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  • 1 MH Egészségügyi Központ, Szív-, Ér- és Mellkassebészet, Anaesthesiologia és Intenzív Therapiás Osztály, 1134 Budapest, Róbert K. krt. 44.
  • 2 Mayo Clinic, Gonda Vascular Center, Dept. Vascular Surgery, Rochester, Minnesota, USA
  • 3 SOTE Városmajori Szív- és Érgyógyászati Klinika, Budapest

Összefoglaló. A thoracoabdominalis aorta kirekesztése a gerincvelő keringésének csökkenését okozza. Az ischemia klinikailag paraparesis, paraplegia formájában jelenik meg. Ez elsősorban nyitott műtétek során jelent aligha kiszámítható szövődményt, de a modern endovascularis technikák sem oldották meg teljes mértékben ennek biztonságos kivédését – bár arányát jelentősen mérsékelték. A javuló eredmények számos tényezőre vezethetők vissza, mint a keringés kirekesztési idejének csökkentése, a gerincvelő-funkció és metabolismus ellenőrzése. Mesterséges keringésjavító direkt és indirekt eljárások, liquor drainage, hűtés mellett a collateralis keringés javítását szolgáló prekondicionáló módszerek kerültek bevezetésre. Kísérletes munkánkban 25–30 kg testsúlyú kutyákon vizsgáltuk – más paraméterek mellett – a distalis perfusio növelésének, a liquornyomás csökkentésének, illetve ezek kombinációjának protektív hatását egyórás thoracoabdominalis aortakirekesztés során. Dolgozatunkban a kísérleti állataink neurológiai végállapotát a keringési paraméterek és szöveti perfusio és a reperfusio változásainak összefüggésein keresztül tárgyaljuk. Megállapítottuk, hogy distalis gerincvelő reperfusiós hyperaemiája szorosan összefügg a neurológiai károsodás mértékével.

Summary. Clamping of the thoracoabdominal aorta reduces perfusion of the spinal cord significantly, which clinically may present as paraparesis or paraplegia – devastating and unpredictable complications of open thoracoabdominal aortic surgery. Introduction of monitoring of evoked potentials and/or biochemical markers, methods increasing distal arterial pressure, indirect procedures enhancing residual flow (like liquor drainage), drugs, and use of hypothermia contributed to achieve better outcome. Preconditioning of spinal cord circulation is also a promising method. New endovascular techniques for thoracoabdominal aortic aneurysms and dissections reduced surgical trauma significantly. Despite all these progressions spinal cord ischemic damage is still a significant risk. To address this problem we carried out an experimental work using a canine model focusing on the protective effect of distal arterial perfusion, spinal fluid drainage, and their combination in a one hour setting of thoracoabdominal aortic clamping. In this paper we publish our data of circulatory and specific perfusion parameters of the spinal cord during and after declamping in correlation of final neurologic outcome.

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  • 1

    Heyman MA, Payn BD, Hofman JIE, Rudolf AM: Blood flow measurements with radionuclide-labeled particels. Prog Cardiovasc Dis 1977; 20: 55–79.

  • 2

    Tarlov IM: Acute spinal cord compression paralysis. J Neurosurg 1972; 36(1): 10–20.

  • 3

    Carrel A: On the experimental surgery of the thoracic aorta and heart. Ann Surg, 1910; 52: 83–95.

  • 4

    Etheredge SN, Yee J, Smith JV, Schoenberger S, Goldman MJ: Successful resection of a large aneurysm of the upper abdominal aorta and replacement with homograft. Surgery, 1955; 38 : 1071–1081.

  • 5

    Cr awford ES, Crawford JL, Safi HJ, Coselli JS, Hess KR, Brooks B, Norton HJ, Glaeser DH: Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients. J Vasc Surg 1986; 3: 389–404.

  • 6

    Safi HJ, Miller CC 3rd, Iliopoulos DC, Letsou GV, Baldwin JC: Staged repair of extensive aortic aneurysms: improved neurologic outcome. Ann Surg 1997; 226(5): 599–605.

  • 7

    Miller DC, Stinson EB, Oyer P: Operative treatment of aortic dissections. Experience with 125 patients over a sixteen-year period. J Thorac Cardiovasc Surg 1979; 78: 365–382.

  • 8

    Svenson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ: Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg 1993; 17(2): 357–370.

  • 9

    Safi HJ, Winnerkvist A, Miller CC 3rd, Iliopoulos DC, Reardon MJ, Espada R, Baldwin JC: Effect of extended cross-clamp time during thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 1998: 66(4): 1204–1209.

