The vascular surgeons at Massachusetts General Hospital (MGH) in Boston have traditionally repaired thoracoabdominal aortic aneurysms (TAA) with a clamp and sew (CS) technique that includes neuro-protective adjuncts like epidural cooling and aggressive intercostal reconstruction (IC) to prevent spinal cord ischemia. The last five years have seen a paradigm shift to distal aortic perfusion (DAP) during aortic cross clamping with the concurrent use of motor evoked potential (MEP) monitoring to provide objective evidence for the need to revascularized intercostals vessels. Details of a new study from researchers at Massachusetts General Hospital (MGH) were revealed today at 64th Vascular Annual Meeting® presented by the Society for Vascular Surgery® June 10 in Boston.
"We evaluated the early impact of DAP with MEP on TAA outcomes, which included 30-day mortality and paraplegia," said Mark F. Conrad, MD, MMSc from the MGH division of vascular and endovascular surgery. "The persistence of post-operative paraplegia after TAA repair has driven the evolution of our operative approach to the routine use of DAP via atriofemoral bypass to support spinal cord collateral circulation during aortic cross clamping and selective IC based on motor evoked potential (MEP) monitoring."
Consecutive patients undergoing repair of non-ruptured Crawford extent I-III TAA using DAP with MEP were compared to a propensity matched cohort of patients treated with CS. There were 52 patients in the DAP cohort vs. 127 undergoing CS. The cohorts differed in age (62.6 years vs. 69.5 years for CS), presence of Marfan's Syndrome (10% DAP vs. 2% CS), and chronic dissection (37% DAP vs. 8% CS).
Mortality was low in both groups (2% DAP vs. 5% CS). Postoperative renal insufficiency, albeit doubled in CS, was not significantly different (8% DAP vs. 17%). There was a significantly lower percentage of IC in the group (10% DAP vs. 34% CS), yet there was no paraplegia (0% DAP vs. 5% CS,>
"In the ongoing evolution of TAA repair, DAP with MEP is now the preferred operative strategy for TAA repair at our institution," said Dr. Conrad. "Our series showed that elective TAA repair was accomplished with a low mortality in both the DAP and CS cohorts. However, the use of MEP in the DAP cohort (despite higher risk because of number of chronic dissections) decreased the need for IC with no paraplegia to date."
SOURCE Society for Vascular Surgery