The Safety Profile of Intentional or Iatrogenic Sacrifice of the Artery of Adamkiewciz and Its Vicinity’s Spinal Segmental Arteries: A Systematic Review

Abstract

Study Design: Systematic review. Objectives: There is paucity of consensus on whether (1) the artery of Adamkiewicz (AoA) and (2) the number of contiguous segmental spinal arteries (SSAs) that can be safely ligated without causing spinal cord ischemia. The objective of this review is to determine the risk of motor neurological deficits from iatrogenic sacrifice of the (1) AoA and (2) its vicinity’s SSAs. Methods: Systematic review of the spine and vascular surgery was carried out in accordance to PRISMA guidelines. Outcomes in terms of risk of postoperative motor neurological deficit with occlusion of the AoA, bilateral contiguous SSAs, or unilateral contiguous SSAs were analyzed. Results: Ten articles, all retrospective case series, were included. Three studies (total N = 50) demonstrated a postoperative neurological deficit risk of 4.0% when the AoA is occluded. When 1 to 6 pairs of SSAs (without knowledge of AoA location) were ligated, the postoperative neurological deficit risk was 0.6%, as compared with 5.4% when more than 6 bilateral pairs of SSAs were ligated (relative risk [RR] = 0.105, 95% CI 0.013-0.841, P = .0337). For unilateral ligation of SSAs of two to nine levels, the risk of postoperative neurological deficit does not exceed 1.3%. Conclusion: The current best evidence indicates that (1) occlusion of the AoA and (2) occlusion of up to 6 pairs of SSAs is associated with a low risk of postoperative neurological deficit. This limited number of low quality studies restrict the ability to draw definitive conclusions. Ligation of AoA and SSAs should only be undertaken when absolutely required to mitigate the small but devastating risk of paralysis.

Vascular Myelopathy Secondary to Compression of the Artery of Adamkiewicz From an Intrathecal Catheter: A Technical Case Report

“…The development of her new symptoms after pump placement and the correlation with imaging findings supported the hypothesis of the catheter as a possible cause of this patient's clinical presentation. Although the AoA can sometimes be sacrificed in both endovascular and surgical procedures without subsequent neurological deficits, 17 for our patient, we suspect that her history of spinal cord injury may have rendered her vulnerable to ischemia from chronic occlusion of the AoA by the abutting catheter.…”

Pre-operative coil-embolisation of a large, myelon-compressing vertebral metastasis involving the artery of Adamkiewicz

“…There is a lack of consensus and high-level evidence concerning the iatrogenic sacri ce of the AKA (and possibly various segmental spinal arteries), its potential neurological detriment as well as preventative or restorative measures in case of spinal cord ischemia [9]. Studies in animals [10,11] as well as human subjects [12,13] indicate an existing but relatively low risk of post-interventional/ post-operative neurological motor de cit of AKA occlusion that may well depend upon the amount of occluded segmental vessels [9,13,14], the degree of collateralization [9,15] as well as the localization of the embolization, with possible resumption or maintenance of blood ow through the AKA despite focal occlusion [16]. The lack of (neurologic) complications after performance of blood-ow controlling, superselective catheterizations of the proximal-most point of the AKA as well as segmental spinal arteries seems to corroborate these hypotheses well, but also emphasizes the requirement for precise diagnostic tools with the outcome of detailed anatomical information.…”

“…A retrospective study by Fanous et al reported 54% of cases, in which DSA imaging had in uenced surgical planning and decision making, resulting in a rate of zero angiography-or surgery-related complications [17]. In absence of the aforementioned anatomical insights, a systematic review by Tan et al recommends that ligation of the AKA and segmental spinal arteries be performed only when absolutely necessary due to the nonnegligible risk of paralysis or paresis [9]. In our speci c case, the planned embolization of the artery of Adamkiewicz before its inevitable resection during surgery and its possibly predominantly tumor feeding nature, might have played a vital part in facilitating surgical resection by limiting blood loss and enabling an unimpeded view of the surgical eld, with the reported lack of spinal cord ischemia.…”

“…However, spinal cord ischemia with transient or permanent paraplegia after inadvertent interruption of the artery of Adamkiewicz represent dreaded complications of surgical and interventional procedures of the spine and thoracoabdominal cavity [7,8]. There is a lack of consensus and high-level evidence concerning the iatrogenic sacri ce of the AKA (and possibly various segmental spinal arteries), its potential neurological detriment as well as preventative or restorative measures in case of spinal cord ischemia [9]. Studies in animals [10,11] as well as human subjects [12,13] indicate an existing but relatively low risk of post-interventional/ post-operative neurological motor de cit of AKA occlusion that may well depend upon the amount of occluded segmental vessels [9,13,14], the degree of collateralization [9,15] as well as the localization of the embolization, with possible resumption or maintenance of blood ow through the AKA despite focal occlusion [16].…”

Iatrogenic spinal cord ischemia: A patient level meta-analysis of 74 case reports and series

“…Additionally, we observed aortic surgeries cause increased frequency of ischemic infarcts in the lumbar region. This could be explained by iatrogenic damage to the Artery of Adamkiewciz and other spinal segmental arteries, which has previously been shown to result in ischemia to the lower thoracic and lumbar regions [20] . Autonomic dysfunction, including bowel and bladder incontinence was also found to be associated with increased ischemia at T10.…”