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J Thorac Cardiovasc Surg 1999;117:898-905
© 1999 Mosby, Inc.

SURGERY FOR ADULT CARDIOVASCULAR DISEASE

DOES THE ADAMKIEWICZ ARTERY ORIGINATE FROM THE LARGER SEGMENTAL ARTERIES?

Tokuo Koshino, MDa, Gen Murakami, MDb, Kiyofumi Morishita, MDa, Tohru Mawatari, MDa, Tomio Abe, MDa

From the Department of Thoracic and Cardiovascular Surgerya and Second Department of Anatomy,b Sapporo Medical University School of Medicine, Sapporo, Japan.

Received for publication Jan 28, 1998. Revisions requested Jan 30, 1998. Revisions received Jan 6, 1999. Accepted for publication Jan 11, 1999. Address for reprints: Tokuo Koshino, MD, Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo 060-8543, Japan.


   Abstract
Top
 Abstract
Introduction
 Materials and methods
 Results
 Discussion
 Study limitation
 References
 
Objective: The Adamkiewicz artery supplies most of the blood to the anterior spinal artery, which perfuses the anterior two thirds of the spinal cord. During operations for thoracoabdominal aortic aneurysm, detailed anatomic knowledge of the Adamkiewicz artery and its correlation with the intercostal and/or lumbar arteries is important to prevent postoperative paraplegia.
Methods: Minute dissection was performed on 102 formol-fixed adult cadavers without any history of circulatory disorders. The Adamkiewicz artery was found in the epidural space after laminectomy of the vertebrae. The entire course between the Adamkiewicz artery and the intercostal and/or lumbar artery was dissected carefully. The vertebral level, laterality, and mean diameter of all Adamkiewicz arteries were investigated. The correlation between the diameter of the Adamkiewicz artery and that of the intercostal and/or lumbar arteries was also determined.
Results: The mean number of Adamkiewicz arteries per cadaver was 1.3 ± 0.65, and the mean diameter was 0.77 ± 0.24 mm (range, 0.50 to 1.49 mm). Approximately 70% of the Adamkiewicz arteries originated from the intercostal and/or lumbar arteries on the left side, frequently at the T8-L1 vertebral level. There was no statistically significant correlation between the diameter of the Adamkiewicz artery and that of intercostal and/or lumbar arteries.
Conclusion: This study provides evidence that, during operations on the thoracoabdominal aorta, the intercostal and/or lumbar arteries should be preserved, regardless of their diameter, to prevent postoperative paraplegia.


   Introduction
Top
 Abstract
 Introduction
Materials and methods
 Results
 Discussion
 Study limitation
 References
 
The Adamkiewicz artery (arteria radicularis magna) is thought to deliver most of the blood to the thoracic and lumbar spinal cord.Go Go 1–3 During replacement and reconstructive surgery of the thoracoabdominal aorta, vascular surgeons have to reconstruct the intercostal artery (ICA) and lumbar artery (LA) to maintain the blood flow through the Adamkiewicz artery, which originates from the ICA/LA. The problem as to which ICA/LA should be reconstructed remains controversial; some surgeons reconstruct all ICA/LAs within a limited level (eg, T8 to and including L1)Go 4; others reconstruct the ICA/LAs with a larger diameter before the smaller ones.Go 5 In the latter case, surgeons seem to consider that wide ICA/LAs take priority over narrow ICA/LAs based on the assumption that a wide Adamkiewicz artery, which is more effective at supplying the spinal cord, emerges from a wide ICA/LA. The aim of this study was to clarify the correlation between the diameter of the ICA/LA and the diameter of the Adamkiewicz artery to establish the basis for choosing the ICA/LA that should be reconstructed.


   Materials and methods
Top
 Abstract
 Introduction
 Materials and methods
Results
 Discussion
 Study limitation
 References
 
Materials
Minute dissection was performed on 102 donated Japanese adult cadavers (50 male and 52 female), with no history of obvious circulatory disorders. In 12 of the 102 formol-fixed cadavers, acrylic polymer red dye (Liquitex; Bonny, Tokyo, Japan) was injected with high pressure through the femoral artery immediately after fixation to identify the radicular artery and anterior spinal artery. There was no difference in diameter of the Adamkiewicz arteries in the cadavers that were injected with dye compared with the others. In the injected cadaver, the connection between the anterior spinal artery and the Adamkiewicz artery could easily be observed.

Exposure of the Adamkiewicz artery and ICA/LA
The cadavers were placed in the prone position, and the Adamkiewicz arteries were located in the epidural spaces after laminectomy of the vertebrae. The cadavers were then moved to the supine position, and the ICA/LAs were dissected between the fifth thoracic and second lumbar vertebral level. The connections between the Adamkiewicz arteries and ICA/LAs were also dissected to determine where the Adamkiewicz arteries originated (Fig. 1).



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  		Fig. 1 Photograph shows the connection of the Adamiewicz artery and the medial dorsal branch of the ICA originated from the ICA as a single stem and then divided separately. The medial dorsal branch of the ICA runs posteriorly to supply blood to the back muscles. Adam, Adamkiewicz artery; ICA, intercostal artery; ICN, intercostal nerve; MD, medial dorsal branch of the ICA; LD, lateral dorsal branch of the ICA; SG, spinal ganglion; DM, dura mater.

