Complications Of Cerebrospinal Fluid Drainage Research Articles

Preoperative and postoperative complications of cerebrospinal fluid drainage in descending thoracic and thoraco-abdominal aortic aneurysm surgery: a single-center retrospective study.

Cerebrospinal-fluid drainage (CSFD) has been performed to prevent paraplegia in descending thoracic or thoraco-abdominal aortic aneurysm (DTA/TAAA) surgery; however, CSFD itself has a risk of severe complications. We retrospectively investigated the incidence rates of CSFD-related preoperative and postoperative complications. Patients who underwent DTA/TAAA surgery with a CSFD catheter that was inserted on the day before surgery were enrolled. The incidence rates of complications from spinal puncture until DTA/TAAA surgery were investigated as preoperative CSFD complications, and the incidence rates from DTA/TAAA surgery to postoperative day 7 were investigated as CSFD-related postoperative complications. Preoperative CSFD complications were analyzed in 123 cases. DTA/TAAA surgery was postponed due to bloody cerebrospinal fluid (2.5%) and due to meningitis (1.7%). The incidence rate of mild preoperative complications was 32.4%. Postoperative CSFD complications were analyzed in 108 cases. Intracranial hemorrhage occurred in 3.9% of cases in open surgery and other postoperative severe CSFD complications did not occur. The incidence rates of moderate/mild complications in open surgery were 2.6%/14.3% and those in TEVAR were 3.2%/19.4%. Bloody cerebrospinal fluid and meningitis, which are severe complications associated with spinal puncture, occurred within 1 day after spinal puncture. The incidence rates of moderate/mild complications were high in both the preoperative and postoperative periods. These results showed that CSFD catheter insertion and management should be performed carefully with consideration given to the risks and benefits of CSFD.

Commentary: The aggregation of marginal gains for spinal cord protection

Commentary: The aggregation of marginal gains for spinal cord protection

Risk factors for spinal cord injury and complications of cerebrospinal fluid drainage in patients undergoing fenestrated and branched endovascular aneurysm repair

ObjectiveSpinal cord injury (SCI) is one of the most devastating complications of thoracoabdominal aortic aneurysm (TAAA) repair. Cerebrospinal fluid drainage (CSFD) is routinely used to prevent and to treat SCI during open TAAA repair. However, the risks and benefits of CSFD during fenestrated-branched endovascular aneurysm repair (F/B-EVAR) are unclear. This study aimed to determine the risk of SCI after F/B-EVAR and to assess the risks and benefits of CSFD. MethodsWe analyzed 106 consecutive patients with TAAAs treated with F/B-EVAR from 2014 to 2019 in a prospective physician-sponsored investigational device exemption study (G130193). Data were collected prospectively and audited by an independent external monitor. All patients were treated with Cook manufactured patient-specific F/B-EVAR devices or the Cook t-Branch devices (Cook Medical, Bloomington, Ind). CSFD was used at the discretion of the principal investigator. Risk factors for SCI were identified, and CSFD complications were assessed. ResultsProphylactic CSFD was used in 78 patients (73.6%), and 28 patients (26.4%) underwent F/B-EVAR without CSFD. Four patients (3.8%) with prophylactic CSFD developed SCI, including two patients (1.9%) with permanent paraplegia (Tarlov grade 1-2) and two patients (1.9%) with paraparesis (Tarlov grade 3). Multivariate analysis revealed that greater extent of thoracic aortic coverage (odds ratio, 1.06; 95% confidence interval, 1.00-1.11; P = .02) and intraoperative blood loss (odds ratio, 1.00; 95% confidence interval, 1.00-1.002; P = .04) were the significant risk factors for SCI. Six patients (7.6% [6/78]) experienced major CSFD-related complications, including subarachnoid hemorrhage in 2.6% (2), spinal hematoma in 2.6% (2), cerebellar hemorrhage in 1.3% (1), and spinal drain fracture requiring surgical laminectomy in 1.3% (1). Minor CSFD-related complications occurred in 20 patients (25.6% [20/78]), including paresthesia during CSFD insertion (10), minimal bloody cerebrospinal fluid (7), drain malfunction (2), and reflex hypotension (1). Technical difficulties during CSFD catheter placement were noted in seven patients (9.0%). Excluding four patients with SCI, intensive care unit stay was 3.3 ± 4.0 days in the CSFD group vs 1.2 ± 0.9 days in the no-CSFD group (P = .007). Total hospital length of stay was 6.0 ± 4.9 days in the CSFD group vs 3.5 ± 1.9 days in the no-CSFD group (P = .01). ConclusionsThe incidence of SCI after F/B-EVAR with selective CSFD was low, and risk factors for SCI were greater with extent of thoracic aortic coverage and intraoperative blood loss. However, the incidence of major CSFD-related complications exceeded the incidence of SCI, and CSFD significantly increased both intensive care unit and total hospital length of stay. Therefore, routine prophylactic CSFD may not be justified, and a prospective randomized trial of CSFD in patients undergoing F/B-EVAR seems appropriate.

