Abstract
ObjectiveSpinal cord injury is a devastating complication after endovascular thoracic and thoracoabdominal aneurysm repair (EVAR). Motor evoked potentials (MEPs) can be monitored to detect spinal cord injury, but may also be affected by peripheral ischemia caused by femoral artery sheaths. We aimed to determine the incidence of peripheral ischemia during EVAR, and whether central and peripheral ischemia can be distinguished using compound muscle action potentials (CMAPs). MethodsWe retrospectively analyzed all EVAR procedures between March 1st 2015 and January 1st 2020 during which MEPs were monitored. Peripheral ischemia was defined as both a reduction in MEP amplitudes reversed by removing the femoral sheaths and no clinical signs of immediate post-procedural paraparesis. All other MEP decreases were defined as central ischemia. ResultsA significant MEP decrease occurred in 14/27 (52%) of all procedures. Simultaneous CMAP amplitude reduction was observed in 7/8 (88%) of procedures where peripheral ischemia occurred, and never in procedures with central ischemia. ConclusionsMEP reductions due to peripheral ischemia are common during EVAR. A MEP-reduction without a CMAP decrease indicates central ischemia. SignificanceCMAP measurements can help to distinguish central from peripheral ischemia, potentially reducing the chance of misinterpreting of MEP amplitude declines as centrally mediated, without affecting sensitivity.
Highlights
Spinal cord injury (SCI) is a devastating complication after thoracic or thoracoabdominal aneurysm (TAA) repair
All patients treated with endovascular thoracic and thoracoabdominal aneurysm repair (EVAR) for thoracic or thoracoabdominal aneurysm in the Leiden University Medical Centre (LUMC) between March 1st 2015 and December 31st 2019 who underwent Intra-operative neuromonitoring (IONM) with measurements of Motor evoked potentials (MEPs) during the procedure were included
There were no significant differences between the group of seven patients with compound muscle action potentials (CMAPs) measurements and eighteen patients without CMAP measurements
Summary
Spinal cord injury (SCI) is a devastating complication after thoracic or thoracoabdominal aneurysm (TAA) repair. Ron in the ventral horn of the spinal cord (or lower motor neuron), which in turn activates the muscles from which MEPs are recorded (Macdonald, 2006). This technique can be used to detect ischemia of the spinal cord before irreversible damage occurs and is commonly used during aortic repair surgery (Greiner et al, 2012; Hattori et al, 2019; Jacobs et al, 2006). During EVAR, MEPs can be used to guide treatment options available such as correcting hemoglobin levels >7 mmol/L, increasing blood pressure, drainage of cerebrospinal fluid or staging the procedure (Malloy et al, 2020; Schurink et al, 2013)
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