 
Measurement of the diameter of the Adamkiewicz arteries and ICA/LAs
The vertebral level and laterality of the Adamkiewicz arteries were investigated. The diameter of the Adamkiewicz artery was measured with a digimatic caliper (Mitutoyo Co, Kawasaki, Japan) immediately after it perforated the dural sac with no distention. Before measurement, it was confirmed that the Adamkiewicz artery was connected to the anterior spinal artery in the dural sac. The form of the connection between them was not examined in this study. Although a fine arterial twig (<0.5 mm in diameter) was frequently observed along the spinal nerve roots, we considered that a spinal branch of more than 0.5 mm in diameter at the fifth thoracic to the second lumbar vertebral level was the "effective" Adamkiewicz artery according to previous anatomic and angiographic reports.Go Go 6-13 Measurement of these fine twigs was difficult and was not always accurate. The outside diameter of the ICA, including the upper LA, was measured immediately after its origin from the aorta.

Statistical analysis
All values are expressed as the mean ± SD. Data were processed with the StatView J-4.5 software (Abacus Concepts Inc, Berkeley, Calif). The correlation between the diameter of the Adamkiewicz artery and that of the ICA/LA was examined by a simple linear regression test.


   Results
Top
 Abstract
 Introduction
 Materials and methods
 Results
Discussion
 Study limitation
 References
 
Number of Adamkiewicz arteries per cadaver
The number of Adamkiewicz arteries was determined in 90 of the 102 cadavers (88%). Only 1 Adamkiewicz artery was found in 67 of the 90 cadavers (74%), whereas more than 2 Adamkiewicz arteries were found in each of the other 23 cadavers (26%). A total of 120 Adamkiewicz arteries were therefore recorded (mean per cadaver, 1.3 ± 0.65). This mean number of Adamkiewicz arteries per cadaver is smaller than that in previous reports,Go Go 10,11 which might be the result of our decision to select the relatively large radicular artery as the Adamkiewicz artery. In those cases in which 2 Adamkiewicz arteries were observed, the relationship of the vertebral level is shown in Fig 2.



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  		Fig. 2 Relationship of the vertebral level in cadaver in which 2 Adamkiewicz arteries (Adam ) were observed.

 
Laterality of the Adamkiewicz arteries
Of the 120 Adamkiewicz arteries identified, 86 (72%) originated from the ICA/LA on the left side, and 34 (28%) progomated on the right side (Fig. 3).In the 23 cases where more than 2 Adamkiewicz arteries were identified, the Adamkiewicz arteries originated unilaterally in 13 cadavers (57%) and bilaterally in 10 cadavers (43%). According to our results, the Adamkiewicz arteries showed a left-sided predominance, which agrees with previous reports.Go Go 6–10



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  		Fig. 3 Frequency of vertebral level termination and laterality of 120 Adamkiewicz arteries in 90 cadavers. The Adamkiewicz artery frequently originated from ICA/LA between the eighth thoracic and first lumbar vertebral level on the left side.

 
Vertebral level of the Adamkiewicz arteries
The bilateral incidence of the Adamkiewicz artery arose from the fifth thoracic (T5) ICA in 2%, T6 in 2%, T7 in 3%, T8 in 5%, T9 in 19%, T10 in 23%, T11 in 25%, T12 in 12%, the first LA (L1) in 8%, and L2 in 3% of cases (Fig. 3Go). Thus the Adamkiewicz artery frequently (91%) originated between the T8 and L1 vertebral levels. Overall, these vertebral levels correspond to those of previous reports.Go Go 6,8

Diameter of the Adamkiewicz arteries
The diameter of the 120 Adamkiewicz arteries examined ranged from 0.50 to 1.49 mm, with a mean of 0.77 ± 0.24 mm. The mean diameter of the Adamkiewicz arteries emerging from the left side was 0.76 ± 0.23 mm and from the right side was 0.76 ± 0.26 mm. This difference was not significant (P = .8). The mean diameter of the Adamkiewicz arteries at each vertebral level is shown in Table I. The mean diameter of all of the Adamkiewicz arteries and of the Adamkiewicz arteries at each vertebral level were compared statistically, and no significant difference was found. These results relating to diameter confirm previous data from studies in whiteGo 14 and in Japanese subjects.Go 15


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  		Table I. The mean diameter of the Adamkiewicz artery at each vertebral level.
 
Correlation between the diameter of the Adamkiewicz arteries and the ICA/LAs. In 44 of the 90 cadavers in which Adamkiewicz arteries were identified, further anatomic dissection was performed to examine the ICA/LAs
Forty-eight Adamkiewicz arteries were present in these 44 cadavers, and the ICA/LAs from which they arose were exposed along their entire course. The diameter of the ICA/LAs at the T5 to L2 vertebral level ranged from 1.42 to 4.58 mm (mean, 2.8 ± 0.66 mm). This diameter was approximately the same as that of the ICA/LAs from which the Adamkiewicz arteries originated (1.57-4.34 mm; mean, 3.0 ± 0.69 mm).