Risk Factors for Spinal Cord Ischemia and Complications of Cerebrospinal Fluid Drainage in Patients Undergoing Fenestrated and Branched Endovascular Aneurysm Repair

Spinal cord injury (SCI) is one of the most devastating complications of thoracoabdominal aortic aneurysm (TAAA) repair and cerebrospinal fluid drainage (CSFD) is routinely used to prevent and treat SCI during open TAAA repair. However, the risks and benefits of CSFD during fenestrated-branched endovascular aneurysm repair (F-BEVAR) are less clear. The purpose of this study was to determine the risk of SCI after F-BEVAR and to assess the risks and benefits of CSFD. A total of 106 consecutive patients with TAAAs treated with F-BEVAR in a prospective physician-sponsored investigational device exemption study (G130193) from 2014 to 2019 were analyzed. Data were collected prospectively and audited by an independent external monitor. All patients were treated with Cook manufactured patient-specific F-BEVAR devices or the Cook t-Branch device. CSFD was used selectively at the discretion of the principal investigator. Risk factors for SCI were identified using univariate and multivariate analysis. CSFD complications were also assessed. Prophylactic CSFD was used in 78 patients (73.6%) and 28 patients (26.4%) underwent F-BEVAR without CSFD. Four patients (3.8%) developed SCI, including 2 patients (1.9%) with permanent paraplegia (Tarlov grade 3) and 2 patients (1.9%) with paraparesis (weakness; Tarlov grade 1 or 2). Multivariate analysis revealed that greater extent of thoracic aortic coverage (P = .02; odds ratio, 1.06; 95% confidence interval, 1.00-1.11) and intraoperative blood loss (P = .04; odds ratio, 1.00; 95% confidence interval, 1.00-1.002) were the significant risk factors for SCI. Six patients (7.6%; 6/78) experienced major complications likely related to CSFD including subarachanoid hemorrhage (n = 2), spinal hematoma (n = 2), cerebellar hemorrhage (n = 1), and spinal drain fracture requiring surgical laminectomy (n = 1). Minor adverse events attributed to CSFD occurred in 20 patients (25.6%; 20/78), including paresthesias during CSFD insertion (n = 10); bloody CSF (n = 7); drain malfunction (n = 2); and reflex hypotension (n = 1). Technical difficulties during CSFD catheter placement were noted in seven patients (9.0%; 7/78). Excluding four patients with SCI, intensive care unit length of stay (LOS) was 3.3 ± 4.0 days in patients with CSFD compared to 1.2 ± 0.9 days in patients without CSFD (P = .007). Total hospital LOS was 6.0 ± 4.9 days in patients with CSFD compared to 3.5 ± 1.9 days in patients without CSFD (P = .01). The overall incidence of SCI after F-BEVAR with selective CSFD was low and risk factors for SCI were greater extent of thoracic aortic coverage and intraoperative blood loss. However, the incidence of major complications related to CSFD exceeded the incidence of SCI and CSFD significantly increased both intensive care unit and total hospital LOS. Therefore, routine prophylactic CSFD may not be justified and a prospective randomized trial of CSFD in patients undergoing F-BEVAR seems appropriate.

Complications of cerebrospinal fluid drainage after thoracic aortic surgery: A review of 504 patients over 5 years

Cerebrospinal fluid drainage, a well-established means of preventing paraplegia after thoracic aortic aneurysm surgery, can result in serious, sometimes lethal complications. In a large group of patients who underwent surgical thoracic aortic aneurysm repair with cerebrospinal fluid drainage, we examined the incidences of and potential risk factors for these outcomes. The records were reviewed of 504 patients who underwent surgical thoracic aortic aneurysm repair with cerebrospinal fluid drainage at the Texas Heart Institute at St. Luke's Episcopal Hospital between February 2005 and December 2009. All historical data, inpatient records, and billing data were searched for evidence of complications. Of the 504 patients, 14 (2.8%) had intracranial hemorrhage, of whom 10 (72%) had subdural hematoma. Postdural puncture headache developed in 49 patients (9.7%), of whom 17 (34.6%) required epidural blood patch placement for resolution. Multivariable analysis identified having a connective tissue disorder (odds ratio, 3.08; 95% confidence interval, 1.33-7.13) as an independent predictor of postdural puncture headache, but not age less than 40 years (odds ratio, 0.97; 95% confidence interval, 0.94-0.99). Cerebrospinal fluid drainage, as performed by our method, seems to be associated with a modest rate of intracranial bleeding in patients who undergo surgical thoracic aortic aneurysm repair. In contrast, postdural puncture headache is not uncommon, particularly in patients with connective tissue disease. Clinicians caring for these patients should consider the likelihood of postdural puncture headache, and any such patient with postoperative headache should be assessed for epidural blood patch placement.

Acute Subdural Hematoma Following Thoracoabdominal Aortic Repair in a Patient with Marfan Syndrome: A Rare Complication of Cerebrospinal Fluid Drainage

Cerebrospinal fluid (CSF) drainage is a routinely used adjunct in operation of thoracoabdominal aortic aneurysm (TAAA), which may reduce the incidence of perioperative paraplegia by improving spinal cord perfusion. Neurological complications of CSF drainage have been reported, possibly due to excessive CSF drainage, and acute subdural hematoma (SDH) in particular may lead to catastrophic complications. We present a rare case of acute SDH due to CSF drainage that was not excessive, after TAAA repair in a patient with Marfan syndrome, who recovered without invasive treatment.

Cerebral epidural hematoma following cerebrospinal fluid drainage during thoracoabdominal aortic repair

Cerebrospinal fluid (CSF) drainage is a common adjunct to thoracoabdominal aortic aneurysm (TAAA) repair. CSF drainage may improve perioperative spinal cord perfusion and thereby decrease the incidence of paraplegia or paraparesis. Complications of CSF drainage may arise. We present a case of cerebral epidural hematoma (EDH), possibly arising from excessive CSF drainage, during thoracoabdominal aortic repair.