Selective Versus Routine Spinal Drain Use for Fenestrated-Branched Endovascular Aortic Repair

Abstract

Spinal drains are used to ameliorate spinal cord ischemia (SCI), but their use may result in inherent morbidity and mortality. The role of spinal drains for fenestrated-branched endovascular aneurysm repair (F/B-EVAR) has not been demonstrated. The aim of this study was to assess the outcomes of spinal cord protection with and without the routine use of spinal drains during F/B-EVAR. A retrospective single-center study was performed using a prospectively maintained data set of all patients undergoing F/B-EVAR during a 4-year period. The primary end point of the study was the frequency of SCI. Prophylactic spinal drain was placed preoperatively in 33 patients (23%) with a median time for removal of 3 days (interquartile range [IQR], 2-3 days). Routine intraoperative neuromonitoring was used. Spinal cord protection relied primarily on maintaining a perioperative systolic blood pressure between 140 and 160 mm Hg or a mean arterial pressure >90 mm Hg, avoiding hypotension, preservation of as many collateral beds as possible, staged repairs, and early lower extremity reperfusion based on neuromonitoring. A total of 145 patients, 104 men (71%) and 41 women (28%) with a median age of 70 years (IQR, 53-62 years) underwent F/B-EVAR. Branched custom-made devices (11%), fenestrated custom-made devices (70%), and off-the-shelf t-Branch (Cook Medical, Bloomington, Ind) device (17%) were used with a median number of branches/fenestrations of four (IQR, three-four). The Society for Vascular Surgery classification of implantation zones was determined as follows: 9 (6%) zone 2, 17 (13%) zone 3, 16 (12%) zone 4, and 89 (68%) zone 5. SCI was present in eight patients (5.5%) and classified according to the Society for Vascular Surgery SCI grading system as follows: one grade 1, five grade 2, and two grade 3a. A high implantation zone (1-4) was not associated with SCI (P = .9). Similarly, prophylactic spinal drain did not demonstrate association with the occurrence of SCI (three [9%] vs five [4%], with and without spinal drain, respectively; P = .3). For patients with high implantation zones, staged repair was performed in 38 patients (26%) at a median time of 2 months (IQR, 2-6 months). Among these patients, the frequency of SCI was 13%. Staged repair was associated with an 80% reduction in the frequency of SCI (odds ratio, 0.19; 95% confidence interval, 0.04-.084; P = .02). F/B-EVAR can be performed with a minimal risk of SCI without the need for routine prophylactic spinal drains. High implantation zones did not predict SCI after F/B-EVAR; however, staged repair significantly decreased the risk of SCI after F/B-EVAR.