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eComment: Re: Acute onset of paraplegia after repair of abdominal aortic aneurysm in a patient with acute type B aortic dissection 30 December 2008

Bakoulev Scientific Center of Cardiovascular Surgery, 135 Roublevskoe Shosse, 121552 Moscow, Russia

Acute onset of paraplegia after repair of abdominal aortic aneurysm in a patient with acute type B aortic dissection

The authors describe a complicated clinical case with positive outcome achieved due to active and well-considered treatment [1]. Several crucial issues of the surgical approach in patients with aortic dissection are pointed out. However, despite the positive outcome the issue requires thorough discussion.

We agree that type B aortic dissection does not indicate surgical treatment when it occurs without aortic expansion, significant compression of true lumen and ischemia of kidney, lower limbs and visceral organs. We also suppose that authors made an absolutely right and opportune decision to perform emergency surgery for progressive true infrarenal abdominal aortic aneurysm (AAA). The crucial point is: whether clinical symptoms described in the article (appearance of abdominal pain, skin paleness) may be considered as a reliable evidence of infrarenal aneurysm progression if CT data do not reveal any signs of complicated aneurysm (expansion, thrombosis or rupture). These symptoms could be caused by progression of dissection or thrombosis of the false lumen.

Another question under discussion concerns the method of infrarenal aneurysm repair. Perhaps such clinical case with acute aortic dissection without malperfusion and with progressive true infrarenal aneurysm may be considered as an indication for endovascular grafting [2]. A retrospective analysis of reported cases showed that endovascular AAA repair could at least prevent serious complications resulting from surgery.

The most dramatic and nevertheless interesting (as positive outcome has been finally achieved) part of the article is the report of paraplegia developed via true lumen thrombosis with total regression after extra-anatomic surgery had been performed. The indubitable cause of that discouraging complication was a thrombosis of the radiculomedullaris magna artery, which probably originated from the true lumen (preoperative CT angiography did not make it possible to visualize the pattern of spinal cord blood supply). After extra-anatomic surgery, total regression of neurological symptoms was observed.

We want to emphasize the unexpectedness of this positive result as surgery was not aimed at the direct restoration of the spinal cord blood supply. Probably there was no significant ischemic spinal cord injury caused by thrombosis of the radiculomedullaris magna artery, and collateral spinal cord circulation was well developed; so these two conditions made it possible for the paraplegia to regress totally.

In conclusion we would like to congratulate the authors for this interesting report describing the positive outcome achieved following a nonstandard approach for the treatment in a patient with type B (III) aortic dissection.

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1. Takahashi Y, Tsutsumi Y, Monta O, Kohshi K, Sakamoto T, Ohashi H. Acute onset of paraplegia after repair of abdominal aortic aneurysm in a patient with acute type B aortic dissection. Interact CardioVasc Thorac Surg 2009;8:240–242.[Abstract/Free Full Text]
2. Svensson LG, Kouchoukos NT, Miller DC, Bavaria JE, Coselli JS, Curi MA, Eggebrecht H, Elefteriades JA, Erbel R, Gleason TG, Lytle BW, Mitchell RS, Nienaber CA, Roselli EE, Safi HJ, Shemin RJ, Sicard GA, Sundt TM 3rd, Szeto WY, Wheatley GH 3rd. Society of Thoracic Surgeons Endovascular Surgery Task Force. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg 2008;85(1 Suppl):S1–S41.[Abstract/Free Full Text]

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