Complications of Cerebral Spinal Fluid Drainage in Thoracoabdominal Aortic Procedures

Abstract

Spinal cord ischemia is a devastating complication of thoracoabdominal aortic procedures. Prophylactic cerebral spinal fluid (CSF) drainage has been shown to reduce the rates of postoperative neurologic deficit. Recent articles have cited a high rate of complications secondary to CSF drain placement, ranging from 7.6% to 9%, with the most worrisome being intracranial hemorrhage (ICH) and have concluded that the risks of drain use may outweigh the benefits. A single-center retrospective cohort study was conducted to investigate our rates of CSF drain-related complications. Patients were included if they underwent a thoracic or thoracoabdominal aortic procedure and had a CSF drain placed in the perioperative period. Patients with pre-existing neurologic deficits or who presented with aortic rupture were excluded. Major complications were defined as permanent paraplegia, ICH, epidural hematoma or abscess, meningitis, or catheter retention requiring a reoperation. Minor complications that were tracked included transient parasthesia, CSF leak, post-dural puncture headache, asymptomatic blood in the CSF, drain failure, and catheter retention not requiring a reoperation. There were 129 patients in the 15-year period who received a CSF drain for spinal cord protection (Table I). Of these, 122 patients (94.6%) had prophylactic CSF drains, 4 had drains placed postoperatively, and 3 patients had both preoperative and postoperative drains. The most common indication for surgery was thoracoabdominal aortic aneurysm (n = 57; 44.2%) (Table I), and the majority of cases were performed endovascularly (n = 72; 55.8%). There were five occurrences of permanent paraplegia for a rate of 3.9% (Table II). There were no cases of ICH nor other major complications due to spinal drain placement. The rate of minor complications was 26.4%, with the most common being transient parasthesia (n = 13; 10.1%) (Table II). No association was found between complication rates and either indication for procedure or type of operation. The rate of minor complications in this cohort is comparable to prior literature, but our major complication rates due to spinal drain insertion were found to be lower, with no incidence of ICH. The rate of permanent paraplegia in the cohort was 3.9%, which is similar to previous studies. The lack of spinal drain placement complications may be due to a well-defined spinal drain protocol at our center and the small group of dedicated anesthesiologists working with vascular surgery. Further research is required to determine which patients benefit most from prophylactic CSF drainage.Table IPatient characteristicsFull cohort (N = 129)Basic demographicsAge, mean (SD), years65.7 (12.3)Gender, No. (%) Male73 (56.6) Female56 (43.4)BMI, mean (SD)29.1 (6.4)Comorbidities, No. (%) Hypertension101 (78.3) Dyslipidemia60 (46.5) Coronary artery disease30 (23.3) COPD29 (22.4) Chronic kidney disease27 (20.9) Diabetes mellitus20 (15.5)Smoking history, No. (%) Current smoker44 (34.1) Prior smoker52 (40.3)Previous aortic operation, No. (%)64 (49.6)Aortic characteristics, No. (%) TAAA57 (44.2)Extent I25 (43.8)Extent II5 (8.8)Extent III16 (28.1)Extent IV11 (19.3)Mean size (SD), cm6.3 (1.2) Acute aortic syndrome, No. (%)40 (31.0)Acute dissection18 (45.0)PAU13 (32.5)IMH9 (22.5)Chronic dissection, No. (%)31 (24.0)Other indication, No. (%)1BMI, Body mass index; COPD, chronic obstructive pulmonary disease; IMH, intramural hematoma; PAU, penetrating aortic ulcer; SD, standard deviation; TAAA, thoracoabdominal aortic aneurysm. Open table in a new tab Table IIStudy outcomesFull cohort (n = 129)TAAA (n = 57)AAS (n = 40)Chronic dissection (n = 31)Major complications, No. (%)5 (3.9)0 (0)3 (7.5)2 (6.5) Permanent paraplegia5 (3.9)0 (0)3 (7.5)2 (6.5) Epidural hematoma0 (0)0 (0)0 (0)0 (0) Epidural abscess0 (0)0 (0)0 (0)0 (0) ICH0 (0)0 (0)0 (0)0 (0) Meningitis0 (0)0 (0)0 (0)0 (0) Catheter reoperation0 (0)0 (0)0 (0)0 (0)Minor complications, No. (%)34 (26.4)14 (24.6)12 (30.0)8 (25.8) Temporary parasthesia13 (10.1)7 (12.3)4 (10.0)2 (6.5) Asymptomatic bleed8 (6.2)1 (1.8)3 (7.5)4 (12.9) PDPH6 (4.7)3 (5.3)2 (5.0)1 (3.2) Drain failure5 (3.9)2 (3.5)2 (5.0)1 (3.2) CSF leak2 (1.6)1 (1.8)1 (2.5)0 (0) Catheter nonoperative0 (0)0 (0)0 (0)0 (0)AAS, Acute aortic syndrome; CSF, cerebrospinal fluid; ICH, intracranial hemorrhage; PDPH, post-dural puncture headache; TAAA, thoracoabdominal aortic aneurysm. Open table in a new tab