Incidence Of Spinal Cord Ischemia Research Articles

A dedicated preventive protocol sustainably avoids spinal cord ischemia after endovascular aortic repair.

To analyze the incidence of spinal cord ischemia (SCI) after complex endovascular aortic repair (EVAR) after the introduction of a dedicated SCI preventive protocol. Retrospective review of all consecutive patients undergoing complex EVAR with branched (BEVAR) and/or fenestrated grafts (FEVAR) during a 6-year period starting January 1st, 2015. The preventive protocol consisted of staging extensive aortic repairs, maintaining a mean arterial pressure (MAP) >80 mm Hg, Hb level >110 g/L, early lower limb reperfusion and neurological control per hour during the post-operative stay in the intensive care unit (36-72 h). Prophylactic cerebrospinal fluid drainage (CSFD) was used selectively. Pre- intra-, and 30-day postoperative clinical data and imaging were collected. Primary end point was the development of perioperative SCI. Secondary outcome included technical and clinical success. Complex EVAR was performed in 205 patients (167 males, 72 (67-75) years, 182 (88.8%) elective) with juxtarenal aneurysms (JRA, 155 patients) or thoracoabdominal aortic aneurysms (TAAA). SCI occurred after JRA repair in two patients (1.3%, both ruptures) and after TAAA repair in three (6.0%, one rupture) (p = 0.06), all within 9 h postoperatively. There was symptom regression in three cases (one partial, two complete), resulting in a persistent SCI level of 0.6% and 4.0% for JRA and TAAA, respectively. Only one patient with persistent SCI could be discharged from the hospital alive. Patients developing SCI were more commonly female (n = 3, p = .016), presented with rupture (n = 3, p < .001), had preoperative renal insufficiency (n = 5, p < .001) and had lower minimal MAP (p = .015). No regression analysis was done due to the limited number of SCI events in relation to the study population size. Primary technical success was achieved in 162 patients (83.5%) and clinical success in 153 patients (75.4%), without any differences between the groups. The incidence of persistent SCI after complex EVAR is low with the use of a dedicated SCI preventive protocol allowing the early diagnosis. Females, patients with ruptured aneurysms and preoperative renal insufficiency are at higher risk. Further studies are needed to customize the protocols particularly in those high-risk patients.

Five-year outcomes of fenestrated and branched endovascular repair of complex aortic aneurysms based on aneurysm extent

ObjectiveThe aim of this study was to evaluate the 5-year outcomes of fenestrated/branched endovascular aortic repair (F/BEVAR) for the treatment of complex aortic aneurysms stratified by the aneurysm extent. MethodsPatients with the diagnosis of complex aortic aneurysm, who underwent F/BEVAR at a single center were included in this study and retrospectively analyzed. The cohort was divided according to the aneurysm extent, comparing group 1 (types I-III thoracoabdominal aneurysms [TAAAs]), group 2 (type IV TAAAs), and group 3 (juxtarenal [JRAAs], pararenal [PRAAs], or paravisceral [PVAAs] aortic aneurysms). The primary endpoints were 30-day and 5-year survival. The secondary endpoints were technical success, occurrence of spinal cord ischemia, primary patency of the visceral arteries, freedom from target vessel instability, and secondary interventions. ResultsOf 436 patients who underwent F/BEVAR between July 2012 and May 2023, 131 presented with types I to III TAAAs, 69 with type IV TAAAs, and 236 with JRAAs, PRAAs, or PVAAs. All cases were treated under a physician-sponsored investigational device exemption protocol with a patient-specific company-manufactured or off-the-shelf device. Group 1 had significantly younger patients than group 2 or 3 respectively (69.6 ± 8.7 vs 72.4 ± 7.1 vs 73.2 ± 7.3 years; P < .001) and had a higher percentage of females (50.4% vs 21.7% vs 17.8%; P < .001). Prior history of aortic dissection was significantly more common among patients in group 1 (26% vs 1.4% vs 0.9%; P < .001), and mean aneurysm diameter was larger in group 1 (64.5 vs 60.7 vs 63.2 mm; P = .033). Comorbidities were similar between groups, except for coronary artery disease (P < .001) and tobacco use (P = .003), which were less prevalent in group 1. Technical success was similar in the three groups (98.5% vs 98.6% vs 98.7%; P > .99). The 30-day mortality was 4.5%, 1.4%, and 0.4%, in groups 1, 2, and 3, respectively, and was significantly higher in group 1 when compared with group 3 (P = .01). The incidence of spinal cord ischemia was significantly higher in group 1 compared with group 3 (5.3% vs 4.3% vs 0.4%; P = .004). The 5-year survival was significantly higher in group 3 when compared with group 1 (P = .01). Freedom from secondary intervention was significantly higher in group 3 when compared with group 1 (P = .003). At 5 years, there was no significant difference in freedom from target vessel instability between groups or primary patency in the 1652 target vessels examined. ConclusionsLarger aneurysm extent was associated with lower 5-year survival, higher 30-day mortality, incidence of secondary interventions, and spinal cord ischemia. The prevalence of secondary interventions in all groups makes meticulous follow-up paramount in patients with complex aortic aneurysm treated with F/BEVAR.

