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We reviewed magnetic resonance (MR) findings of the spinal cord in patients who had a spinal cord injury after descending and thoracoabdominal aortic repair, to speculate the specific cause of the injury.Between 2000 and 2012, 746 patients underwent descending or thoracoabdominal aortic surgery: 480 received an open repair with adjuncts of spinal cord protection [distal perfusion, cerebrospinal fluid (CSF) drainage, reattachment of intercostal arteries and hypothermia] and 266 received an endovascular repair. Twenty-six (3.5%) suffered a spinal cord injury. Of these, 18 (14 open repair and 4 endovascular repair) underwent postoperative spinal cord MRI. Preoperative identification of the Adamkiewicz artery (ARM) was obtained in all patients except 1. Aortic pathology was dissection in 2 and non-dissection in 16 patients.There were 3 types MRI finding: sporadic infarction involving a range of spinal cord (sporadic); focal and asymmetrical infarction within a few segments of vertebra (focal); and diffuse and symmetrical infarction around the level of the ARM (diffuse). In endovascular repair, sporadic infarction was observed in all patients (4 of 4). In open repair, sporadic infarction was observed in 3 (21%), focal infarction in 7 (50%) and diffuse infarction in 4 (29%). In all patients who had sporadic or focal infarction, the aortic pathology was non-dissection.From these findings, embolism is 1 of the major causes of spinal cord injury in the era of adjuncts to optimize spinal cord haemodynamics during aortic repair.
The deposition characteristics of a low temperature electroless cobalt plating bath and the magnetic properties of the deposited cobalt films have been investigated. The optimum bath composition and operating conditions were found to be; cobalt sulfate 0.1M, sodium hypophosphite 0.2M, sodium pyrophosphate 0.4M, ammonium sulfate 0.5M, bath pH10.5 (adjusted with ammonia), operating temperature 60°C. The magnetic properties of deposited films were improved when they were deposited from low temperature bath. Therefore, this type of bath was suitable to the low temperature bath for magnetic plating. The phosphorous content of Co-P films deposited from these baths was relatively high compared with that from other type of bath due to co-deposition of phosphorous from the pyrophosphate anion in the solution
Central MessageSubtotal aortic replacement was successfully completed using frozen elephant trunk for extensive aortic dissecting aneurysm with recanalized patent ductus arteriosus caused by ACTA2 mutation. Subtotal aortic replacement was successfully completed using frozen elephant trunk for extensive aortic dissecting aneurysm with recanalized patent ductus arteriosus caused by ACTA2 mutation. Mutations in the actin, alpha-2, smooth muscle, aorta (ACTA2) gene is among the main causes of familial thoracic aortic aneurysms and dissections. Patent ductus arteriosus (PDA) in childhood or acute aortic dissection during teenage years has been reported as relatively frequent complication in patient with ACTA2 mutation.1Regalado E.S. Mellor-Crummey L. De Backer J. Braverman A.C. Ades L. Benedict S. et al.Clinical history and management recommendations of the smooth muscle dysfunction syndrome due to ACTA2 arginine 179 alterations.Genet Med. 2018; 20: 1206-1215Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar In patient with ACTA2 mutation with thoracoabdominal aortic aneurysm, PDA may complicate surgeries requiring cardiopulmonary bypass (CPB) because of left-to-right shunt and strong adhesion.2Wada T. Ohuchi S. Oyama S. Type A acute aortic dissection in a patient with patent ductus arteriosus.Ann Thorac Surg. 2022; 113: 99-101Abstract Full Text Full Text PDF Scopus (1) Google Scholar Although several reports describe usefulness of frozen elephant trunk (FET) for closure of a PDA, use of FET for connective tissue disorder has been often reported negatively.3Varma P.K. Vallath G. Nema P.K. Sinha P.K. Sivadasanpillai H. Menon M.U. et al.Clinical profile of post-operative ductal aneurysm and usefulness of sternotomy and circulatory arrest for its repair.Eur J Cardiothoracic Surg. 2005; 27: 416-419Crossref PubMed Scopus (12) Google Scholar Herein, we describe the successful treatment of a patient with an ACTA2 mutation with recurrent PDA and acute type B aortic dissection complicated by thoracoabdominal aortic aneurysm. This report was included in an investigational study approved by our institutional review board (M30-057; September 5, 2018). Written informed consent for publication was obtained from the patient. A 13-year-old girl experiencing abrupt epigastric pain was