulatory arrest, concomitantly with hemiarch replacement, therefore represents an attractive solution in the management of acute type A aortic dissection complicated by malperfusion. This strategy does not require complex arch reconstruction and may thus be a feasible option among cardiac and vascular surgeons in lower volume aortic centers. Here we present a step-by-step approach to acute type A aortic dissection repair with hemiarch repair and delivery of an uncovered arch stent for a patient presenting with malperfusion.

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