Spinal cord protective strategies during descending and thoracoabdominal aortic aneurysm repair in the modern era: The role of intrathecal papaverine

Objectives: An array of neuroprotective strategies has evolved to limit spinal cord injury during descending thoracic aneurysm and thoracoabdominal aortic aneurysm repair. This study prospectively assessed the neuroprotective impact of intrathecal papaverine added to other techniques in aortic aneurysm repairs. Methods: From January 2002 to January 2010, 398 consecutive patients underwent descending thoracic aneurysm and thoracoabdominal aortic aneurysm repairs at Cleveland Clinic, 68 under hypothermic circulatory arrest. We focused on the remaining 330, in whom a combination of neuroprotective adjuncts was used intraoperatively to mitigate spinal cord ischemia. These included distal aortic perfusion with moderate hypothermia, cerebrospinal fluid drainage, and intrathecal papaverine. Two patient groups were discriminated according to whether intrathecal papaverine was (n=250) or was not (n=80) administered. Postoperative outcomes were analyzed from a prospectively maintained clinical database. Results: Preoperative patient characteristics and comorbidities were similar between groups. Extent of aortic disease was also similar: descending thoracic aneurysm (34% with papaverine vs 28%) and Crawford types I (25% vs 34%), II (27% vs 24%), III (13% vs 13%), and IV (2% vs 2.5%). Groups had similar inhospital mortality (6.4% vs 11%; P=.11) and permanent stroke (4.4% vs 7.5%; P=.3). Permanent paraplegia (3.6% vs 7.5%; P=.01) and paraparesis (1.6% vs 6.3%; P=.01) were significantly lower in the intrathecal papaverine group. Conclusions: Adding intrathecal papaverine to the neuroprotective protocol for descending thoracic aneurysm and thoracoabdominal aortic aneurysm repairs may enhance spinal cord perfusion and provide additional spinal cord protection. (J Thorac Cardiovasc Surg 2012;143:945-52)