Neurologic complications of reoperative and emergent abdominal aortic reconstruction

Patients undergoing emergent and reoperative abdominal aortic reconstructions are at increased risk for ischemic neurologic complications. Between 1986 and 1992 five patients sustained ischemic injuries to the spinal cord, nerve roots, or lumbosacral plexus. Four patients underwent reoperative aortic procedures including removal of an infected aortobifemoral graft and extra-anatomic bypass (n=3) and aortofemoral graft revision for primary graft failure (n=1). A fifth patient had a ruptured common iliac aneurysm repaired with an aortobifemoral graft. Three patients undergoing reoperative aortic procedures developed lower extremity paraparesis, patchy sensory deficits, and bowel and bladder dysfunction. Physical examination and electromyography localized the injury to the level of the cauda equina or lumbosacral plexus. The other patient in this group developed incomplete T12 paraplegia. Surgical reconstruction resulted in internal iliac exclusion in all four patients. The incidence of neurologic deficits during this study period was 18% (3/17) in patients requiring aortofemoral graft excision for infection. The patient undergoing aneurysm repair was noted to have paraplegia after surgery and died on the fourth postoperative day. Autopsy revealed evidence of multiple emboli to the kidneys, bowel, and spinal cord. Neurologic deficits after reoperative and emergent abdominal aortic reconstructions are uncommon but devastating complications. Of particular concern is the incidence of neurologic deficits after removal of aortofemoral grafts with disruption of collateral flow to the spinal cord and nerve roots. Consideration should be given to maintaining retrograde perfusion of at least one internal iliac artery via common femoral artery reconstruction in these patients.