Near real-time bedside detection of spinal cord ischaemia during aortic repair by microdialysis of the cerebrospinal fluid
- 1 May 2020
- journal article
- research article
- Published by Oxford University Press (OUP) in European Journal of Cardio-Thoracic Surgery
- Vol. 58 (3), 629-637
- https://doi.org/10.1093/ejcts/ezaa124
Abstract
OBJECTIVES Spinal cord ischaemia (SCI) remains the most devastating complication after thoraco-abdominal aortic aneurysm (TAAA) repair. Its early detection is crucial if therapeutic interventions are to be successful. Cerebrospinal fluid (CSF) is readily available and accessible to microdialysis (MD) capable of detecting metabolites involved in SCI [i.e. lactate, pyruvate, the lactate/pyruvate ratio (LPR), glucose and glycerol] in real time. Our aim was to evaluate the feasibility of CSF MD for the real-time detection of SCI metabolites. METHODS In a combined experimental and translational approach, CSF MD was evaluated (i) in an established experimental large animal model of SCI with 2 arms: (a) after aortic cross-clamping (AXC, N = 4), simulating open TAAA repair and (b) after total segmental artery sacrifice (Th4–L5, N = 8) simulating thoracic endovascular aortic repair. The CSF was analysed utilizing MD every 15 min. Additionally, CSF was collected hourly from 6 patients undergoing open TAAA repair in a high-volume aortic reference centre and analysed using CSF MD. RESULTS In the experimental AXC group, CSF lactate increased 3-fold after 10 min and 10-fold after 60 min of SCI. Analogously, the LPR increased 5-fold by the end of the main AXC period. Average glucose levels demonstrated a 1.5-fold increase at the end of the first (preconditioning) AXC period (0.60±0.14 vs 0.97±0.32 mmol/l); however, they decreased below (to 1/3 of) baseline levels (0.60±0.14 vs 0.19±0.13 mmol/l) by the end of the experiment (after simulated distal arrest). In the experimental segmental artery sacrifice group, lactate levels doubled and the LPR increased 3.3-fold within 30 min and continued to increase steadily almost 5-fold 180 min after total segmental artery sacrifice (P < 0.05). In patients undergoing TAAA repair, lactate similarly increased 5-fold during ischaemia, reaching a maximum at 6 h postoperatively. In 2 patients with intraoperative SCI, indicated by a decrease in the motor evoked potential of >50%, the LPR increased by 200%. CONCLUSIONS CSF is widely available during and after TAAA repair, and CSF MD is feasible for detection of early anaerobic metabolites of SCI. CSF MD is a promising new tool combining bedside availability and real-time capacity to potentially enable rapid detection of imminent SCI, thereby maximizing chances to prevent permanent paraplegia in patients with TAAA.Keywords
Funding Information
- Barts Health National Health Service Trust
- BioResource
- National Institute of Health (143355, 14/EE/00)
- the European Union Horizon 2020 research programme (733203)
- German Research Foundation (ET 127/2-1, ET 127/1-1, 278040814)
This publication has 24 references indexed in Scilit:
- Microdialysis to Optimize Cord Perfusion and Drug Delivery in Spinal Cord InjuryAnnals of Neurology, 2016
- Outcomes of 3309 thoracoabdominal aortic aneurysm repairsThe Journal of Thoracic and Cardiovascular Surgery, 2016
- Total-tau and neurofilament light in CSF reflect spinal cord ischaemia after endovascular aortic repairNeurochemistry International, 2015
- Consensus statement from the 2014 International Microdialysis ForumIntensive Care Medicine, 2015
- Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery†European Journal of Cardio-Thoracic Surgery, 2015
- Tissue gas tensions and tissue metabolites for detection of organ hypoperfusion and ischemiaActa Anaesthesiologica Scandinavica, 2011
- Physiopathology of shockJournal of Emergencies, Trauma, and Shock, 2011
- LMNA Mutations, Skeletal Muscle Lipid Metabolism, and Insulin ResistanceJournal of Clinical Endocrinology & Metabolism, 2010
- Spinal cord blood flow and ischemic injury after experimental sacrifice of thoracic and abdominal segmental arteries☆European Journal of Cardio-Thoracic Surgery, 2008
- Thoracoabdominal Aneurysm Repair: A 20-Year PerspectiveThe Annals of Thoracic Surgery, 2007