Page 108 - Read Online

Monaco et al. Vessel Plus 2023;7:23 Vessel Plus
DOI: 10.20517/2574-1209.2023.113

Review Open Access

A multimodal approach to prevent spinal cord

ischemia in patients undergoing thoracoabdominal
aortic aneurism repair - from pathophysiology to

anesthesiological management

Fabrizio Monaco , Jacopo D'Andria Ursoleo , Gaia Barucco, Margherita Licheri, Carolina Faustini,
Stefano Lazzari, Ambra Licia Di Prima

Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy.
Correspondence to: Dr. Fabrizio Monaco, Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute,
Via Olgettina 60, Milan 20132, Italy. E-mail: monaco.fabrizio@hsr.it
How to cite this article: Monaco F, D'Andria Ursoleo J, Barucco G, Licheri M, Faustini C, Lazzari S, Di Prima AL. A multimodal
approach to prevent spinal cord ischemia in patients undergoing thoracoabdominal aortic aneurism repair - from
pathophysiology to anesthesiological management. Vessel Plus 2023;7:23. https://dx.doi.org/10.20517/2574-1209.2023.113

Received: 27 Aug 2023 First Decision: 26 Sep 2023 Revised: 6 Oct 2023 Accepted: 20 Oct 2023 Published: 27 Oct 2023
Academic Editor: Paolo Nardi Copy Editor: Fangyuan Liu Production Editor: Fangyuan Liu

Abstract
Thoraco-abdominal aortic aneurysm (TAAA) open repair is a high-risk surgery further burdened with both
mortality and morbidity. Despite numerous experimental endeavors and technical advancements, spinal cord
ischemia (SCI) is still the most formidable morbidity to be resolved, irrespective of the open or endovascular
surgical approach. It presents a spectrum of severity, ranging from temporary or permanent paraparesis to
paraplegia with or without autonomic dysfunction. The timing of SCI occurrence is a crucial factor, with
approximately 15% of cases manifesting intraoperatively, 50% within 48 h post-surgery, and the remaining 35%
classified as late SCI, occurring more than 48 h after the procedure. The mechanism responsible for SCI is complex
and multifactorial; hence, understanding its underlying pathophysiology is essential for its effective management.
Over the last decade, strategies to enhance spinal cord perfusion and minimize the risk of SCI during TAAA open
repair have been implemented. These include optimization of hemodynamics, hemoglobin levels, cardiac function,
and cerebrospinal fluid pressure, ensuring collateral vascular network stability and distal aortic perfusion and
intrathecal administration of drugs. A multimodal approach involving anesthesiologists and surgeons can lead to
improved neurological recovery and a reduced incidence and severity of SCI.

Keywords: Thoraco-abdominal aorta aneurysm, spinal cord ischemia, aneurysm repair, anesthetic management,
aortic surgery, cerebrospinal fluid drainage, collateral network, partial left heart bypass, cardiac function

© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0
International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing,
adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as
long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and
indicate if changes were made.

www.oaepublish.com/vp