CASE REPORTS Use of Cerebrospinal Fluid Drainage Catheters During Single-Stage Transmediastinal Repair of Ascending/Descending Aortic Aneurysms Bhiken Naik, MBBCh,* Emilio B. Lobato, MD,* Tomas D. Martin, MD,† Jessica Willert, MD,* Gregory M. Janelle, MD,* and Felipe Urdaneta, MD* S URGICAL PROCEDURES of the thoracic aorta present unique perioperative challenges and carry with them sig- nificant morbidity and mortality, not only because of the pres- ence of severe comorbid conditions, but also because of the interruption of blood flow to critical organs. Atherosclerotic thoracic aortic aneurysms, if left untreated, have a high inci- dence of complications. The incidence of rupture or dissection is 31% for ascending aneurysms greater than 6 cm in diameter and 43% for descending thoracic aneurysms larger than 7 cm. 1 The conventional surgical approach for aneurysms affecting the ascending aorta, aortic arch, and descending thoracic aorta is the “staged elephant trunk” procedure, first described by Borst et al 2-4 in 1983. The first component of the staged procedure is the repair of the ascending aorta and aortic arch aneurysm under cardiopulmonary bypass (CPB) and deep hy- pothermic circulatory arrest (DHCA), via a median sternotomy incision. A residual length of graft is left in the descending aorta to facilitate repair of the descending aortic aneurysm at a later stage. Because this approach involves 2 major surgical procedures, with their corresponding risks and complications, some patients are unable to have the repair completed. 5-7 Recently, Beaver and Martin, 8 from this institution, described a single-stage repair of the ascending aorta, aortic arch, and de- scending thoracic aorta via median sternotomy through a trans- mediastinal approach. The operation is performed on patients in whom the descending thoracic aortic aneurysm tapers to a normal caliber above the level of the diaphragm. It is performed under conditions of CPB; DHCA; and, as described, with retrograde cerebral perfusion. This single-stage procedure involves initially the anastomosis of a Dacron graft to the distal descending aorta through a transmediastinal transverse supradiaphragmatic aorto- tomy incision, followed by reimplantation of arch vessels and suturing of the proximal graft to the ascending aorta, at which point the patient is rewarmed and separated from CPB 8 (Figs 1-3). Their reported perioperative mortality was 14% with a 21% inci- dence of neurologic injury. Of interest, 2 of 3 patients who suffered neurologic injury presented with lower-extremity para- plegia, and a third patient had reversal of the neurologic deficit after a cerebrospinal fluid (CSF) drainage catheter was placed in the postoperative period. This outcome prompted the authors to begin placing CSF drainage catheters 12 hours preoperatively because of concerns of major bleeding associated with CPB and DHCA in this population, as well as the theoretical risk of placing spinal drains postoperatively. In this report, experience with a similar patient who had successful reversal of postoperative paresis with CSF drainage placement and 2 subsequent patients who underwent single- stage surgery with preoperative placement of a CSF drainage catheter are described. A brief review and discussion of the literature concerning the use of spinal drains to protect the spinal cord during surgical procedures of the thoracic aorta follows the case reports. CASE 1 A 68-year-old woman was found to have aneurysms in the descend- ing thoracic aorta (6 cm), ascending aorta (5 cm), and aortic arch (5 cm) during routine workup for an episode of syncope. Cardiac catheteriza- tion also showed a 90% occlusion of the right coronary artery, which was not amenable to angioplasty. A combined coronary artery bypass graft single-stage transmediastinal repair of the ascending aorta, aortic arch, and descending thoracic aorta was performed. The total CPB time was 177 minutes, whereas the retrograde cerebral circulation and myocardial cross-clamp times were 59 and 83 minutes, respectively. The first neurologic examination in the intensive care unit showed no lower-extremity paresis. However, approximately 12 hours postop- eratively, routine neurologic examination revealed bilateral lower-ex- tremity paresis. A CSF drainage catheter was immediately placed in the lumbar area and opened to drain at 0 cm H 2 O. Within 6 hours of drain placement, the patient had full recovery of her motor function. The drain was removed without difficulty 6 days after placement, and the patient was neurologically intact with no evidence of focal paresis. The patient was discharged to an inpatient rehabilitation unit for approxi- mately 3 weeks. During that period, the patient demonstrated an ability to perform all her activities of daily living without assistance. In addition, she was able to stand/pivot and ambulate independently. The patient was discharged home 5 weeks after surgery. CASE 2 A 61-year-old woman was scheduled for repair of an ascending aorta, aortic arch, and descending aortic aneurysm via the single-stage procedure. Her previous history was notable for aortic valve replace- ment with a prosthetic St Jude’s valve (St. Jude Medical, St Paul, MN), for which she was taking coumadin. One year after the aortic valve From the Departments of *Anesthesiology and †Surgery (Division of Thoracic and Cardiovascular Surgery), University of Florida College of Medicine, Gainesville, FL. Reprints are not available. © 2004 Elsevier Inc. All rights reserved. 1053-0770/04/1805-0014$30.00/0 doi:10.1053/j.jvca.2004.07.002 Key words: paraplegia, spinal drain, thoracic aortic aneurysm 624 Journal of Cardiothoracic and Vascular Anesthesia, Vol 18, No 5 (October), 2004: pp 624-627