The results of the statistical analysis of the correlation between the diameter of the Adamkiewicz arteries and of their original ICA/LAs at the T5 to L2 vertebral level are shown in Fig. 4.As can be seen, the diameter of the Adamkiewicz arteries ranged from 0.50 to 1.32 mm, although that of the ICA/LAs ranged from 1.57 to 4.34 mm. There was no significant correlation between the diameter of the Adamkiewicz artery and that of the ICA/LA from which the Adamkiewicz artery originated (r = 0.255; P = .08). When the maximum and minimum diameters of the Adamkiewicz arteries and ICA/LAs were compared, however, a marked relationship was noted. When the ICA was 1.57 mm (minimum) in diameter, the Adamkiewicz artery was 1.32 mm in diameter. When the ICA was 4.34 mm (maximum) in diameter, the Adamkiewicz artery was only 0.50 mm (minimum) in diameter. Furthermore, within the T8 to L1 vertebral level, the diameter of the ICA/LA varied considerably and did not correlate with that of the Adamkiewicz artery. Consequently, it was noted that a narrow Adamkiewicz artery possibly emerged from a wide ICA/LA and vice versa.



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  		Fig. 4 Correlation between the diameter of the Adamkiewicz artery and of the ICA/LA, which existed between the fifth thoracic and second lumbar vertebral level. No significant correlation was observed between them.

 

   Discussion
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
Study limitation
 References
 
The results of the present study demonstrate that, in most cases, the size of the ICA/LA does not correspond to that of the Adamkiewicz artery. Thus reconstruction of a wide ICA/LA does not necessarily ensure the maintenance of the spinal blood supply through the Adamkiewicz artery. Therefore the question of which ICA/LA should be reconstructed during aortic replacement operation should be asked. On the basis of the results of this study, we recommend that all ICA/LAs within a given level (eg, T8-L1)Go Go 4,16 should be preserved. Although many surgeons have already pointed out the importance of preserving the lower thoracic ICAs and upper LAs to prevent postoperative paraplegia,Go Go 17,18 we suspect that some surgeons do not always reconstruct all lower ICAs and upper LAs but reconstruct only the larger ICA/LAs.

According to the law of Hagen-Poiseuille, blood flow volume per time = {partial} x diameter4/length of vessel (ie, blood flow through a vessel 1.0 mm in diameter is 16 times greater than that through a vessel 0.5 mm in diameter, with the assumption that these lengths are almost equal). Thus the diameter of the ICA/LA and that of the Adamkiewicz artery are the most critical factors for blood supply to the spinal cord. The larger amount of blood supplied through a wide ICA/LA, however, did not always seem to depend on the demand from the spinal cord but on that of other tissues such as the back muscles, although muscular branches were not measured in this study.

Overall, the present results confirm our working hypothesis that all lower ICAs and upper LAs should be preserved, even if they are narrow.


   Study limitation
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Study limitation
References
 
In the present study, the large numbers of cadavers examined gives us considerable confidence that our data regarding the distribution, laterality, and diameter of the Adamkiewicz artery are reliable. However, in this study, we investigated the correlation between the diameter of the Adamkiewicz artery and of the ICA/LA using adult cadavers without aneurysmal change of the aorta or aortic dissection. In patients with thoracoabdominal aortic aneurysms or aortic dissections, the functional relationship between the ICA/LA and Adamkiewicz artery seems to be more complicated. It is possible that occlusion of the ICA/LA that emerged from the Adamkiewicz artery might occur as a result of atherosclerotic change. Consequently, radicular arteries less than 0.5 mm in diameter may play an important role in supplying blood to the spinal cord. The Adamkiewicz arteries identified anatomically in this study therefore may not always coincide with the Adamkiewicz arteries that are functionally effective clinically. Furthermore, the role of the collateral circulation between the radicular arteries is not clear. In our dissections, we could not identify the collateral vessels; previous angiographic reports have shown them to be extremely thin.Go Go 19–22 Ideally, more detailed anatomic studies of the circulation to the spinal cord will unveil some of these factors that are important in preventing postoperative paraplegia after operations on the thoracoabdominal aorta.

During operations for thoracoabdominal aortic aneurysm or aortic dissection, we have routinely reconstructed the intact ICA/LAs within the T8 to L1 vertebral level to maintain the blood supply to the spinal cord, thinking that the Adamkiewicz artery originated from one of these levels. On the basis of the data from this study, however, we believe that more general and complete reconstruction of the ICA/LAs, regardless of their diameter, could reduce the incidence of postoperative paraplegia. This hypothesis is likely to form the basis of our working strategy from now on.


   Acknowledgments
 
We are grateful to the following persons for use of materials: Professor T. Nakao (Akita University School of Medicine), Professor H. Kiyama (Asahikawa Medical College), Professor J. Kodama (Hokkaido University School of Medicine), and Professor Y. Inoue (Hokkaido University School of Medicine).


   References
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Study limitation
 References
 

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