CASE REPORT
A 69-year-old man was referred for the treatment of a chronic aneurysm
involving the ascending aorta and arch. An angio-computed tomography
(CT) revealed dilatation of the ascending aorta (58mm) and the aortic
arch (57mm) with thrombotic stratification (Fig. 1A, B). A transthoracic
echocardiogram showed normal left ventricular function with moderate
aortic regurgitation.
At operation arterial perfusion was through the right axillary artery
and venous drainage through the right atrium. After aortic
cross-clamping, the proximal aorta was opened and the heart arrested
with crystalloid cardioplegia. The aortic valve was repaired by
plication of the prolapsed non-coronary and left cusps. At 26° of
esophageal temperature antegrade cerebral perfusion was started through
the right axillary and selective cannulation of left carotid artery.
After observing an adequate back-flow, the left subclavian artery origin
was occluded to avoid a possible subclavian steal. During perfusion
adequacy of flow was continuously controlled and blood pressure in the
brachiocephalic vessels maintained between 50 and 70 mmHg. The ascending
aorta and arch were replaced with a FET using a quadrifurcated 30/36 mm
Thoraflex graft (Vascutek Ltd, Inchinnan, Scotland ). Prior to
distal anastomosis a catheter was advanced through the graft into the
descending aorta for visceral perfusion; systemic perfusion was
restarted by cannulating the 4th side branch of the
graft and the left subclavian and left carotid arteries were reattached
to the graft. During rewarming the proximal aortic anastomosis was
completed and the brachiocephalic artery reattached to the graft. Aortic
cross-clamp, circulatory arrest and total cardiopulmonary bypass times
were 176, 40, and 230 minutes.
After 4 hours, suspension of sedation with complete awakening of the
patient, evidenced complete paraplegia while tactile and painful
sensibility was maintained. Corticosteroid therapy was immediately
started together with CSFD by inserting a catheter in the subarachnoid
space between L4 and L5. After insertion of the needle a leakage of
about 30 ml of liquor occurred under pressure. Initially, CSF pressure
was 25 mmHg and a total of 100 mL of spinal liquor were drained to reach
and maintain a target pressure less than 10 mmHg. Continuous monitoring
of CSF pressure was performed in the following 96 hours with a target
spinal chord perfusion pressure of >70 mmHg. This goal was
achieved by maintaining a mean arterial pressure >80 mmHg,
CSF pressure <10 mmHg, and central venous pressure
<10 mmHg. Five hours later, when definitely woken up, the
patient started to regain motility of both legs with a complete
resolution of the neurological deficit after few days.
A control CT scan ruled out possible acute aortic events confirming the
adequacy of repair (Fig. 1 C), while a nuclear magnetic resonance showed
signs of medullary ischemic lesion (Fig. 1 D). The subsequent course was
uncomplicated, the patient discharged to the ward on postoperative day 6
and transferred to a rehabilitation center to continue a program of
physiokinesitherapy. At 1-year follow-up he has recovered completely
from his neurological injury.