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MINIMAL INVASIVE PRECONDITIONING OF THE SPINAL CORD COLLATERAL NETWORK BY PREOPERATIVE SEGMENTAL ARTERY COIL EMBOLIZATION FOR EXTENDED THORACOABDOMINAL ANEURYSM REPAIR
Christian D. Etz, Maximilian Luehr, Aida Salameh, Alexandro Hoyer, Felix F. Girrbach, Konstantin von Aspern, Stefan Dhein, Friedrich Wilhelm Mohr.
Leipzig Heart Center, Leipzig, Germany.

OBJECTIVE: Paraplegia remains the most devastating complication following extensive descending and thoracoabdominal aortic aneurysm repair (TAA/A). The Collateral Network (CN) concept of spinal cord perfusion suggests segmental artery (SA) occlusion to trigger arteriogenesis leading to the restoration of spinal cord blood flow from alternative arterial sources within 96-120h. A “two-staged” approach to TAA/A-repair--which has been shown to significantly reduce paraplegia--is challenging, particularly in the absence of an appropriate vascular segment for the “staged” anastomosis or an endovascular landing zone. Selective, transarterial “Minimally Invasive SA-Coil Embolization” (MISACE) provides a solution to endovascularly trigger arteriogenic CN preconditioning. MISACE--prior to conventional open or endovascular repair--may enable safe “single-stage”-repair of extensive TAA/A.
METHODS: An experimental study was undertaken to explore the feasibility of MISACE. A 6F sheet was introduced via the groin in the sedated animal and a 4F right Judkins catheter allowed for selective angiography and coil insertion. All thoracic and lumbar aortic SAs (T3-L5) were successfully identified by dye injection. Pediatric platinum endovascular coils (Trufill Pushable Coils, 3x20mm, Cordis®, Germany) were used to serially occlude the segmental arteries mimicking a "first-stage" preconditioning procedure.
RESULTS: Successful SA coil deployment was verified intraoperatively: MISACE achieved successful coil occlusion (100%) with a coil-to-occlusion and cath-positioning time of 30-45 seconds and 15-30 seconds per SA, respectively. The total MISACE procedure time was less than 45 minutes. Intra- and postoperative hemodynamics were much more stable than after conventional open “first-stage” procedure, thus preventing acute CN-pressure fluctuations during the most vulnerable period in the first 48h postoperatively. No intraoperative coil dislodgement occurred. Autopsy revealed complete occlusion of all embolized SAs enhanced by early local thrombus formation. No SA dissection was observed.
CONCLUSIONS: A two-staged approach has been suggested to dramatically reduce paraplegia after open or hybrid TAA/A-repair. MISACE allows for rapid serial endovascular selective occlusion of thoracic/lumbar aortic SAs to trigger preconditioning of the paraspinous arterial CN and may be performed in any cath lab or hybrid theater without the daunting side-effects of an open surgical procedure. After successful endovascular MISACE preconditioning conventional open or complete endovascular TAA/A-repair might be feasible in one single step with zero paraplegia.


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