Luehr Maximilian, Salameh Aida, Haunschild Josephina, Hoyer Alexandro, Girrbach Felix F, von Aspern Konstantin, Dhein Stefan, Mohr Friedrich-Wilhelm, Etz Christian D
From the Department of Cardiac Surgery, Leipzig Heart Center-University of Leipzig, Leipzig, Germany.
Innovations (Phila). 2014 Jan-Feb;9(1):60-5. doi: 10.1097/IMI.0000000000000038.
Paraplegia remains the most devastating complication after thoracic and thoracoabdominal aortic aneurysm (TAA/A) repair. The collateral network (CN) concept of spinal cord perfusion suggests segmental artery (SA) occlusion to mobilize redundant intraspinal and paraspinal arterial sources and ultimately trigger arteriogenesis, leading to spinal cord blood flow restoration within 96 to 120 hours. This principle is used by the two-staged approach to TAA/A-repair--which has lead to an elimination of paraplegia in an experimental model. However, the clinical implementation of a two-staged surgical procedure is challenging, particularly in the absence of an appropriate vascular segment for a "staged" open anastomosis or an appropriate endovascular landing zone. Selective, transfemoral minimally invasive SA coil embolization (MISACE) could provide the solution for one-stage repair of extensive aortic pathologies by triggering arteriogenic CN preconditioning and thereby allowing for recruitment of otherwise redundant arterial collaterals to the spinal cord.
The feasibility of MISACE was explored in a single animal using an established piglet model. A 6F sheet was introduced via the femoral artery, and a 4F standard Judkins catheter was used for selective angiography and coil insertion. All thoracic and lumbar aortic SAs (15 pairs; Th4-L5) were successfully identified by dye injection. Pediatric platinum endovascular coils (Trufill Pushable Coils, 3 × 20 mm; Cordis, Waterloo, Belgium) were deployed to serially occlude the SA mimicking a CN preconditioning procedure.
All intercostal (thoracic) and lumbar aortic SAs (Th4-L5) were successfully identified and occluded by coil embolization. Successful SA coil embolization was verified intraoperatively by selective dye injection on angiography. No intraoperative coil dislodgement occurred. Autopsy revealed complete occlusion of all embolized SAs enhanced by early local thrombus formation. Thrombotic material was found only distally to the coils. No SA dissection was observed at the aortic SA origins.
The MISACE technique allows for rapid serial endovascular occlusion of all thoracic and lumbar SAs. This new innovative approach bares the potential to CN preconditioning at the respective level of aortic pathology--to allow for adequate perioperative spinal cord blood supply--before conventional open or endovascular surgery. Selective, transarterial MISACE might lead to a dramatic reduction of ischemic spinal cord injury after open and endovascular TAA/A repair in the future.
截瘫仍然是胸主动脉和胸腹主动脉瘤（TAA/A）修复术后最具毁灭性的并发症。脊髓灌注的侧支网络（CN）概念提示，节段动脉（SA）闭塞可动员冗余的脊髓内和椎旁动脉来源，并最终触发动脉生成，从而在96至120小时内恢复脊髓血流。这一原则被用于TAA/A修复的两阶段方法中，该方法已在实验模型中消除了截瘫。然而，两阶段手术的临床实施具有挑战性，尤其是在缺乏用于“分期”开放吻合的合适血管段或合适的血管内着陆区的情况下。选择性经股微创SA线圈栓塞术（MISACE）可以通过触发动脉生成性CN预处理，为广泛主动脉病变的一期修复提供解决方案，从而使原本冗余的动脉侧支向脊髓募集。
使用已建立的仔猪模型在单只动物中探索MISACE的可行性。通过股动脉插入一个6F导管鞘，使用一个4F标准Judkins导管进行选择性血管造影和线圈插入。通过染料注射成功识别了所有胸段和腰段主动脉SA（15对；Th4-L5）。部署儿科铂类血管内线圈（Trufill Pushable Coils，3×20 mm；Cordis，比利时滑铁卢）以连续闭塞SA，模拟CN预处理程序。
所有肋间（胸段）和腰段主动脉SA（Th4-L5）均通过线圈栓塞成功识别并闭塞。术中通过血管造影选择性染料注射验证了SA线圈栓塞成功。术中未发生线圈移位。尸检显示，所有栓塞的SA均完全闭塞，早期局部血栓形成增强了闭塞效果。仅在栓塞线圈的远端发现血栓物质。在主动脉SA起源处未观察到SA夹层。
MISACE技术允许对所有胸段和腰段SA进行快速连续的血管内闭塞。这种新的创新方法有可能在传统开放或血管内手术之前，在主动脉病变的相应水平进行CN预处理，以确保围手术期脊髓有足够的血液供应。选择性经动脉MISACE可能会在未来显著降低开放和血管内TAA/A修复术后缺血性脊髓损伤的发生率。
