CASE REPORT
A 69-year-old man was referred for the treatment of a chronic aneurysm involving the ascending aorta and arch. An angio-computed tomography (CT) revealed dilatation of the ascending aorta (58mm) and the aortic arch (57mm) with thrombotic stratification (Fig. 1A, B). A transthoracic echocardiogram showed normal left ventricular function with moderate aortic regurgitation.
At operation arterial perfusion was through the right axillary artery and venous drainage through the right atrium. After aortic cross-clamping, the proximal aorta was opened and the heart arrested with crystalloid cardioplegia. The aortic valve was repaired by plication of the prolapsed non-coronary and left cusps. At 26° of esophageal temperature antegrade cerebral perfusion was started through the right axillary and selective cannulation of left carotid artery. After observing an adequate back-flow, the left subclavian artery origin was occluded to avoid a possible subclavian steal. During perfusion adequacy of flow was continuously controlled and blood pressure in the brachiocephalic vessels maintained between 50 and 70 mmHg. The ascending aorta and arch were replaced with a FET using a quadrifurcated 30/36 mm Thoraflex graft (Vascutek Ltd, Inchinnan, Scotland ). Prior to distal anastomosis a catheter was advanced through the graft into the descending aorta for visceral perfusion; systemic perfusion was restarted by cannulating the 4th side branch of the graft and the left subclavian and left carotid arteries were reattached to the graft. During rewarming the proximal aortic anastomosis was completed and the brachiocephalic artery reattached to the graft. Aortic cross-clamp, circulatory arrest and total cardiopulmonary bypass times were 176, 40, and 230 minutes.
After 4 hours, suspension of sedation with complete awakening of the patient, evidenced complete paraplegia while tactile and painful sensibility was maintained. Corticosteroid therapy was immediately started together with CSFD by inserting a catheter in the subarachnoid space between L4 and L5. After insertion of the needle a leakage of about 30 ml of liquor occurred under pressure. Initially, CSF pressure was 25 mmHg and a total of 100 mL of spinal liquor were drained to reach and maintain a target pressure less than 10 mmHg. Continuous monitoring of CSF pressure was performed in the following 96 hours with a target spinal chord perfusion pressure of >70 mmHg. This goal was achieved by maintaining a mean arterial pressure >80 mmHg, CSF pressure <10 mmHg, and central venous pressure <10 mmHg. Five hours later, when definitely woken up, the patient started to regain motility of both legs with a complete resolution of the neurological deficit after few days.
A control CT scan ruled out possible acute aortic events confirming the adequacy of repair (Fig. 1 C), while a nuclear magnetic resonance showed signs of medullary ischemic lesion (Fig. 1 D). The subsequent course was uncomplicated, the patient discharged to the ward on postoperative day 6 and transferred to a rehabilitation center to continue a program of physiokinesitherapy. At 1-year follow-up he has recovered completely from his neurological injury.