A multimodal approach to prevent spinal cord ischemia in patients undergoing thoracoabdominal aortic aneurism repair - from pathophysiology to anesthesiological management

Thoraco-abdominal aortic aneurysm (TAAA) open repair is a high-risk surgery further burdened with both mortality and morbidity. Despite numerous experimental endeavors and technical advancements, spinal cord ischemia (SCI) is still the most formidable morbidity to be resolved, irrespective of the open or endovascular surgical approach. It presents a spectrum of severity, ranging from temporary or permanent paraparesis to paraplegia with or without autonomic dysfunction. The timing of SCI occurrence is a crucial factor, with approximately 15% of cases manifesting intraoperatively, 50% within 48 h post-surgery, and the remaining 35% classified as late SCI, occurring more than 48 h after the procedure. The mechanism responsible for SCI is complex and multifactorial; hence, understanding its underlying pathophysiology is essential for its effective management. Over the last decade, strategies to enhance spinal cord perfusion and minimize the risk of SCI during TAAA open repair have been implemented. These include optimization of hemodynamics, hemoglobin levels, cardiac function, and cerebrospinal fluid pressure, ensuring collateral vascular network stability and distal aortic perfusion and intrathecal administration of drugs. A multimodal approach involving anesthesiologists and surgeons can lead to improved neurological recovery and a reduced incidence and severity of SCI.

Use of Spinal Anesthesia during Thoracic Endovascular Aortic Repair

The purpose of this study was to assess outcomes after spinal anesthesia (SA) versus general anesthesia (GA) in patients undergoing thoracic endograft placement and to evaluate the adjunctive use of cerebrospinal fluid drainage (CSFD) placement. A single-center retrospective review of patients that underwent thoracic endograft placement from 2001 to 2019 was performed. Patients were stratified based on the type of anesthesia they received: GA, SA or epidural, GA with CSFD, and SA with CSFD. Primary outcomes included 30-day mortality and length of stay (LOS). Baseline characteristics were analyzed with Student's t-test and Pearson's chi-squared test. Multivariate logistic regression analysis was performed to identify risk factors for 30-day mortality and longer LOS. A total of 333 patients underwent thoracic endograft placement; 104 patients received SA, 180 patients received GA, 30 patients received GA and CSFD, and 19 patients received SA and CSFD. Of the total patients, 16.2% underwent thoracic endograft placement for type B aortic dissection, 3.3% for type A aortic dissection, and 12.3% for penetrating ulcer. The mean age of the study population was 68.7years old. Patients undergoing SA were older with a mean age of 73.4years versus 64.7years for patients undergoing GA (P<0.001). Spinal anesthesia (SA) was preferred in patients at high risk for GA (>75years old: 52.9% vs. 33.3%, P<0.001; renal comorbidities: 20.6% vs. 10.6%, P=0.03, and current smokers: 26.7% vs. 9.6%, P<0.001). Length of stay (LOS) was decreased in the SA group (4.29days vs. 9.70days, P<0.001). There was a lower incidence of spinal cord ischemia in the SA group (1.0% vs. 2.2%, P=0.44), as well as significantly decreased 30-day mortality (0% vs. 5.6%, P=0.01), reintervention (19.2% vs. 26.8%, P=0.02), and return to the operating room (6.8% vs. 12.7%, P=0.02). Of the 19 patients that had SA+CSFD, there were no signs and symptoms of spinal cord ischemia and decreased incidence of perioperative complications (0% vs. 33.3%, P=0.01). There was no difference in the risk for intraoperative complications, neurologic complications, or 30-day mortality between GA+CSFD patients versus SA+CSFD patients. Age >75 (P=0.002), intraoperative complications (P<0.001), and perioperative complications (P=0.02) were associated with increased mortality after thoracic endograft placement per multivariate logistic regression analysis. Spinal anesthesia (SA) in select high-risk patients was associated with reduced 30-day mortality, neurologic complications, and LOS compared to GA. The concurrent use of spinal drainage and SA had satisfactory results compared to spinal drainage and GA.

