Prevención de Isquemia Medular en Cirugía Aórtica

Dr. Luis Raúl Sandoval
Médico Especialidad en Cirugía Vascular Periférico
Caja Costarricense del Seguro Social
San José, Costa Rica.

Dra. Sofía Rojas Jiménez
Médico General
Licenciatura y Doctorado en Medicina y Cirugía.
Investigadora independiente
San José, Costa Rica.

Dra. Ana Laura Sandoval
Médico General
Licenciatura y Doctorado en Medicina y Cirugía.
Investigadora independiente
San José, Costa Rica.

Dra. Michelle Volio González
Médico General
Licenciatura y Doctorado en Medicina y Cirugía.
Investigadora independiente
San José, Costa Rica.

Resumen

La cirugía aórtica es un procedimiento que ha venido en evolución en los últimos años. Sin embargo, continúan existiendo complicaciones devastadoras a nivel de médula espinal que son limitantes para la realización segura de la misma.

La patogénesis de la lesión medular puede presentarse durante la cirugía o posterior a esta. Es multifactorial, pudiendo presentarse como una reducción temporal o permanente del flujo sanguíneo espinal. La isquemia medular y la paraplejía concomitante son de las complicaciones más temidas de la reparación endovascular de aneurisma aórtico-torácica. Ante esto se debe realizar una detección temprana debido a que permite el inicio de medidas anti-isquémicas antes de llegar a infarto medular y paraplejía permanente, utilizando monitoreos potenciales somatosensoriales evocados (SSEP) y/o motores evocados (MEP). Estos procedimientos ofrecen al equipo quirúrgico una oportunidad de revertir la causa de la hipoperfusión, maximizando la perfusión medular y revirtiendo la injuria espinal.

Existen múltiples protocolos que se enfocan en optimizar la perfusión medular y disminuir las demandas metabólicas y de oxígeno además de promover una detección rápida de déficit neurológico. Para esto, las guías internacionales actuales mencionan diferentes estrategias de prevención, donde por ejemplo para el caso de TEVAR, se recomiendan evitar períodos de hipotensión y el uso selectivo de drenaje fluido cerebroespinal en pacientes de alto riesgo de lesión isquémica espinal.

Palabras claves

Cirugía aórtica, isquemia medular, aneurisma aórtico torácico.

Abstract

Aortic surgery is a procedure that has been evolving in recent years. However, there are still devastating complications at the spinal cord level that are limiting for its safe performance.

The pathogenesis of spinal cord injury can occur during, or after, surgery. It is multifactorial and can present as a temporary or permanent reduction in spinal blood flow.

Spinal cord ischemia and concomitant paraplegia are one of the most feared complications of endovascular repair of thoracic aortic aneurysm. In view of this, early detection must be carried out because it allows the initiation of anti-ischemic measures before reaching spinal cord infarction and permanent paraplegia.

Using somatosensory evoked potential (SSEP) and/or motor evoked potential (MEP) monitoring, offer the surgical team an opportunity to reverse the cause of hypoperfusion, maximizing spinal cord perfusion and reversing spinal injury.

There are multiple protocols that focus on optimizing spinal cord perfusion and reducing metabolic and oxygen demands, as well as promoting early detection of neurological deficit. The current international guidelines mention different prevention strategies, where, for example, in the case of TEVAR, it is recommended to avoid periods of hypotension and the selective use of cerebrospinal fluid drainage in patients at high risk of spinal ischemic injury.

Keywords

Aortic surgery, medullar isquemia, thoracic aortic aneurysm.

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