The role of spinal angiography in operations on the thoracic aorta: Myth or reality?

Background. The importance of preserving the artery of Adamkiewicz during replacement of the thoracoabdominal aorta is debated. We report our experience with the use of preoperative spinal angiography and modification of the surgical technique. Methods. Between September 1993 and March 1996, 46 patients (mean age, 57 years; range, 25 to 73 years) underwent spinal angiography at our institution, 23 for an aneurysm and 23 for chronic dissection. Localization of the artery of Adamkiewicz between T-9 and L-3 was successful in 30 (65%) patients: T-9, left = 2, right = 1; T-10, left = 4;T-11, left = 10, right = 2;T-12, left = 3, right = 1; L-1, left = 1, right = 2;L-2, left = 2, right = 1; and L-3, left = 1. Thirty-one patients subsequently underwent replacement of the descending thoracic aorta and 13 underwent replacement of the thoracoabdominal aorta. Left atrial-femoral artery bypass was used in 23 patients and full extracorporeal circulation was used in 20 patients. Twelve procedures included the reimplantation of crucial intercostal/lumbar branches. Results. The operative mortality rate was 6.8% (3 of 44 patients) and 1 (2.27%) patient had paraparesis. In addition to the 12 patients who underwent targeted reimplantation of the intercostal branches, evaluation of the spinal cord blood supply influenced the operative technique in 19 other patients. Conclusions. Selective angiography can demonstrate the spinal cord blood supply even in patients with complex aortic pathology. It is a helpful tool for planning extensive replacement of the thoracic and thoracoabdominal aorta.