Spinal cord ischemia during endovascular repair of the thoracic aorta

Background and objectives: This work aims to analyze the incidence of medullary ischemia (MI) and identify the factors contributing to its development during endovascular repair of the descending thoracic aorta in patients requiring complete coverage. Material and methods: A retrospective study. Between April 1999 and December 2014, 176 thoracic aortic endovascular repairs were performed. Sixty-two patients (48 male and 14 female) were treated with thoracic stents from the aortic arch to the celiac trunk due to thoracoabdominal aneurysms (n = 13), aortic dissections (n = 42), intramural hematomas (n = 4), post-traumatic pseudoaneurysms (n = 2) and aortic ulcers (n = 1). All procedures were performed under general anesthesia with strict invasive blood pressure control. Cerebrospinal fluid drainage was performed in 5 patients. Results: The success rate of stent placement was 96.7%, and mortality was 4.84%. The incidence of spinal cord ischemia was 4.84% (3 patients, one in the immediate postoperative period and two during follow-up). Permanent paraplegia was observed in 1.6%. Overall survival (Kaplan-Meier) at 1, 3, and 6 years was 76%, 69.1%, and 64.32%, respectively. Conclusions: thoracic aortic coverage is an effective procedure with a high probability of success. Our study identified a previous procedure on the abdominal aorta and a thromboembolic aortic event as risk factors for developing medullary ischemia in patients requiring complete coverage of the thoracic aorta. In this study, full coverage of the thoracic aorta and left subclavian artery alone are not predictors of paraplegia.

Treatment Planning During Shared Decision-making With Fit Patients With Complex Abdominal Aortic Aneurysm Should Take Into Consideration the Incidence of Spinal Cord Ischemia

Treatment Planning During Shared Decision-making With Fit Patients With Complex Abdominal Aortic Aneurysm Should Take Into Consideration the Incidence of Spinal Cord Ischemia

Pro: Fluoroscopic Guidance Should Be Routinely Used to Place Cerebrospinal Fluid Drains for Patients Undergoing Aortic Surgery

PER THE SOCIETY for Vascular Surgery clinical guidelines, use of cerebrospinal fluid drains (CSFDs) should be considered for appropriately-selected patients undergoing extensive aortic repair. 1 Upchurch GR Escobar GA Azizzadeh A et al. Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms. J Vasc Surg. 2021; 73: 55S-83S Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar Use of CSFDs enhances spinal cord perfusion pressure, thus ameliorating the detrimental effects in vulnerable watershed regions caused by the surgical reduction in blood supply, and thereby preventing devastating spinal cord ischemia (SCI). It is important to note that patients who experience SCI after aortic repairs have significantly worse long-term survival than those without this complication. More importantly, patients who have a return of neurologic function after SCI can anticipate similar life expectancy compared to those without SCI. There is plenty of evidence suggesting that prophylactic use of CSFDs in selected high-risk patients undergoing aortic repairs reduces the incidence of postoperative SCI. 2 DeSart K Scali ST Feezor RJ et al. Fate of patients with spinal cord ischemia complicating thoracic endovascular aortic repair. J Vasc Surg. 2013; 58 (e2): 635-642 Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar A recent meta-analysis that included 3,561 patients from 34 studies, demonstrated a lower incidence of SCI when CSFDs were placed routinely, as opposed to use only in patients meeting specified criteria. 3 Zhang Z Zhou Y Lin S et al. Systematic review and meta-analysis of association of prophylactic cerebrospinal fluid drainage in preventing spinal cord ischemia after thoracic endovascular aortic repair. J Vasc Surg. 2022; 75 (e5): 1478-1489 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Hence, the use of CSFDs will be warranted in selected patients undergoing aortic repairs who are at a high risk of SCI. 4 Arora H Ullery BW Kumar PA et al. Pro: Patients at risk for spinal cord ischemia after thoracic endovascular aortic repairs should receive prophylactic cerebrospinal fluid drainage. J Cardiothorac Vasc Anesth. 2015; 29: 1376-1380 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Although CSFDs are an essential tool in the prevention of SCI caused by the surgery, CSFD placement is not without risk. Rong et al. published a meta-analysis that included 4,714 patients across 34 studies who underwent open and endovascular aortic repairs with CSFDs. 5 Rong LQ Kamel MK Rahouma M et al. Cerebrospinal-fluid drain-related complications in patients undergoing open and endovascular repairs of thoracic and thoraco-abdominal aortic pathologies: a systematic review and meta-analysis. Br J Anaesth. 2018; 120: 904-913 Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar This analysis focused on CSFD-related complications, with a 6.5% rate of pooled events, 2.5% of which represented severe complications, including epidural hematoma, intracranial hemorrhage, subarachnoid hemorrhage, meningitis, and/or catheter-related neurologic deficit. Risk factors for increased technical difficulty or even failed CSFD placement included atypical anatomy, such as from prior lumbar spine surgery, osteoarthritis or scoliosis, and poor surface landmarks, as can occur with a higher body mass index. 6 Awad H Ramadan ME Tili E et al. Fluoroscopic-guided lumbar spinal drain insertion for thoracic aortic aneurysm surgery. Anesth Analg. 2017; 125: 1219-1222 Crossref PubMed Scopus (4) Google Scholar

