Pro: Fluoroscopic Guidance Should Be Routinely Used to Place Cerebrospinal Fluid Drains for Patients Undergoing Aortic Surgery

Abstract

PER THE SOCIETY for Vascular Surgery clinical guidelines, use of cerebrospinal fluid drains (CSFDs) should be considered for appropriately-selected patients undergoing extensive aortic repair. 1 Upchurch GR Escobar GA Azizzadeh A et al. Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms. J Vasc Surg. 2021; 73: 55S-83S Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar Use of CSFDs enhances spinal cord perfusion pressure, thus ameliorating the detrimental effects in vulnerable watershed regions caused by the surgical reduction in blood supply, and thereby preventing devastating spinal cord ischemia (SCI). It is important to note that patients who experience SCI after aortic repairs have significantly worse long-term survival than those without this complication. More importantly, patients who have a return of neurologic function after SCI can anticipate similar life expectancy compared to those without SCI. There is plenty of evidence suggesting that prophylactic use of CSFDs in selected high-risk patients undergoing aortic repairs reduces the incidence of postoperative SCI. 2 DeSart K Scali ST Feezor RJ et al. Fate of patients with spinal cord ischemia complicating thoracic endovascular aortic repair. J Vasc Surg. 2013; 58 (e2): 635-642 Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar A recent meta-analysis that included 3,561 patients from 34 studies, demonstrated a lower incidence of SCI when CSFDs were placed routinely, as opposed to use only in patients meeting specified criteria. 3 Zhang Z Zhou Y Lin S et al. Systematic review and meta-analysis of association of prophylactic cerebrospinal fluid drainage in preventing spinal cord ischemia after thoracic endovascular aortic repair. J Vasc Surg. 2022; 75 (e5): 1478-1489 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Hence, the use of CSFDs will be warranted in selected patients undergoing aortic repairs who are at a high risk of SCI. 4 Arora H Ullery BW Kumar PA et al. Pro: Patients at risk for spinal cord ischemia after thoracic endovascular aortic repairs should receive prophylactic cerebrospinal fluid drainage. J Cardiothorac Vasc Anesth. 2015; 29: 1376-1380 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Although CSFDs are an essential tool in the prevention of SCI caused by the surgery, CSFD placement is not without risk. Rong et al. published a meta-analysis that included 4,714 patients across 34 studies who underwent open and endovascular aortic repairs with CSFDs. 5 Rong LQ Kamel MK Rahouma M et al. Cerebrospinal-fluid drain-related complications in patients undergoing open and endovascular repairs of thoracic and thoraco-abdominal aortic pathologies: a systematic review and meta-analysis. Br J Anaesth. 2018; 120: 904-913 Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar This analysis focused on CSFD-related complications, with a 6.5% rate of pooled events, 2.5% of which represented severe complications, including epidural hematoma, intracranial hemorrhage, subarachnoid hemorrhage, meningitis, and/or catheter-related neurologic deficit. Risk factors for increased technical difficulty or even failed CSFD placement included atypical anatomy, such as from prior lumbar spine surgery, osteoarthritis or scoliosis, and poor surface landmarks, as can occur with a higher body mass index. 6 Awad H Ramadan ME Tili E et al. Fluoroscopic-guided lumbar spinal drain insertion for thoracic aortic aneurysm surgery. Anesth Analg. 2017; 125: 1219-1222 Crossref PubMed Scopus (4) Google Scholar