Treatment strategies of spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysm

Abstract

It is more than 20 years since the first endovascular repair of thoracoabdominal aortic aneurysm was performed. Significantly reducing risk of morbidity and mortality compared with open aortic repair, the advent of endovascular repair has revolutionized the treatment of complex aortic disease. It is now the first-line treatment for most thoracoabdominal aortic aneurysm patients. However, spinal cord ischemia (SCI) remains one of the most threatening complications after the procedure, and significantly reduces overall survival. The pathophysiology of spinal cord ischemia remains unclear but may well be multifactorial. Risk factors for SCI include excessive aortic coverage, detriment to the collateral network through occlusion of the left subclavian or internal iliac arteries, perioperative hypotension and chronic renal failure. SCI could be predicted, prevented and ameliorated through the application of motor evoked potential, permissive perioperative hypertension, cerebrospinal fluid drainage (CSFD), preoperative or concomitant left subclavian artery (LSA) revascularization and some drugs. However, there are certain complications and contraindications for CSFD and arterial revascularization. As a result, we must balance the pros and cons of these invasive measures. So we summarize our clinical experience and propose the employment of LSA revascularization and CSFD in certain kinds of high-risk patients respectively. With the development of technology and preventive measures, we believe that SCI could be minimized in the forseeable future.