Aggressive use of prophylactic cerebrospinal fluid drainage to prevent spinal cord ischemia during thoracic endovascular aortic repair is not supportive.

We investigated whether prophylactic preoperative cerebrospinal fluid drainage (CSFD) was effective in preventing spinal cord ischemia (SCI) during thoracic endovascular aortic repair of degenerative descending thoracic aortic aneurysms, excluding dissecting aneurysms. We retrospectively reviewed the medical records of patients who underwent thoracic endovascular aortic repair involving proximal landing zones 3 and 4 between 2009 and 2020. Eighty-nine patients with preemptive CSFD [68 men; median (range) age, 76.0 (71.0-81.0) years] and 115 patients without CSFD [89 men; median (range) age, 77.0 (74.0-81.5) years] were included in this study. Among them, 59 from each group were matched based on propensity scores to regulate for differences in backgrounds. The incidence rate of SCI was similar: 8/89 (9.0%) in the CSFD group and 6/115 (5.2%) in the non-CSFD group (P = 0.403). Shaggy aorta (odds ratio, 5.13; P = 0.004) and iliac artery access (odds ratio, 5.04; P = 0.005) were identified as positive predictors of SCI. Other clinically important confounders included Adamkiewicz artery coverage (odds ratio, 2.53; P = 0.108) and extensive stent graft coverage (&gt;8 vertebrae) (odds ratio, 1.41; P = 0.541) were not statistically significant. Propensity score matching yielded similar incidence of SCI: 4/59 (6.8%) in the CSFD group and 3/59 (5.1%) in the non-CSFD group (P = 0.697). Aggressive use of prophylactic CSFD was not supportive in patients without complex risks of SCI.

Transsternal and Transpericardial Approach to Descending Thoracic Aorta via Median Sternotomy-An Option for Extensive Aortic Surgery.

We describe a technique for approaching the distal descending thoracic aorta via median sternotomy and posterior pericardiotomy, which enabled us to perform the extensive aortic repair. While this approach shared the lesser invasiveness of the frozen elephant trunk procedure with less confinement by anatomic features, the advantage was counterbalanced by the high incidence of spinal cord ischemia. This approach can be an option in highly selected patients who require extensive aortic repair but have factors prohibiting other conventional approaches.

Left Subclavian Artery Revascularization May Not Influence the Incidence of Spinal Cord Ischemia in Elective Thoracic Endovascular Aortic Aneurysm Repair

