Artery of Adamkiewicz and the clinical repercussion of its lesion in thoracoabdominal surgeries: a systematic review

of aortic pathologies; however, its vasculature is complex due to the caliber of its arteries that pass through a three-dimensional network with great anatomical variability. Its clinical importance is evidenced during the preoperative procedure of thoracic and thoracoabdominal aortic surgeries, because its identification is essential for the prevention of spinal cord injuries. This study consists of a literature review, in which searches were conducted in the databases - Bireme, Science Direct, Pubmed and Lilacs. Articles published between 1999 and 2020, written in English, Portuguese or Spanish, were selected. The search was conducted using the descriptors Anatomy, Spinal Cord Irrigation and Spinal Cord Ischemia. The Adamkiewicz artery is the main artery responsible for the arterial supply to the lower part of the spinal cord. Thus, paraplegia is a complication of this type of surgical approach resulting from ischemic suffering of the spinal cord during the process. Therefore, further study on these factors should be encouraged, because the preservation of this vessel is relevant given the search for protection of the spinal cord and the maintenance of its functions in this type of procedure.


Introduction
One of the applications in the field of medical neurology are neurovascular syndromes, which can have different etiologies such as atherosclerotic, arteriovenous malformations, aortic aneurysm repair, The knowledge of the spinal cord irrigation is important for the therapeutic planning of aortic pathologies; however, its vasculature is complex due to the caliber of its arteries that pass through a three-dimensional network with great anatomical variability. Its clinical importance is evidenced during the preoperative procedure of thoracic and thoracoabdominal aortic surgeries, because its identification is essential for the prevention of spinal cord injuries. This study consists of a literature review, in which searches were conducted in the databases -Bireme, Science Direct, Pubmed and Lilacs. Articles published between 1999 and 2020, written in English, Portuguese or Spanish, were selected. The search was conducted using the descriptors Anatomy, Spinal Cord Irrigation and Spinal Cord Ischemia. The Adamkiewicz artery is the main artery responsible for the arterial supply to the lower part of the spinal cord. Thus, paraplegia is a complication of this type of surgical approach resulting from ischemic suffering of the spinal cord during the process. Therefore, further study on these factors should be encouraged, because the preservation of this vessel is relevant given the search for protection of the spinal cord and the maintenance of its functions in this type of procedure.  [3][4].
Knowledge about the irrigation of the spinal cord is important for therapeutic planning of aortic diseases, but its vasculature is complex and difficult to study due to the small caliber of its arteries, which travel through an intricate three-dimensional network that has great anatomical variability [5].
This irrigation was first studied by the Polish pathologist Albert W.
Adamkiewicz in 1882. For this reason, the arteria radicularis magna, the most calibrous of the radicular arteries and responsible for the irrigation of the lower two thirds of the spinal cord, bears his name as an eponym and is known as the Adamkiewicz Artery [6][7][8]. can have variations such as being located on the right side of the aorta or originating at a level outside of T8 to L1 [12][13].

Results (Review)
The bibliographical review study showed the anatomic relations and clinical correlations of the arteria radicularis magna.  Arteries that supply the spinal cord are divided into a central system, fed by the sulcal arteries, and another peripheral system, the pial plexus, which gives rise to perforating branches [1]. to prevent postoperative damages [14].  [19].
Consequently, paraplegia is a serious complication of this type of surgical approach, being in most cases an irreversible deficit, resulting from spinal cord ischemic suffering during the process [19]. The loss of sensation and the appearance of paresthesia are also possible complications of these conditions [25].
Thus, a further study of these factors, aiming to reduce neurological injuries through the development of better preoperative planning, should be encouraged, as the preservation of this vessel is of fundamental importance given to the search for protection for the spinal cord and maintenance of their functions in this type of procedure.

Table 1. Overview of the articles in the bibliographical review
Author, year Description References Bley et al., 2010 This study aim evaluating the use of time-resolved magnetic resonance (MR) angiography in the presurgical localization of the artery of Adamkiewicz prior to reimplantation of the feeding intercostal artery, lumbar artery, or both during aortic aneurysm repair.
[20] Boll et al., 2006 This article focused on describing the visualization of the spinal cord´s blood supply, especially Adamkiewicz artery and its variants. [18]

Charles et al., 2011
The aim of this study is to analyze the anatomique topography of the Adamkiewicz artery and the blood supply from patients that underwent spinal surgery. [17]

Koakutsu et al., 2016
The Adamkiewicz artery often bifurcates from a lumbar spine or an intercostal artery at the thoracic junction, where spinal injury most commonly occurs.
[31] Koshino et al., 1999 This article is focused on the significance of the Adamkiewicz artery to a well succeeded cirurgical pratica, helping to prevent postoperative paraplegia. [21]

Melissano et al., 2009
The study shows the feasibility of the Adamkiewicz´s artery noninvasive detection by multidetector computer analysis without the need of high cost hardware. The open-source OsiriX software was successfully used.

[19]
Piola et al., 2020 The study ratifies the efficiency of MCTA in the identification of the Adamkiewicz´s artery. It also confirmed that brazilians have the most common origin of the AKA, which is the left side and between T8-T12.   Moore et al., 2011 This chapter aims at confirming the relevance of the Adamkiewicz artery`s anatomy knowledge of its variants to the surgical practice and therefore avoiding lumbar surgical complications, such as parapleghy.
[16] Mônaco et al., 2007 This article is focused on evaluating the influence of IPC on the neuromuscular performance of trained individuals.

Discussion and Conclusion
Preoperative identification of Adamkiewicz's artery is necessary to Artery of Adamkiewicz and the clinical repercussion of its lesion in thoracoabdominal surgeries