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J Thorac Cardiovasc Surg 2006;131:336-342
© 2006 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Extensive deployment of the stented elephant trunk is associated with an increased risk of spinal cord injury

Department of Cardiovascular Surgery, Hokkaido University Graduate School of Medicine, Hokkaido, Japan

Received for publication July 7, 2005; revisions received September 2, 2005; accepted for publication September 15, 2005.

^_* Address for reprints: Takashi Kunihara, MD, PhD, Department of Cardiovascular Surgery, Hokkaido University Graduate School of Medicine, N14W5, Kita-Ku, Sapporo, Hokkaido, Japan 060-8648 (Email: kunihara{at}med.hokudai.ac.jp).

OBJECTIVE: Thoracic aortic aneurysm repair with the stented elephant trunk technique seems to be associated with an increased risk of spinal cord injury. We investigated whether severe atherosclerosis of the distal landing zone or extensive deployment of the stented elephant trunk is associated with increased risk of spinal cord injury.

METHODS: Twenty-five patients underwent thoracic aortic aneurysm repair with the stented elephant trunk technique. The study population included 19 men and had a mean age of 73 ± 7 years. All patients underwent a median sternotomy with cardiopulmonary bypass and selective cerebral perfusion. The elephant trunk was fixed with a Z-stent distal to the aneurysm during hypothermic circulatory arrest. Thirteen patients underwent concomitant total aortic arch replacement.

RESULTS: Six (24%) patients had spinal cord injury. The presence of severe atherosclerosis at the distal landing zone demonstrated a tendency to increase the incidence of spinal cord injury (36% vs 9%, P = .1218). More distal deployment of the stented elephant trunk was significantly associated with increased risk of spinal cord injury (T8.0 ± 0.6 vs T6.5 ± 1.1, P = .0043). Univariate logistic regression analysis identified a history of abdominal aortic aneurysm repair (P = .0296) and the vertebral level of the distal landing zone (P = .0249) as significant independent risk factors for spinal cord injury, and only the latter was significant in multivariate analysis (P = .0396). The combination of a distal landing zone of T7 or greater and a history of abdominal aortic aneurysm repair was the strongest predictor for spinal cord injury (71% vs 6%, P = .0047).

CONCLUSIONS: Spinal cord injury after stented elephant trunk deployment might be related to occlusion of the excessive intercostal arteries or thromboembolism. Patients with a history of abdominal aortic aneurysm repair who require extensive deployment of the stented elephant trunk seem to be at a higher risk for spinal cord injury.

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