To analyze whether left subclavian artery (LSA) revascularization in patients undergoing elective thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm (TAA) is associated with decreased spinal cord ischemia (SCI). The national Vascular Quality Initiative TEVAR module was queried for all procedures performed between 2014 and 2021. Patients presenting with acute aortic dissections or aortic ruptures were excluded from the analysis. Only patients undergoing elective TEVAR for TAA and had their LSA covered during the procedure were included. Patients were divided into two groups according to their LSA revascularization (before or during TEVAR). A descriptive analysis was done to evaluate the change in frequency of LSA revascularization over the study interval. Univariate analysis was done to compare preoperative and intraoperative variables, and primary outcomes of SCI and cerebral stroke between the two groups. Among patients who had elective TEVAR for TAA, 669 patients had the LSA covered. The LSA was revascularized in 67% of these patients (n = 446). The incidence of LSA revascularization increased over the study period (Fig 1) (P < .001). Average age was 69 years, and 65% (n = 433) were male. Demographics and past medical history are summarized in Table I. Spinal cord ischemia developed in 20 patients (3%), and cerebral stroke in 29 patients (4%). No significant difference was seen when comparing postoperative SCI, cerebral stroke, 30-day or 1-year mortality between patients who had LSA revascularization and those who did not (Table II). Long-term survival did not differ between the two groups on Kaplan-Meier analysis (Fig 2). In patients with TAA undergoing elective TEVAR with LSA coverage, an increasing percentage of patients underwent preoperative or concomitant LSA revascularization over the course of the study—81% in 2021. In this study, LSA revascularization, however, did not aff5ct the incidence of postoperative SCI, cerebral stroke, or short or long-term mortality. In conclusion, LSA revascularization did not protect against SCI and may carry its own morbidity in elective TAAs requiring LSA coverage. More detailed studies are needed to help define the role of LSA revascularization in this setting.TableComparison of baseline characteristics, comorbidities, intraoperative variables, and postoperative outcomes between patients who had left subclavian artery (LSA) revascularization and those who did notOverall (n = 669)LSA nonrevascularized (n = 223)LSA revascularized (n = 446)P valueBaseline characteristics Age, years, mean (SD)69 (11)70 (11)69 (11).48 Gender, No. (%).69Male433 (65)142 (64)291 (65)Female236 (35)81 (36)155 (35) Race, No. (%).41African American115 (17)39 (18)76 (17)White474 (71)164 (74)310 (70)Others80 (12)20 (9)60 (14) BMI, mean (SD)28.4 (6.7)28.1 (6.8)28.5 (6.7).45 Smoking status, No. (%).94Never171 (26)59 (27)112 (25)Prior343 (51)113 (51)230 (52)Current154 (23)51 (23)103 (23)Medical History CVD, No. (%)81 (12)31 (14)50 (11).31 CAD, No. (%)111 (17)43 (19)68 (15).19 Congestive heart failure, No. (%)93 (14)33 (15)60 (13).63 COPD, No. (%)193 (29)73 (33)120 (27).12 Hypertension, No. (%)608 (91)199 (89)409 (92).22 Diabetes, No. (%)97 (14)38 (17)59 (13).19 Prior aortic surgery, No. (%)279 (42)103 (46)176 (40).10 Prior aneurysm repair, No. (%)226 (34)82 (36)145 (32).50Intraoperative variables Contrast volume, mL, mean (SD)118 (73)115 (72)120 (73).41 EBL, mL, mean (SD)243 (448)228 (399)251.2 (470).01 Fluoro time, minutes, mean (SD)23.2 (20.3)22.6 (23.0)23.5 (18.9).061 Procedure time, minutes, mean (SD)176 (100)158 (111)186 (94)<.01 Spinal drain placement, No. (%).38None343 (51.4%)111 (49.8%)232 (52.3%)Prophylactic311 (46.6%)106 (47.5%)205 (46.2%)Postoperative11 (1.6%)6 (2.7%)5 (1.1%)Outcomes Spinal cord ischemia, No. (%)20 (3)8 (4)12 (3).52 Cerebral stroke, No. (%)29 (4)9 (4)20 (5).79 30-Day mortality, No. (%)26 (4)5 (2)21 (5).12 1-Year mortality, No. (%)65 (10)21 (9)44 (10).85COPD, Chronic obstructive pulmonary disease; CVD, cerebrovascular disease; EBL, estimated blood loss; PCI, percutaneous coronary interventions; SD, standard deviation. Open table in a new tab Fig 2Kaplan-Meier curves comparing long-term survival between patients who underwent left subclavian artery (LSA) revascularization and those who did not.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Association between aortic coverage and spinal cord ischemia after endovascular repair of type B aortic dissection.

To examine the association between aortic coverage and occurrence of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection. Thirty-eight consecutive patients (mean age 52years; 35 men) who underwent TEVAR for type B aortic dissection at our centre were included. Patients were stratified into two groups based on stent graft length (SGL): group I (≤ 200mm; n = 19) and group II (> 200mm; n = 19). All the procedures were performed under strict blood pressure monitoring. Preoperative cerebrospinal fluid (CSF) drain was instituted in two patients. Mean SGLs were 200mm in group I and 277 ± 27mm in group II. The number of segmental arteries covered was significantly different between the two groups (p < 0.001). There was no significant difference in vertebral artery dominance between groups I and II (p = 0.99). One patient in group II, who also had bilateral internal iliac artery occlusion, developed postprocedural neurological deficit referrable to SCI, which resolved completely after institution of CSF drainage. However, the incidence of SCI was not significantly different between group I and group II (p = 0.5). Based on our experience, we recommend longer aortic coverage (beyond 200mm) in type B aortic dissection (TBAD) for better aortic remodelling, provided that the mean arterial pressure of > 90mm Hg is maintained perioperatively to avoid SCI.

Preventing spinal cord ischemia from thoracoabdominal aortic repair remains elusive

Spinal cord ischemia (SCI) remains the Achilles heel of thoracic and thoracoabdominal aortic repair. Despite improvements in the surgical technique and methods to reduce the risk of SCI, this devastating complication continues to be a formidable challenge. While endovascular repair has decreased the relative incidence of SCI, it has also enabled repair of older, sicker, and more frail patients who may be at higher risk of this complication. Although we have learned a lot about which patients are high-risk for SCI, much remains uncertain.

