Adjunctive therapy for spinal cord protection during thoracoabdominal aortic aneurysm repair.

Paraplegia, resulting from spinal cord ischemia during thoracoabdominal aortic aneurysm (TAA) repair, continues to be a devastating complication. The incidence of neurological complications, including paraplegia and paraparesis following TAA repair, ranges from 4% to 32% and averages 13% for nondissecting TAA and higher for dissecting TAA. Our current understanding of spinal cord ischemia associated with TAA repair has evolved from animal research and clinical experience. The pathophysiology of spinal cord ischemia is intricately related to three physiological variables. These include the severity and duration of spinal cord ischemia, neuronal reperfusion after reestablishment of spinal cord blood flow, and the neuronal metabolic rate during the ischemic insult. We have developed a multimodality approach to the prevention of neurological deficits, during and after TAA repair, which includes minimizing the severity of spinal cord ischemia, reducing the anticipated reperfusion phenomenon, and lowering the spinal cord metabolic rate. Over the past 16 years, the senior author has undertaken surgical repair of 265 TAAs using a multimodality approach in the protection of spinal cord integrity. In our experience, a combination of adjunctive therapies is critical to minimize the ischemic interval, reduce the neuronal reperfusion injury, and decrease spinal cord metabolism. These techniques have evolved over time, resulting in an overall neurological deficit rate of 4.5% and a neurological deficit at the time of hospital discharge of 1.9%. This article will outline our multimodality approach for spinal cord protection during TAA repair.