  • 10

    Laschinger, JC, Cunningham JN Jr, Nathan IM, Knopp EA, Cooper MM, Spencer FC: Experimental and clinical assessment of the adequacy of partial bypass in maintenance of spinal cord blood flow during operations on the thoracic aorta. Ann Thorac Surg 1 983; 36(4): 417–426.

  • 11

    Kieffer E, Richard T, Chiras J, Godet G, Cormier E: P reoperative Spinal cord arteriography in aneurysmal disease of the descending thoracic and thoracoabdominal aorta: Preliminary results in 45 patients . Ann Vasc Surg 19 89; 3(1): 34–46.

  • 12

    Coselli JS, LeMaire S , Preventza O, de la Cruz KI, Cooley DA, Price MD, Stolz AP, Green SY, Arredondo CN, Rosengart TK : Outcomes of 3309 thoracoabdominal aortic aneurysm repairs. J Thorac Cardiovasc Surg 2016; 151(5): 1323–1337.

  • 13

    Miyamoto K, Ueno A, Wada T, Kimoto S: A new and simple method of preventing spinal cord damage following temporary occlusion of the thoracic aorta by draining the cerebrospinal fluid. J Cardiovasc Surg (Torino) 19 60; 1: 188–197.

  • 14

    Bower TC, Murray MJ, Gloviczki P, Yaksh TL, Hollier LH, Pairolero PC : Effects of thoracic aortic occlusion and cerebrospinal fluid drainage on regional spinal cord blood flow in dogs: Correlation with neurologic outcome. J Vasc Surg; 1989 ; 9(1): 135–144.

  • 15

    Elmore JR, Gloviczki P, Harper CM Jr, Murray MJ, Wu OH, Bower TC, Pairolero PC, Naessens JM, Daube JR: Spinal cord injury in experimental thoracic aortic occlusion: investigation of combined methods of protection. J Vasc Surg 1992; 15(5): 789–798.

  • 16

    Coselli JS, LeMaire SA, Schmittling ZC, Köksoy C: Cerebrospinal fluid drainage in thoracoabdominal aortic surgery. Semin Vasc Surg 2 000; 13(4): 308–314.

  • 17

    Griepp RB, Di Luozzo G: Hypothermia for Aortic Surgery. J Thorac Cardiovasc Surg, 2 013; 145(3): S56–8.

  • 18

    Dzsinich Cs, Nagy G, Selmeci L, Sepa G, Fazekas L, Kékesi V, Juhász-Nagy S: Effect of regional hypothermia on cerebrospinal fluid (CSF) parameters during thoracoabdominal aortic clamping in dogs. Magy Seb 2005 ; 3: 79–84.

  • 19

    Svensson LG, Hess KR, Coselli JS, Safi HJ: The influence of regional spinal cord hypothermia on transcranial myogenic motor-evoked potential monitoring and the efficacy of spinal cord ischemia detection. J Vasc Surg 1991; 18(6): 1038–1045.

  • 20

    Jacobs MJ, Mess W, Mohtar B, Nijenhuis RJ, Statius van Eps RG, Schurink GWH: The value of motor evoked potentials in reducing paraplegia during thoracoabdominal aneurysm repair. J Vasc Surg 2006; 43(2): 239–246.

  • 21

    Nagy G, Dzsinich Cs, Selmeci L, Sepa G, Dzsinich M, Kékesi V, Juhász-Nagy S: Biochemical alterations in cerebrospinal fluid during thoracoabdominal aortic cross-clamping in dogs. Ann Vasc Surg 2 002; 16(4): 436–441.

  • 22

    Granger DN: Ischemia-reperfusion: Mechanisms of microvascular dysfunction and the influence of risk factors for cardiovascular disease. Microcirculation 19 99; 6(3): 167–178.

  • 23

    Awad H, Ramadan ME, El Sayed HF, Tolpin DA, Tilli E, Collard ChD: Spinal cord injury after thoracic endovascular aortic aneurysm repair. Can J Anaesth 2017; 64(12): 1218–1235.

  • 24

    Murana G, Castrovinci S, Kloppenburg G, Yousif A, Kelder H, Schepens M, deMaat G, Sonker U, Morshuis W, Heijmen R: Open thoracoabdominal aortic aneurysm repair in the modern era: results from a 20-year single-centre experience. Eur J Cardio-Thor Surg 2016; 49(5): 1374–1381.

  • 25

    Mazersky D, Flesarova S, Sulla I: Arterial blood supply to the spinal cord in animal models of spinal cord injury. A review. N eurobiology, 2017; http://doi.org/10.1002/ar.23694

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