Role of historical and procedural staging during elective fenestrated and branched endovascular treatment of extensive thoracoabdominal aortic aneurysms

ObjectiveProcedural staging is often performed to reduce the incidence of spinal cord ischemia (SCI) during endovascular treatment of extensive thoracoabdominal aortic aneurysms (TAAAs). However, its role in the case of previous thoracic or infrarenal aortic repair (historical staging) has been controversial. In the present study, we evaluated the SCI rates when procedural staging was routinely used and studied its potential benefits when previous aortic repairs had already been performed. MethodsThe data from patients treated electively with fenestrated/branched endovascular aortic repair for extent I, II, III, and V TAAAs were retrieved from a multicenter registry (four high-volume national teaching hospitals) and analyzed. The primary endpoint was the rate of SCI and its association with preoperative and postoperative variables, including historical staging, procedural staging, and an impaired collateral network (subclavian or hypogastric stenosis >75% per occlusion). Variables were defined in accordance with the Society for Vascular Surgery reporting standards. A logistic regression model with stepwise selection was used to identify the predictors of SCI. ResultsA total of 240 patients (76% male; median age, 73 years) were analyzed. Of the 240 patients, 43 (18%) had presented with an impaired collateral network, 136 (57%) had had historical staging, and 157 (65%) had received procedural staging. Preoperative spinal fluid cerebrospinal drainage was performed in 130 patients (54%). Permanent grade 3 SCI was observed in 13 patients (5%) and was negatively affected by both an impaired collateral network (odds ratio [OR], 17.3; 95% confidence interval [CI], 1.7-176; P = .016) and the presence of bilateral iliac occlusive disease (OR, 10.1; 95% CI, 1.1-98.3; P = .046). Both historical (OR, 0.02; 95% CI, 0.001-0.46; P = .014) and procedural (OR, 0.01; 95% CI, 0.02-0.7; P = .019) staging mitigated the permanent SCI rates. The need for postoperative transfusions (OR, 1.4; 95% CI, 1.1-1.8; P = .014) and the occurrence of postoperative renal complications (OR, 6.5; 95% CI, 1.2-35.0; P < .001) were associated with the development of SCI. Among the patients with historical staging, no further benefit from procedural staging was observed (SCI with procedural staging, 1%; vs no staging, 2%; P = NS). ConclusionsFor patients with extensive TAAAs treated with fenestrated/branched endovascular aortic repair, both historical and planned procedural staging were associated with reduced permanent SCI rates. However, no additional benefit was observed when procedural staging was performed in patients with historical staging and an intact collateral network. The protective role of preoperative cerebrospinal fluid drainage placement requires further investigation.

Multi-Staged Endovascular Repair of Thoracoabdominal Aneurysms by Fenestrated and Branched Endografts

To report outcomes of a multi-staged approach for endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) by fenestrated/branched endografting (F/B-EVAR). Between 2010 and 2020 (June), patients undergoing F/B-EVAR for TAAAs were collected. Data of cases managed by a multi-staged approach, to reduce the incidence of spinal cord ischemia (SCI), were retrospectively analyzed and reported in a cohort study. Thirty-day mortality and SCI were assessed as study's outcomes. One hundred and thirty-seven patients underwent TAAAs repair by F/B-EVAR. A multi-staged approach was applied in 73(53%) cases, more frequently for Crawford's extent I-III (60/78) compared with IV (13/59) (P < 0.0001). A complete TAAAs exclusion was achieved in 2, 3 or 4 steps in 64(88%), 8(11%) and 1(1%) cases, respectively, within the same hospitalization in 68(93%) cases. The mean time between first and last step was 16 ± 8days, with a mean hospital stay of 21 ± 12days. In 3(4%) cases the complete TAAA repair was not achieved due to inter-steps mortality (2) or permanent paraplegia (1). There were no cases of aortic rupture or target visceral vessels occlusions between the different steps. Seven (10%) patients suffered postoperative SCI with 2(4%) cases of permanent paraplegia. In 5/7 cases SCI occurred after the first stage; in 3/5 cases TAAAs exclusion was successfully completed with total SCI recovery. The 30-day mortality was 4% (3/73). A multi-staged endovascular repair with F/B-EVAR can be safely performed for TAAAs repair. The majority of cases can be treated within a single, long hospitalization. The cost/effectiveness of the prolonged in-hospital time should be evaluated.

