Spinal cord injury in patients undergoing total arch replacement: A cautionary note for use of the long elephant technique

ObjectivesSpinal cord injury in patients undergoing total arch replacement via median sternotomy is a rare but catastrophic complication. With recent surgical advances, including the long elephant trunk technique or open stent procedure, the incidence of spinal cord injury is increasing. In our institute, the long elephant trunk procedure is routinely performed when appropriate to the patient's status. The aim of our study was to determine risk factors for spinal cord injury during total arch replacement.MethodsSince April 2004, 61 patients underwent total arch replacement with a 4-branched prosthetic graft. The study population included 44 men and 17 women (mean age, 69.8 ± 11.1 years). Thirty-three patients underwent the long elephant trunk procedure with a mean length of 12.0 ± 3.5 cm (range, 7-21.6 cm). The Adamkiewicz artery was detected by computed tomography in 11 patients. We assessed the perioperative factors associated with spinal cord injury.ResultsFour (6.6%) patients had spinal cord injury (3 cases of paraplegia and 1 case of paraparesis). This constitutes 12% of all patients having the long elephant trunk procedure. No patients with direct distal anastomosis had a spinal cord injury. Univariate logistic regression analysis identified female gender, elephant trunk more than 10 cm from the left subclavian artery, and nonpreserved Adamkiewicz artery as significant independent risk factors for spinal cord injury. Both female gender (P = .017) and long elephant trunk (P = .005) were significant by multivariate analysis.ConclusionsElephant trunk more than 10 cm from the left subclavian artery was associated with increased risk of spinal cord injury. We recommend short elephant trunk or long elephant trunk with preservation of the Adamkiewicz artery to prevent spinal cord injury in patients having total arch replacement.