1. The Impact of Preoperative Identification of the Adamkiewicz Artery on Spinal Cord Protection in Descending and Thoracoabdominal Aortic Repair: A Japanese Multicenter Study Hiroshi Tanaka 1, Hitoshi Ogino 2, 1, Kenji Minatoya 1, Yoshiro Matsui 3, Tetsuya Higami 4, Hitoshi Okabayashi 5, Yoshikatsu Saiki 6, Shigeyuki Aomi 7, Norihiko Shiiya 8, Yoshiki Sawa 9, Takahiro Katsumata 14, Yutaka Okita 10, Taijiro Sueda 11, Shigeaki Aoyagi 12, Yukio Kuniyoshi 13, Hitoshi Matsuda 1, Hiroaki Sasaki 1, Yutaka Iba 1 1. Department of Cardiovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan. 2. Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan. 3. Department of Cardiovascular Surgery, Hokkaido University, Sapporo, Japan. 4. Second Department of Surgery, Supporo Medical University, Sapporo, Japan. 5. Department of Cardiovascular Surgery, Iwate Medical University, Morioka, Japan. 6. Department of Cardiovascular Surgery, Tohoku Univerisity, Sendai, Japan. 7. Department of Cardiovascular Surgery, Tokyo Women's Medical University, Tokyo, Japan. 8. First Department of Surgery, Hamamatsu Medical University, Hamamatsu, Japan. 9. Department of Cardiovascular Surgery, Osaka University, Osaka, Japan. 10. Department of Cardiovascular Surgery, Kobe University, Kobe, Japan. 11. First Department of Surgery, Hiroshima University, Hiroshima, Japan. 12. Department of Surgery, Kurume University, Kurume, Japan. 13. Second Department of Surgery, Ryukyu University, Naha, Japan. 14. Department of Thoracic and Cardiovascular Surgery, Osaka Medical University, Osaka, Japan.

2. No disclosure

3. Objectives To investigate whether preoperative identification of the Adamkiewicz artery could be an adjunct to reduce the incidence of spinal cord injury in descending and thoracoabdominal aortic repair.

4. Patients and Methods Multicenter study - 12 Japanese cardiovascular centers January 2000 – December 2010 2,435 descending and thoracoabdominal aortic repairs 1,471 open repairs, 964 endovascular repairs Preoperative AKA examNo AKA examTotal Open repair878 (60%)593 (40%)1,471 Endovascular repair374 (39%)590 (61%)964

5. Detect of the Adamkiewicz Artery (AKA)

6. Distribution of the location of the AKA Right Left Identified in 1,096 / 1,252 (87.6%)

7. Patients Profile – Open repair (n=1471) n% Age (y)64±13 Male Gender106972.7 Hypertension121382.5 Hyperlipidemia37025.2 Diabetus15710.7 Smoking82756.2 Coronary artery disease25417.3 Renal failure20213.7 Dialysis513.4 Cerebrovascular disease18912.8 Chronic lung disease25317.2 Liver disease80.5 Aortic pathology Dissection89336.7 Non - dissection138556.9 infection793.2 Emergent43717.9 AKA identification74850.8 Operative procedures

8. ExtentMortality (%)Spinal cord injury (%) I10.09.4 II10.014.0 III13.214.4 IV10.54.2 V5.77.2 Descending4.34.2 Total9.27.3 Risk factors for spinal cord injury (multivariate analysis) OR95% CIp Male gender2.051.13 - 3.730.018 Age > 65 yo2.581.49 - 4.470.0007 Chronic lung disease1.230.72 - 2.080.44 Renal failure1.450.81 - 2.610.21 Extent I, II, III4.342.69 - 7.00<. 0001 Emergent2.531.31 - 4.890.0055 AKA identification1.140.66 - 1.960.63

9. Open repair : 1471 SCI (7.3%) Identified AKA : 748 (7.8) No AKA exam : 593 (6.9) No definite AKA identified : 128 (6.3) Operation involving AKA: 454 (8.6)Operation not involving AKA : 244 (7.4) AKA preserved or reconstructed : 349 AKA ligated : 51Occluded AKA : 54

10. Multivariate analysis of risk factors for SCI in open repairs involving AKA OR95% CIp Male gender2.280.88 – 5.890.090 Age > 65 yo2.811.19 – 6.650.019 Chronic lung disease0.900.39 - 2.090.80 Renal failure1.350.53 – 3.480.53 Extent I, II, III3.581.57 – 8.160.002 Emergent2.200.53 – 9.160.279 AKA ligation2.641.08 – 6.470.034

11. Endovascular repair : 964 SCI (2.9%) Identified AKA : 344 (3.5) No AKA exam : 590 (2.5) No definite AKA identified : 30 (3.3) Operation involving AKA: 62 (3.2)Operation not involving AKA : 282 (3.5) No significant risk factors for SCI Endovascular Repair (n=964) Hospital mortality 62 / 964 (6.4%)

12. Conclusions In open descending and thoracoabdominal aortic repair involving the origin of the AKA, preoperative identification of the AKA and its following intraoperative reconstruction could be an adjunct for spinal cord protection.