The short-term safety and effectiveness of a new distal perforating stent graft in Type B aortic dissection: a retrospective study

BackgroundSpinal artery ischemia (SCI) events can result from over coverage of the descending thoracic aorta with a coated stent during Thoracic Endovascular Aortic Repair (TEVAR). The aim of this study was to determine whether a new distal perforating stent could reduce the incidence of spinal cord ischemia while remodeling the true lumen.MethodsTBAD patients treated with Talos stent in the vascular surgery Department of Yan 'an Hospital affiliated to Kunming Medical University between December 2017 and October 2019 were retrospectively analyzed to investigate the short-term safety and effectiveness of Talos stent.ResultsA total of the 20 patients, including 14 males and 6 females, with an average age of 52.65 ± 8.98 years (range 37–68 years), were included in the analysis. Stent-grafts were successfully implanted in all patients under local anesthesia, with a technical success rate of 100%. The average operation time was 50.75 ± 13.01 min. A total of 2 cases (10%) presented chest pain associated with intercostal artery ischemia that was relieved on the 3rd and 5th postoperative day, respectively. Postoperative mean follow-up was 16.15 ± 3.99 months. No paraplegia or other complications occurred. And stenting did not induce new tears. No migration, deformation, or fracture of the stents occurred. There was a significant difference in the remolding of the true lumen preoperatively and at 12 months postoperatively (P < 0.05).ConclusionsTalos stent has achieved satisfactory clinical treatment results in short term.

Postoperative complications of endovascular blunt thoracic aortic injury repair

BackgroundThoracic endovascular aortic repair (TEVAR) has become the standard of care for thoracic aortic aneurysms and increasingly for blunt thoracic aortic injury (BTAI). Postoperative complications, including spinal cord ischemia and...

Incidence of spinal cord ischemia according to the patency of reimplanted segmental arteries during thoracoabdominal aortic replacement.

This study aimed to investigate the impact of segmental artery reimplantation and its patency on spinal cord ischemia (SCI) in thoracoabdominal aorta replacement. For 193 patients who underwent early postoperative computed tomographic (CT) angiography after thoracoabdominal aorta replacement, the technique of segmental artery reimplantation, their patency, and postoperative SCI were retrospectively investigated. The early patency rate of reimplanted segmental artery was 83.3% (210 of 252), as 13 were taken down intraoperatively and 42 were not visualized in the postoperative CT angiography. The patency rate differed according to the reimplantation technique: 93.6% (131/140) for en bloc patch, 95.6% (43/45) for small individual patch, and 53.7% (36/67) for graft interposition. SCI occurred in 13 (6.3%) patients, 4 of whom (2.0%) remained paraplegic permanently. SCI was significantly more frequent (P=0.044) in the patients in whom segmental artery reimplantation was not successful (take-down or occlusion, 6/37=16.2%) than in those who had all segmental arteries sacrificed intentionally (2/64=3.1%) and those who showed patency of all reimplanted segmental arteries (5/92=5.4%). Especially, there was no permanent paraplegia in the last group. Failure of intended segmental artery reimplantation was a significant risk factor of postoperative SCI in logistic regression analysis (P=0.012; odds ratio 4.65, 95% confidence interval 1.41-15.36). During thoracoabdominal aorta replacement, attention should be paid to the segmental artery reimplantation technique, which affects the risk of occlusion or intraoperative take-down and thereby may have impact on postoperative SCI.

Optimization of factors for the prevention of spinal cord ischemia in thoracic endovascular aortic repair.

Spinal cord ischemia following thoracic endovascular aortic repair (TEVAR) is a devastating complication. This study seeks to demonstrate how a standardized protocol to prevent spinal cord ischemia affects incidence in patients undergoing TEVAR. Using CPT codes 33880 and 33881, all TEVAR procedures performed at a single tertiary care center from January 2017 to December 2018 were examined. Patients who had concomitant ascending aortic repairs or a TEVAR for traumatic indications were excluded from analysis, leaving 130 TEVAR procedures. Comorbid conditions, procedural characteristics, extent of coverage, peri-procedural management strategies, and post-operative outcomes were collected and analyzed retrospectively. One hundred thirty patients undergoing TEVAR were examined for four perioperative variables: postoperative hemoglobin greater than 10 g/dL, subclavian revascularization, preoperative spinal drain placement, and somatosensory evoked potential monitoring (SSEP). All conditions were met in 46.2% (60/130) of procedures; 37.8% (28/74) in emergent/urgent cases and 61.5% (32/52) in elective cases. Of patients who required subclavian coverage, 87.1% (54/62) underwent subclavian revascularization; 70.8% (92/130) of patients received spinal drains preoperatively; 68.5% (89/130) of patients had SSEP monitoring; 73.8% (93/130) of patients obtained a postoperative hemoglobin of >10 g/dL. Out of all patients, two (1.5%) developed spinal cord ischemia. Incidence of spinal cord ischemia in our cohort was low at 1.5% (2/130). Individual and bundled interventions for the prevention of spinal cord ischemia were unable to demonstrate a statistically significant effect given the low rate. Nonetheless, we advocate for a proactive approach for the prevention of spinal cord ischemia given our experience in this complex population.

