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J Thorac Cardiovasc Surg 2002;124:1259-1260
© 2002 The American Association for Thoracic Surgery

Letters to the Editor

Successful reversal of delayed paraplegia after endovascular stent grafting

University Hospital Graz, Department of Cardiac Surgery, Department of Vascular Surgery, Department of Interventional Radiology, Auenbruggerplatz 29, Graz A-8036, Austria

To the Editor:

We read with great interest the recent report by Fleck and colleagues ¹ wherein they describe a successful reversal of delayed paraplegia after endovascular stent grafting of an acute type B aortic dissection.

Despite the use of various strategies for the prevention of spinal cord ischemia, paraplegia and paraparesis may occur in 5% to 16% of operations involving conventional thoracic aortic aneurysm repair. It is generally agreed that neurologic deficits are attributable to the duration of spinal cord ischemia sustained during aortic crossclamping. The use of cerebrospinal fluid (CSF) drainage perioperatively has dramatically reduced the risk of paraplegia. ^2,3

Stent-graft implantation for the treatment of acute type B aortic dissection, as well as descending thoracic aortic aneurysms, appears to be an effective and safe therapy. ^4,5 Although this transluminal approach avoids spinal cord ischemia resulting from aortic crossclamping, there still might be a risk for spinal cord injury due to occlusion of critical intercostal arteries covered by the stent graft. Application of short endografts and avoidance of placing stent grafts between Th8 and L2 is therefore recommended to prevent spinal cord ischemia.

Delayed spinal cord dysfunction is a complex phenomenon related to postoperative hypotension, increased CSF pressure, and ischemia-reperfusion injury. It was first described by Crawford and associates ⁶ in 1988 after surgical repair of thoracoabdominal aortic aneurysm.

To our knowledge we reported for the first time full reversal of delayed paraplegia after endovascular thoracic aortic repair by the use of CSF drainage. ⁷ Twelve hours after implantation of 3 Dacron-covered, self-expanding nitinol stent grafts (Talent, World Manufacturing Corporation, Sunrise, Fla) with a total length of 31 cm, a 74-year-old man with a true aneurysm of the descending aorta exhibited left leg paralysis and right-sided paresis. Immediate intrathecal catheter placement and drainage of CSF for 48 hours, maintaining a CSF pressure of 10 mm Hg, fully reversed the neurologic deficit. The rationale for the use of CSF drainage postoperatively is to decrease spinal cord edema. After thoracoabdominal aortic aneurysm surgery or endoluminal treatment, the postischemic spinal cord is edematous, causing spinal compression with decreased spinal cord perfusion. CSF drainage resolves the edema and restores normal spinal cord perfusion.

The authors have addressed a very pertinent issue in that CSF drainage is the most potentially therapeutic factor in reversal of delayed paraplegia after thoracic aortic aneurysm repair. In conclusion, we also would recommend peri-interventional routine CSF drainage for patients undergoing endoluminal stent-graft placement of lengthy descending thoracic aortic aneurysms and/or acute type B aortic dissection.

References

1. Fleck T, Hutschala D, Weissl M, Wolner E, Grabenwöger M. Cerebrospinal fluid drainage as a useful treatment option to relieve paraplegia after stent-graft implantation for acute aortic dissection type B. J Thorac Cardiovasc Surg. 2002;123:1003-5.[Free Full Text]
   
2. Coselli JS, Lemaire SA, Koksoy C, Schmittling ZC, Curling PE. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. J Vasc Surg. 2002;35:631-9.[Medline]
   
3. Estrera AL, Rubenstein FS, Miller CC 3rd, Huynh TT, Letsou GV, Safi HJ. Descending thoracic aortic aneurysm: surgical approach and treatment using the adjuncts cerebrospinal fluid drainage and distal aortic perfusion. Ann Thorac Surg. 2001;72:481-6.[Abstract/Free Full Text]
   
4. Nienaber CA, Fattori R, Lund G, Dieckmann C, Walter W, von Kodolitsch Y, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent graft placement. N Engl J Med. 1999;340:1539-45.[Medline]
   
5. Mitchell RS, Miller DC, Dake MD, Semba CP, Moore KA, Sakai T. Thoracic aortic aneurysm repair with an endovascular stent-graft: the "first generation." Ann Thorac Surg. 1999;67:1971-4.
   
6. Crawford ES, Mizrahi EM, Hess KR, Coselli JS, Safi HJ, Patel VM. The impact of distal aortic perfusion and somatosensory evoked potential monitoring on prevention of paraplegia after aortic aneurysm operation. J Thorac Cardiovasc Surg. 1988;95:357-67.[Abstract]
   
7. Tiesenhausen K, Amann W, Koch G, Hausegger KA, Oberwalder P, Rigler B. Cerebrospinal fluid drainage to reverse paraplegia after endovascular thoracic aortic aneurysm repair. J Endovasc Ther. 2000;7:132-5.[Medline]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Peter J. Oberwalder Bruno Rigler Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Oberwalder, P. J. Articles by Rigler, B. Search for Related Content PubMed PubMed Citation Articles by Oberwalder, P. J. Articles by Rigler, B.