Anatomical considerations in the surgical management of blunt thoracic aortic injury.
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PURPOSE: Blunt aortic injury (BAI) involving the thoracic aorta is usually described as occurring at the isthmus. We hypothesized that injuries 1 cm or less from the inferior border of the left subclavian artery (LSCA) are associated with an increased mortality rate compared with injuries that are more distal. METHODS: A retrospective review of patients admitted with the diagnosis of BAI was performed. Injuries were divided into two groups: group I, injuries that were 1 cm or less from the junction of the LSCA and the thoracic aorta; group II, injuries that were more than 1 cm from the LSCA. Primary outcome measures included cross-clamp time, rupture, and death. RESULTS: In a 14-year period, 122 patients were admitted with BAI. The anatomy relative to the LSCA could be determined in 91 patients who underwent operative repair. Forty-two injuries (46%) were classified as group I, and 49 injuries were classified as group II. Group I injuries were characterized by an increased mortality rate (18/42 or 43% in group I vs 11/49 or 22% in group II, P = .04), intraoperative rupture rate (7/42 or 17% in group I vs 1/49 or 2% in group II, P = .003), and cross-clamp time (39.5 +/- 21.9 minutes in group I vs 28.4 +/- 13 minutes in group II, P = .04). Three ruptures occurred while proximal control was being obtained. CONCLUSION: Increased technical difficulty and risk of rupture characterize injuries that occur proximally in the descending thoracic aorta, 1 cm from the LSCA. These injuries may be better managed by instituting bypass before attempting to obtain proximal control and by routinely clamping proximal to the LSCA. (+info)
Acute posttraumatic paraplegia caused by epidural hematoma at the vertex.
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Vertex epidural hematomas (VEDHs) are well known but uncommon. Their clinical presentation may be misleading and missed by routine CT axial scanning; thus, diagnosis may be delayed, with possibly fatal consequences. We report a case of acute posttraumatic paraplegia caused by a VEDH, which was evident at CT and for which the patient underwent successful surgery. (+info)
Paraplegia secondary to spinal cord ischemia is a devastating complication in operations on the descending and thoracoabdominal aorta. We hypothesized that the tolerance of the spinal cord to an ischemic insult could be improved by means of regional administration of lidocaine. Thirty-one New Zealand white rabbits were anesthetized and spinal cord ischemia was induced by the placement of clamps both below the left renal vein and above the aortic bifurcation. The animals were divided into 5 groups. Aortic occlusion time was 20 minutes in Group 1 and 30 minutes in all other groups. Groups 1 and 2 functioned as controls. Lidocaine (Group 5) or normal saline solution (Group 3) was infused into the isolated aortic segment after cross-clamping. Group 4 animals received 20% mannitol regionally, before and after reperfusion. Postoperatively, rabbits were classified as either neurologically normal or injured (paralyzed or paretic). Among controls, 20 minutes of aortic occlusion did not produce any neurologic deficit (Group 1: 0/4 injured), while 30 minutes of occlusion resulted in more consistent injury (Group 2: 6/8 injured). Animals that received normal saline (Group 3) or mannitol (Group 4) regionally showed 80% neurologic injury (4/5). Animals treated with the regional lidocaine infusion (Group 5) showed much better neurologic outcomes (7/9 normal: 78%). This superiority of Group 5 over Groups 2, 3, and 4 was significant (P <0.02). We conclude that regional administration of lidocaine reduced neurologic injury secondary to spinal cord ischemia and reperfusion after aortic occlusion in the rabbit model. (+info)
Urethral pressure measurement after division of the external sphincter.
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The completeness and permanence of 'division of the external sphincter' is assessed in a group of 30 spinal injury patients. The urethral pressure profile technique is effective in estimating the completeness of the operation. Both in the short-term and the long-term (four month to 16 years) the results of the operation are excellent with no mortality. (+info)
Risk of spinal cord ischemia after endograft repair of thoracic aortic aneurysms.
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BACKGROUND: Surgical repair of thoracoabdominal aneurysms may be associated with a significant risk of perioperative morbidity including spinal cord ischemia, which occurs at a rate of between 5% and 21%. Spinal cord ischemia after endovascular repair of thoracic aortic aneurysms (TAAs) has also been reported. This investigation reviews the occurrence of spinal cord ischemia after endovascular repair of descending TAAs at the Mount Sinai Medical Center. PATIENTS AND METHODS: Between May 1997 and April 2001, 53 patients underwent endovascular exclusion of their TAA. Preprocedure computed tomography scanning and angiography were performed on all patients. All were performed in the operating room using C-arm fluoroscopy. Physical examinations and computed tomography scans were performed at discharge and at 1, 3, 6, and 12 months postoperatively and then annually thereafter. Spinal cord ischemia developed in three of the 53 patients (5.7%) postoperatively. In one patient, cord ischemia developed that manifested as early postoperative left leg weakness occurring after concomitant open infrarenal abdominal and endovascular TAA repair. The neurologic deficit resolved 12 hours after spinal drainage, steroid bolus, and the maintenance of hemodynamic stability. The remaining two patients developed delayed onset paralysis, one patient on the second postoperative day and the other patient 1 month postrepair. Both of these patients had previous abdominal aortic aneurysm repair, and both required long grafts to exclude an extensive area of their thoracic aortas. Irreversible cord ischemia and paralysis occurred in both of these patients. CONCLUSIONS: Endovascular repair of TAA has shown a promising reduction in operative morbidity; however, the risk of spinal cord ischemia remains. Concomitant or previous abdominal aortic aneurysm repair and long segment thoracic aortic exclusion appear to be important risk factors. Spinal cord protective measures (ie, cerebrospinal fluid drainage, steroids, prevention of hypotension) should be used for patients with the aforementioned risk factors undergoing endovascular TAA repair. (+info)
Traumatic rupture of the thoracic aorta: cohort study and systematic review.