Parallel Grafting Should Be Considered as a Viable Alternative to Open Repair in High-Risk Patients With Paravisceral Aortic Aneurysms

Parallel grafting presents a viable method for treating patients with complex aortic aneurysms. The current literature is limited to mostly pararenal configurations. We examined our results in patients with SMA and/or Celiac artery involvement. A retrospective analysis was performed for all patients undergoing parallel grafting during the period of 2014 to 2018 at a single institution. All patients had at least SMA with and/or without Celiac artery parallel grafting. Seventy-nine patients (65% male, median age 74) were treated with 208 parallel grafts. Median ASA score is 4. Forty-nine cases were elective, 22 urgent, and 8 emergent. Mean pre-operative aneurysm diameter was 7.1 cm (4.6-15 cm). Self-expanding covered stents were used for the renal arteries (mean 6.3mm), and balloon-expandable covered stents were used for the SMA and Celiac (mean SMA 8.6 mm, mean celiac 8.3 mm). Axillary exposure was the choice of access in 68 patients (86%). Technical success was achieved in all cases. We defined this as aneurysm sac exclusion with patent visceral stent grafts, and absent to mild gutter leaks. Mean aortic graft proximal seal achieved was 48mm. Coverage extended above the celiac artery in 75% (10% stented and 65% covered). Median contrast volume was 145ml, operative duration was 4 hours, fluoroscopy time was 56 min, and EBL was 250 ml. Perioperative mortality was 6.1%. 4.5%, and 25%, for the elective, urgent, and emergent groups, respectively. There was no incidence of spinal cord ischemia. Axillary access was complicated in 4 patients, requiring patch closure of the axillary artery. One patient developed postprocedural ESRD from a rupture and ATN despite patent renal stents. Of those patients with a patent GDA and celiac coverage, 2 required a cholecystectomy. Nine patients had a persistent gutter leak at the conclusion of the procedure. Median follow-up was 12 months. On follow-up imaging, all SMA and Celiac stents were patent. Six renal stents were occluded and 2 patients progressed to ESRD, both solitary renal periscope configurations at the index procedure. Only 4 patients had persistent gutter leaks with 2 requiring reintervention. Ninety-five percent of patients demonstrated sac regression or stabilization with a mean sac size of 6.5 cm. Parallel grafting presents a safe, efficacious and off the shelf alternative to conventional repair of complex aortic aneurysms involving the visceral aorta.

Protocolized Based Management of CSF Drains in TEVAR Procedures

Abstract Objectives Spinal cord ischemia (SCI) resulting in paraplegia is a devastating complication associated with thoracic endovascular aortic aneurysm repair (TEVAR) whose incidence has significantly declined over time. In this review we present our experience with a multi-disciplinary clinical protocol for cerebrospinal fluid (CSF) drain management in patients undergoing TEVAR. Furthermore, we aimed to characterize complications of CSF drain placement in a large, single center experience of patients who underwent TEVAR. Methods This retrospective review is of patients undergoing TEVAR with and without CSF drain placement between January 2014 to December 2019 at a single institution. Patient demographics, hospital course, and drain related complications were analyzed to assess the incidence of CSF drain-related complications. Results A total of 235 patients were included in this study of which 85 received CSF drains. 80 (94.1%) were placed by anesthesiologists, while 5 (5.9%) were placed under fluoroscopic guidance by interventional neurosurgery. The most common level of placement was L3-L4 in 38 (44.7%) cases followed by L4-L5 in 36 (42.4%) cases. The mean duration of CSF drain was 1.9 ± 1.4 days. Complications due to CSF drainage occurred in 5 (5.9%) patients and included partial retainment of catheter, subdural edema, epidural hematoma, headache and bleeding near the drain site. The overall 30-day mortality rate was 5.5% and did not differ between those who received a CSF drain and those who did not (p = 0.856). The overall incidence of spinal cord ischemia resulting in paraplegia was 1.7% in the studied patients. Conclusion A protocol-based CSF drainage program for spinal cord protection involves a multifaceted approach in identification and selection of patients meeting criteria for prophylactic drain placement, direct closed loop communication, and perioperative management by an experienced team. Despite the inherent advantages of CSF drain placement, it is not without complications, thus risk and benefit need to be weighed in context of the procedure and the patient with close communication and team approach.