Results of Adjunctive Spinal Drainage and/or Left Subclavian Artery Bypass in Thoracic Endovascular Aortic Repair

Abstract

The adjunctive use of a preoperative cerebrospinal fluid (CSF) drain and/or left subclavian artery (LSA) bypass for thoracic endovascular aortic repair (TEVAR) to minimize neurologic complications remains controversial. A retrospective review was conducted of a prospective database of patients undergoing TEVAR from April 2005 through August 2012. CSF drainage was performed under local anesthesia in a staged fashion prior to TEVAR. When possible, LSA bypass was also performed prior to TEVAR. Adjunctive procedures were not performed for patients in emergent operations. Preoperative characteristics, operative variables, outcomes, neurologic complications, and survival status were recorded. Ninety patients underwent TEVAR at our institution during the study period with a mean follow-up of 23 months (IQR 7-50). Mean age was 67.3 years (SD 13.8) and 48 (53%) were male. One (1%) patient had a connective tissue disorder. Sixty-six (73%) patients presented with degenerative aneurysm, 13 (14%) with chronic type B dissection, 6 (7%) with pseudoaneurysm, and 5 (6%) with traumatic aortic pathology. Fourteen (16%) had acute ruptures. Sixty-seven (74%) patients underwent adjunctive procedures for TEVAR including a CSF drain (n = 48, 53%), LSA bypass (n = 7, 8%), or both (n = 12, 13%). CSF drain placement was uncomplicated in all instances. Cerebral ischemia was seen in 2 (2%), which recovered with further surgical therapy. Embolic stroke was appreciated in 1 (1%). Delayed spinal cord ischemia (SCI) occurred in 3 (3%) patients and was reversed with hypertensive therapy in 2 to ambulatory status at discharge. The 30-day permanent SCI and mortality were 0.9% and 3%, respectively. CSF drain placement was associated with improved 1-year survival (P= 0.03). Our use of adjunctive procedures for TEVAR demonstrated better SCI results compared with those of prior reports of selective CSF drainage when SCI arises. Our approach was associated with improved 1-year survival. Preoperative CSF drain placement allows for rapid, intensive therapy for SCI and should be considered when clinically feasible.