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CC BY 4.0 · Aorta (Stamford) 2021; 09(02): 045-055
DOI: 10.1055/s-0041-1725121
State-of-the-Art Review

Hemodynamic Patterns of Spinal Cord Perfusion in Thoracoabdominal Aortic Aneurysm Repair

Giuseppe Rescigno   *
1   Foundation Alexis Carrel, Basiglio, Milan, Italy
,
Carlo Banfi    *
1   Foundation Alexis Carrel, Basiglio, Milan, Italy
,
Claudio Rossella    *
1   Foundation Alexis Carrel, Basiglio, Milan, Italy
,
Stefano Nazari 
1   Foundation Alexis Carrel, Basiglio, Milan, Italy
› Author Affiliations Funding None.
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Abstract

Paraplegia in aortic surgery is due to its impact on spinal cord perfusion whose hemodynamic patterns (SCPHP) are not clearly defined. Detailed morphological analysis of vascular network and collateral network modifications within Monro–Kellie postulate due to the fixed theca confines was performed to identify SCPHP. SCPHP may begin with intraspinal “backflow” (I-BF), that is, hemorrhage from anterior and posterior spinal arteries, backward via the connected anterior and posterior radicular medullary arteries, through the increasing diameter and decreasing resistance of segmental arteries (SAs), off their aortic orifices outside vascular network at 0 operative field pressure. The I-BF blood bypasses both intra- and extraspinal capillary networks and causes depressurization (0 diastolic pressure) and full ischemia of dependent spinal cord. When the occlusion of those SAs orifices arrests I-BF, the hemodynamic pattern of intraspinal “steal” (I-S) may take place. The formerly I-BF blood, in fact, is now variably shared between the fraction maintained in its physiological intraspinal network and that keeping flowing as I-S through the extraspinal capillary network. I-S is, however, counteracted by the extraspinal “steal” from the connected mammary/paraspinous-independent extraspinal feeders, all physically competing for the same room left by the missed physiological SA direct aortic blood inflow. Steal phenomenon evolves within the 120-hour time frame of CNm, whose intraspinal anatomical changes may offer the physical basis within the Monro–Kelly postulate, respectively of the intraoperative and postoperative paraplegia. The current procedures could not prevent the unphysiological SCPHP but awareness of details of their various features may offer the basis for improvements tailored, to the adopted intra- and postoperative procedures.

Keywords

spinal cord perfusion - backflow - steal phenomenon - paraplegia - thoracoabdominal aortic repair - aneurysm

Note

Part of manuscript data ([Figs. 5] and [6]) were included in the author video presentation at the Tech-Con STS/AATS at 53 STS Annual Meeting, Houston, TX, January 21, 2017.


* Voluntary, free cooperators with the first author before or/and independently by their current institutional affiliations.




Publication History

Received: 31 March 2019

Accepted: 11 November 2020

Article published online:
07 October 2021

© 2021. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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