Case 3—2005 Risk and Benefits of Cerebrospinal Fluid Drainage During Thoracoabdominal Aortic Aneurysm Surgery

Abstract

Repair of descending thoracic and thoracoabdominal aortic aneurysms (TAAAs) is associated with a substantial risk of perioperative spinal cord ischemia that may or may not lead to permanent postoperative paralysis. Several techniques that aim to increase the ischemia tolerance time of the spinal cord during the period of aortic cross-clamping have been described in the literature. 1 Afifi S. Cerebrospinal fluid drainage protects the spinal cord during thoracoabdominal aortic reconstruction surgery. J Cardiothorac Vasc Anesth. 2002; 16: 643-649 Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Hypothermia, left heart bypass, various shunts, myriad drugs, and cerebrospinal fluid (CSF) drainage have all been used alone or in combination to potentially improve neurologic outcome after surgery. CSF drainage and distal aortic perfusion have been shown to lower the incidence of neurologic complications after repair of type I and type II TAAAs. 2 Coselli J. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair Results of a randomized clinical trial. J Vasc Surg. 2002; 35: 631-639 Abstract Full Text Full Text PDF PubMed Scopus (527) Google Scholar Distal aortic perfusion increases distal aortic pressure, and CSF drainage decreases CSF pressure. These techniques potentially lead to an augmentation of spinal cord perfusion pressure during the period of aortic cross-clamping. However, CSF drainage can be associated with potentially serious complications, including fracture of the catheter during removal, catheter-associated meningitis, and/or temporary abducens nerve palsy, among others. 3 Cheung A.T. Pochettino A. Guvakov D.V. et al. Safety of lumbar drains in thoracic aortic operations performed with extracorporeal circulation. Ann Thorac Surg. 2003; 76: 1190-1197 Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar Also, epidural hematoma at the catheter insertion site can complicate the clinical assessment of postoperative spinal ischemic injury. 4 Weaver K. Weisman D.B. Farber M. et al. Complications of lumbar drainage after thoracoabdominal aortic aneurysm repair. J Vasc Surg. 2001; 34: 623-627 Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar Intracranial subdural hematomas, with excessive CSF drainage, have also been reported and are associated with significant morbidity and mortality. 5 Dardik A. Perler B.A. Roseborough G.S. et al. Subdural hematoma after thoracoabdominal aortic aneurysm repair An underreported complication of spinal fluid drainage?. J Vasc Surg. 2002; 36: 47-50 Abstract Full Text PDF PubMed Scopus (122) Google Scholar Subsequently, some authors have challenged the efficacy of CSF drainage and question the acceptable risk:benefit ratio of the technique. 6 Wallace L. Cerebrospinal fluid drainage does not protect the spinal cord during thoracoabdominal aortic reconstruction surgery. J Cardiothorac Vasc Anesth. 2002; 16: 650-652 Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar , 7 Ling E. Arellano R. Systematic overview of the evidence supporting the use of cerebrospinal fluid drainage in thoracoabdominal aneurysm surgery for prevention of paraplegia. Anesthesiology. 2000; 93: 1115-1122 Crossref PubMed Scopus (48) Google Scholar