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PURPOSE: Through a systematic review of the literature, we identified the optimal management of traumatic ruptures of the thoracic aorta (TRTA) and reported the results of a cohort of patients treated with the clamp-and-sew technique (CAS) at a tertiary trauma center. METHODS: Studies were identified through Medline and the Cochrane library and from reference lists and papers from the authors' files. Studies with a single consistent protocol (CAS, Gott shunt [GS], left heart bypass [LHB], or partial cardiopulmonary bypass [PCPB]) that reported mortality and neurologic outcomes were included. Relevance, validity, and data extraction were performed in duplicate. A retrospective review of charts from June 1992 to August 2000 provided the database for our experience. RESULTS: Twenty studies reporting on 618 patients were found to be relevant. Interobserver agreement for relevance and validity decisions was high. Mortality rates for repair with CAS, GS, LHB, and PCPB were 15%, 8%, 17%, and 10%, respectively, and for paraplegia they were 7%, 4%, 0%, and 2%, respectively. The difference in mortality rates was not statistically significant. CAS had a higher incidence of neurologic deficits than GS (odds ratio [OR], 1.8; 95% CI, 0.4-8), LHB (OR, 6.4; 95% CI, 0.8-50), and PCPB (OR, 3.4; 95% CI, 1-10). In our cohort of 25 patients, 21 underwent surgery with CAS. The median abbreviated injury severity score was 20 (range, 4-50). The mean aortic clamp time was 30 +/- 12 minutes. Aortic repair was achieved with graft interposition in 43% of patients, and simple suture was achieved in 57% of patients. Mortality (10%) and neurologic complication (paraplegia, 11%; paraparesis, 5%) rates were not statistically different from those reported in the literature. CONCLUSION: CAS is associated with a similar mortality rate but a higher incidence of neurologic deficits than methods with distal aortic perfusion. (+info)
Thoracic and thoracoabdominal aortic aneurysm repair: use of evoked potential monitoring in 118 patients.
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PURPOSE: Paraplegia is the most dreaded and severe complication of surgery on the descending thoracic aorta (TAA) and thoracoabdominal aorta (TAAA). The functional integrity of the spinal cord can be monitored by means of intraoperative recording of myogenic-evoked responses after transcranial electrical stimulation (tcMEP) and somatosensory-evoked potential (SEP) monitoring. In this study, we evaluated the results of evoked potential monitoring and the adequacy of the strategy followed. METHOD: The spinal cord of 118 patients (78 men; age, 65 +/- 12 years; 79 TAAAs, 39 TAAs) undergoing surgery on the TAA or TAAA was monitored with tcMEP and SEP. Spinal cord protection was achieved by means of a multimodality approach: moderate hypothermia (32 degrees C rectal temperature), continuous cerebrospinal fluid drainage to keep the pressure less than 10 mm Hg, reimplantation of intercostal arteries, left ventricular bypass grafting, and staged clamping. In the case of evoked potential changes more than 50% of baseline, the strategy was adjusted: reattachment of more segmental arteries when technically feasible, higher distal and proximal perfusion pressures, and enhanced cerebrospinal fluid drainage. RESULTS: Forty-two of 118 patients (35.6%) had a more than 50% of baseline tcMEP reduction during cross-clamping. At this point, only 5 of those 42 cases were also associated with SEP reduction of more than 50% of baseline. On the basis of the tcMEP findings, the strategy was adjusted. Five patients had postoperative paraplegia (4.2%). CONCLUSION: tcMEP monitoring seems to be a useful adjunct of the protective techniques and may cause substantial adjustments in strategy, reducing the incidence of postoperative paraplegia. (+info)
Spiroergometric and telemetric investigations during the XXI International Stoke Mandeville Games 1972 in Heidelberg.
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Spiroergometric and telemetric investigations were carried out on 100 paralysed athletes during the XXI International Stoke Mandeville Games in Heidelberg, 1972. The technical and organisational difficulties in carrying out these measurements were engendered by the disabilities of subjects. The maximum oxygen uptake observed and the oxygen pulse were lower than in non-disabled persons. There were no differences in the peak heart rates (180-200 beats/min.) as compared with non-disabled athletes during particular competition situations. Sports characterised by quickness, dexterity and strength are not able to train the cardiopulomnary system substantially. Swimming is recommended as beneficial. Psychological and training physiological considerations suggest that long-distance wheelchair races should be adopted as a Stoke Mandeville event. (+info)