Reversal of Fortune: Induced Endoleak to Resolve Neurological Deficit After Endovascular Repair of Thoracoabdominal Aortic Aneurysm

Abstract

To describe a direct anatomical treatment approach using an induced type Ib endoleak to increase spinal cord perfusion and reverse paraplegia occurring after endovascular exclusion of a type 2 thoracoabdominal aortic aneurysm (TAAA). The approach is illustrated in an 82-year-old woman who underwent branched endovascular repair of an asymptomatic, 6.8-cm-diameter type 2 TAAA. In 4-hour procedure, 3 aortic components were implanted beginning 50 mm distal to the origin of the left subclavian artery and ending 33 mm proximal to the aortic bifurcation. Upon awakening, the patient had sluggish movement in her legs. She responded to vasoactive agents and cerebrospinal fluid (CSF) drainage, but 3 recurrent episodes of paraplegia within 24 hours and severe headache indicated that the limits of CSF drainage had been reached. The patient was taken back to the operating room, and a type Ib (distal) endoleak was created by placing a balloon-expandable stent between the distal end of the infrarenal stent-graft component and the aortic wall, partially re-establishing flow into the aneurysm. The patient had no further recurrence of lower extremity paraplegia or paraparesis. At 3.5 months postoperatively, a Palmaz stent was deployed inside the distal end of the infrarenal stent-graft component to crush and occlude the Express LD stent, re-establishing a complete seal to preclude flow into the aneurysm. The patient remains clinically stable without lower extremity neurological deficit 3 months after the last procedure and 7 months after endovascular TAAA repair. A direct anatomical approach to reverse spinal cord ischemia following endovascular TAA or TAAA repair is feasible by creating a type I or type III endoleak to afford partial, temporary reperfusion of the excluded aorta.