Intercostal artery management in thoracoabdominal aortic surgery: To reattach or not to reattach?

Background: The need for intercostal artery (ICA) reattachment in surgery for descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) remains controversial. We reviewed our experience over a 14-year period to assess the effects of ICA management on neurologic outcome after DTAA/TAAA repair. Methods: Intraoperative data were reviewed to ascertain the status of T3-12 ICAs and L1-4 ICAs. Arteries were classified as reattached, ligated, occluded, or not exposed. Temporality of reattachment or ligation in response to an intraoperative ischemic event (ie, loss of motor evoked potentials [MEPs]) was noted. Adjustment for other predictors of immediate or delayed paraplegia (DP) was performed by multiple logistic regression. The effects of specific artery level and type of reattachment technique were assessed using stratified contingency tables. Results: A total of 1096 DTAA/TAAAs were performed between 2001 and 2014. The mean patient age was 64 +/- 15 years, and 37% were female. Spinal cord ischemia was identified in 10% of patients, including 35 (3%) immediate cases and 77 (7%) DP cases. Overall DP resolution was 47% at discharge. ICA ligation and intraoperative MEP changes were strong predictors of postoperative paraplegia. Multivariable analysis demonstrated that T8-12 ICA ligation significantly increased the risk for paraplegia (odds ratio, 1.3/artery; P < .041) even after adjustment for age >65 years, glomerular filtration rate, extent of II/III aneurysm, increased operative time, and intraoperative MEP loss. Conclusions: Loss of intraoperative MEPs is serious, and increases the risk of paraplegia in any ICA management strategy. Even with intact MEP, ligation of T8-12 ICAs is associated with increased risk. These findings support reattachment of T8-12 ICAs whenever feasible.