Artery of Adamkiewicz and the clinical repercussion of its lesion in thoracoabdominal surgeries: a systematic review

The knowledge of the spinal cord irrigation is important for the therapeutic planning of aortic pathologies; however, its vasculature is complex due to the caliber of its arteries that pass through a three-dimensional network with great anatomical variability. Its clinical importance is evidenced during the preoperative procedure of thoracic and thoracoabdominal aortic surgeries, because its identification is essential for the prevention of spinal cord injuries. This study consists of a literature review, in which searches were conducted in the databases - Bireme, Science Direct, Pubmed and Lilacs. Articles published between 1999 and 2020, written in English, Portuguese or Spanish, were selected. The search was conducted using the descriptors Anatomy, Spinal Cord Irrigation and Spinal Cord Ischemia. The Adamkiewicz artery is the main artery responsible for the arterial supply to the lower part of the spinal cord. Thus, paraplegia is a complication of this type of surgical approach resulting from ischemic suffering of the spinal cord during the process. Therefore, further study on these factors should be encouraged, because the preservation of this vessel is relevant given the search for protection of the spinal cord and the maintenance of its functions in this type of procedure.

The Relevance of Preoperative Identification of the Adamkiewicz Artery in Posterior Mediastinal Pediatric Tumors

Background Injury to the artery of Adamkiewicz (AKA) during surgery may lead to spinal cord ischemia and severe neurologic complications. Posterior mediastinal tumors may be adjacent to AKA, but data on preoperative visualization of AKA in children are rare. This study analyzed the importance of identifying the AKA preoperatively by spinal digital subtraction angiography (DSA) in children with posterior mediastinal tumors for therapeutic procedure. Methods Between 2002 and 2021, 36 children with posterior mediastinal tumors were evaluated for surgery at the authors’ clinic. In 10 children with left-sided or bilateral tumor located at vertebral levels T8 to L1, spinal DSA was performed during preoperative workup to assess AKA. The patient and tumor characteristics as well as the diagnostic and therapeutic procedures were analyzed. Results The median age of the 10 children at examination was 69 months (range, 16–217 months). Three of the children were younger than 2 years. The tumor entities were neuroblastoma, ganglioneuroblastoma, ganglioneuroma, local relapse of a hepatocellular carcinoma, and neurofibroma. The AKA was identified in all cases, and proximity to the tumor was detected in four patients, three of whom had their planned surgery changed to irradiation. No complications occurred during spinal DSA or surgery. Conclusions In posterior mediastinal pediatric tumors, spinal DSA is a safe and reliable method for preoperative visualization of the AKA. It can show proximity to the tumor and guide the local therapy, thereby avoiding critical intra- and postoperative situations.

Anterior Spinal Cord Syndrome is a Complication Following Embolisation of Bleeding Intercostal Artery in Penetrating Trauma: A Case Report

Background:Transcatheter arterial embolisation of intercostal vessels is a minimally invasive procedure that is increasingly being used in the management of haemothorax in the trauma patient, however significant complications – such as spinal ischaemia can occur. We present a rare case of paralysis in a patient following embolisation of the intercostal arteries due to bleeding from penetrating trauma.Case presentation:A 46-year-old male presented to the Emergency department with two stab wounds to the right posterior chest. Computed tomography scan of the chest revealed active contrast extravasation from the right 9th intercostal artery. Selective embolisation of the right 9th intercostal artery using Gelfoam® and coils as well as further embolisation of the 7th, 8th and 10th intercostal arteries was performed. Unfortunately due to ongoing bleeding and hypotension, the patient subsequently required emergency surgery that revealed two penetrating injuries to the right inferior lobe of the lung. After the patient was extubated, he was found to have bilateral motor from the level of L4 and below and sensory deficits from L2 and below. Magnetic resonance imaging of the spine showed spinal cord infarction at the level of T11 and T12 that was thought to be secondary to the embolisation of the intercostal arteries inadvertently affecting the artery of Adamkiewicz.Conclusions:Transcatheter arterial embolisation has an established roll in haemostasis of the trauma patient – particularly in intercostal arteries for the management of haemothorax. Although extremely rare, spinal complications from this procedure can be significantly life changing for the patient. The variable anatomy of the artery of Adamkiewicz should be carefully considered on a case-by-base basis in the stable trauma patient and balance of risk versus benefit be determined if the artery is unable to be identified on pre-procedure angiography.