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Monaco et al. Vessel Plus 2023;7:23 https://dx.doi.org/10.20517/2574-1209.2023.113 Page 11 of 14

Figure 4. Multimodal therapeutic algorithm to treat spinal cord ischemia. CSF: Cerebrospinal fluid; CSFP: cerebrospinal fluid pressure;
SpO : peripheral capillary oxygen saturation; Hb: hemoglobin; MAP: mean arterial pressure; CVP: central venous pressure; CI: cardiac
2
index; BSA: body surface area; SCPP; spinal cord perfusion pressure.

situation. Several strategies (e.g., perfusion, metabolism, and oxygen delivery to the spinal cord) can be
employed to mitigate the risk of spinal cord ischemia. These are based on acknowledging the most
important factors in protecting the spinal cord during and after thoracic and thoracoabdominal aortic
replacement, both when spinal cord blood flow is significantly reduced and after aortic replacement, while
the co-axial collateral network is recruited to restore resting blood flow to near-normal levels. The
anesthesiologist must ensure adequate spinal cord perfusion by elevating MAP within the range of
90-100 mmHg to promote spinal cord collateral network circulation and reduce CSFP through CSF
drainage. Cardiac output should be maximized to ensure adequate DO and CVP should be reduced to < 10
2
mmHg to avoid a significant increase in CSFP and reduced spinal cord outflow. In addition, Hb levels > 10
g/dL should be maintained, hypoxia and hypercapnia are to be avoided, and arrhythmias (e.g., tachycardia,
which can increase myocardial oxygen demand, ventricular wall tension, and overall myocardial work)
should be prevented and treated. Nonetheless, in the case of SCI occurrence, various strategies can be
implemented as well, involving a thorough and multimodal approach that focuses on CSF drain status, O
2
delivery, and comprehensive hemodynamic management, as summarized in Figure 4. By fulfilling the
aforementioned objectives, anesthesiologists can optimize cardiac function and promote favorable
outcomes in patients undergoing TAAA open repair.

DECLARATIONS
Authors’ contributions
Designed the work, drafted the manuscript and revised it critically: Monaco F
Designed the work, collected and analyzed the data and drafted the manuscript: D’Andria Ursoleo J
Collected and analyzed the data and revised the manuscript critically: Barucco G, Licheri M, Faustini C,
Lazzari S
Collected and analyzed the data and drafted the manuscript: Di Prima AL
All authors gave final approval of the version to be published and agree to be accountable for all aspects of
the work in ensuring that questions related to the accuracy or integrity of any part of the work are
appropriately investigated and resolved.