referred to our hospital. She had previously undergone PDA ligation via median sternotomy followed by coil embolization for PDA recanalization before she was aged 1 year. However, recurrent recanalization was detected 6 months before the onset of this presentation. Computed tomography angiography (CTA) revealed type B aortic dissection with a large primary entry at the descending aorta surrounded by a low-density area (Figure 1) and described no signs of visceral ischemia related to the dissection. Ascending aortic enlargement (43 mm) was concomitantly detected. Shrinkage of the low-density area was confirmed under optimal blood pressure control. Because strong adhesion around recurrent PDA was supposed, which was unsuitable for proximal arch clamp for partial bypass, staged complete aortic repair was planned. On day 14 of admission, CPB was initiated with ascending aorta cannulation and bicaval drainage to perform total arch replacement (TAR). Under lower body circulatory arrest at 25 °C, the PDA was sutured using autopericardium inside the pulmonary trunk. The aortic arch was transected just distal to the left common carotid artery and an FET (21 × 90 mm) (J Graft Frozenix; Japan Lifeline) was inserted covering the PDA orifice inside the aorta. Thereafter, TAR was completed under selective antegrade cerebral perfusion using a 4-branched graft (22 mm Gelweave 4Branch; Terumo) (Video 1). On postoperative CTA, the PDA was effectively closed, and the false lumen of the proximal descending aorta surrounding the FET was thrombosed. Five days after TAR, the patient was placed in a right semirecumbent position, and a left thoracotomy was created through the sixth intercostal space linking retroperitoneal laparotomy and a diaphragm incision. After femorofemoral partial CPB and active cooling was established at 30 °C, the FET was clamped at the Th6 level. A proximal stump was made at the edge of the FET, followed by a running suture with 4-branched graft (20 mm Gelweave Coselli Thoracoabdominal Graft; Terumo). Under visceral perfusion, the 11th intercostal artery, which was confirmed as the feeder of the Adamkiewicz artery on CTA, was reconstructed by the graft interposition technique. The aorta was beveled between the upper left and lower right renal arteries for distal anastomosis to match the prosthetic graft diameter, then the visceral arteries were individually reconstructed (Video 2). Preoperative cerebrospinal fluid drainage was not planned for fear of iatrogenic complications. The day after the second surgery, she developed paraparesis but quickly recovered after spinal drainage and blood pressure augmentation. Postoperative CTA indicated aortic remodeling around the FET (Figure 2). Subsequently, she was discharged without any symptoms and later diagnosed with ACTA2 mutation after a genetic examination. Patients with ACTA2 mutations tend to experience type B dissections more frequently at younger ages compared with type A. ACTA2 mutations are also associated with PDA, which frequently recanalizes despite previous treatment.1Regalado E.S. Mellor-Crummey L. De Backer J. Braverman A.C. Ades L. Benedict S. et al.Clinical history and management recommendations of the smooth muscle dysfunction syndrome due to ACTA2 arginine 179 alterations.Genet Med. 2018; 20: 1206-1215Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar In this case, to prevent blowout rupture, urgent thoracoabdominal aortic aneurysmal replacement was considered to be most promising. However, some difficulties for proximal anastomosis via left thoracotomy were anticipated. Firstly, severe adhesion around a recanalized PDA might disrupt exposure of the proximal descending aorta. Secondly, left-to-right shunt through the PDA during the core cooling to perform open proximal anastomosis could cause systemic hypoperfusion. Stent grafting for patients with connective tissue disease is debatable owing to concerns regarding unknown effects to their fragile aortic wall.4Glebova N.O. Cameron D.E. Black III, J.H. Treatment of thoracoabdominal aortic disease in patients with connective tissue disorders.J Vasc Surg. 2018; 68: 1257-1267Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar However, FET may be justified as a bridge therapy to definitive open surgery like the present staged strategy. FET is also effective for excluding residual PDA and relocating aortic trimming for distal anastomosis of TAR in patients with aortic arch disease.2Wada T. Ohuchi S. Oyama S. Type A acute aortic dissection in a patient with patent ductus arteriosus.Ann Thorac Surg. 2022; 113: 99-101Abstract Full Text Full Text PDF Scopus (1) Google Scholar
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