Combined use of Adamkiewicz artery demonstration and motor-evoked potentials in descending and thoracoabdominal repair

Background. We retrospectively reviewed the outcome of distal descending aortic and thoracoabdominal aortic repair with preoperative identification of the Adamkiewicz artery by magnetic resonance angiography and intraoperative monitoring of transcranial motor-evoked potentials. Methods. We began combined use of demonstration of the Adamkiewicz artery and intraoperative recording of motor-evoked potentials for prevention of spinal cord complications in descending and thoracoabdominal aortic aneurysm repair in 1998. Ninety-two consecutive patients were studied, with descending aneurysm in 53 and thoracoabdominal aneurysm in 39 patients. The repair was performed through a left thoracic or thoracoabdominal incision, using partial cardiopulmonary bypass to prevent spinal cord injury. Magnetic resonance angiography revealed the Adamkiewicz artery in 70.7% of cases. During surgery, spinal cord ischemia was monitored using motor- evoked potentials. Anastomoses were performed using a segmental clamp technique to reduce spinal cord ischemic time. Based on the findings of magnetic resonance angiography and motor- evoked potentials, the Adamkiewicz artery and other relevant intercostals and lumbar arteries were revascularized or preserved, or both. Results. The mean durations of partial cardiopulmonary bypass, cross- clamping, and surgery, respectively, were 144.4 +/- 232.2, 106.0 +/- 65.5, and 411.8 +/- 170.7 minutes. Three hospital deaths (3.3%) occurred in patients with a thoracoabdominal aortic aneurysm. Motorevoked potentials changed in 9 patients (9.8%), in 8 (88.9%) of whom they were eventually restored. Although paraplegia developed in 1 patient (1.1%) with a mycotic descending aneurysm, the other patients survived without spinal cord injury. Conclusions. Combined visualization of the Adamkiewicz artery and determination of motor- evoked potentials are useful in preventing spinal cord injury in descending and thoracoabdominal aortic repair.