Prevention Of Spinal Cord Ischemia Research Articles

A direct aorta to segmental artery bypass for prevention of spinal cord ischemia after endovascular aortic repair

Spinal cord ischemia remains a persistent challenge after endovascular aortic aneurysm repair. We present a novel direct aorta to segmental artery bypass before aneurysm repair in a 64-year-old woman presenting with an enlarging aneurysm following dissection. Through an eighth intercostal incision, a polyester graft was sewn into the aorta using pledgeted sutures. An entry needle was used to directly access the previously treated aortic segment, and the opening was stented and angioplasty was performed to create inflow. Anastomoses were performed to a prominent left T10 segmental artery with a harvested saphenous vein. The patient remained neurologically intact postoperatively and the 1-month follow-up angiography demonstrated bypass patency.

Strategies for prevention of spinal cord ischemia in the management of thoracic and thoracoabdominal aneurysms

Spinal cord ischemia (SCI) is undoubtedly the most devastating adverse event that occurs after either a thoracic aortic aneurysm (TAA) or thoracoabdominal aortic aneurysm (TAAA) repair. While open surgery techniques and minimally invasive endovascular options are now available for treating complex anatomy aortic aneurysms, spinal cord ischemia still occurs to a greater extent than desirable. Multiple risk factors have been associated with this adverse event, such as advanced age, perioperative hypotension, extent of the repair, and ligation of multiple intercostal and lumbar arteries during the surgical repair. The present literature review aims to analyze the contributing risk factors for SCI in the context of aortic surgery, explore the most relevant strategies for preventing postoperative SCI, and discuss the current management strategy when this complication occurs.

A Novel Bypass Technique to Prevent Vexing Spinal Cord Ischemia in Endovascular Thoracoabdominal Aortic Intervention.

Spinal cord ischemia remains a devastating complication when treating patients with complex thoracoabdominal aortic aneurysms using fenestrated endovascular aortic repair. This approach is progressively deployed. However, to date, no strategy has been identified to reduce the feared risk of spinal cord ischemia. To introduce a novel bypass technique using a customized composite graft to create a direct extra-anatomic revascularization before fenestrated endovascular aortic repair in patients with high-risk of spinal cord ischemia. To demonstrate this novel concept, we present here a clinical case that reports the strategy of this novel concept in detail. An 83-year-old man with medical history of endovascular repair of an abdominal aortic aneurysm and thoracic aorta presented with a type IA endoleak, located along the posterior superior aspect of the aortic stent graft adjacent to the lumbar arteries. A multidisciplinary plan was developed, which included a novel bypass from the profunda femoris to the left L1 radicular artery before fenestrated endovascular aortic repair to prevent spinal cord ischemia. The patient successfully receives the novel extra-anatomic revascularization bypass before fenestrated endovascular aortic repair. During the first implementation of this strategy, no intraoperative difficulties and postoperative complications were observed. This case demonstrates a novel surgical technique before fenestrated endovascular aortic repair for prevention of spinal cord ischemia. In addition, this concept provides a promising direction to not only complement the existing surgical techniques but also to generate more future innovations.

Cerebrospinal Fluid Drainage for Prevention of Spinal Cord Ischemia in Thoracic Endovascular Aortic Surgery-Pros and Cons.

Thoracic endovascular aortic repair (TEVAR) carries a risk of spinal cord ischemia (SCI) which exerts a devastating impact on patient's quality of life and life expectancy. Although routine prophylactic cerebrospinal fluid (CSF) drainage is not unequivocally supported by current data, several studies have demonstrated favorable outcomes. Patients at high risk for SCI following TEVAR likely will benefit from prophylactic CSF drains. However, the intervention is not risk free, and thorough risk/benefit analysis should be individualized to each patient.

Prevention of spinal cord ischemia by cerebrospinal fluid drainage during the endovascular treatment of extensive aortic pathologies

Spinal cord ischemia is a dramatic complication of extended endovascular aortic repair. Preventive measures are necessary to reduce its occurrence. The preventive use of cerebrospinal fluid (CSF) drainage is controversial. This work reports the experience of our center after introduction of a protocol of prevention of spinal cord ischemia including CSF drainage.

Feasibility and Preliminary Patency of Prophylactic Hypogastric Artery Stenting for Prevention of Spinal Cord Ischemia in Complex Endovascular Aortic Repair

BackgroundTo report early results of feasibility and patency of prophylactic hypogastric artery (HA) stenting during complex endovascular aortic repair. MethodsThis is a single centre retrospective non comparative cohort study of all consecutive patients undergoing prophylactic HA stenting during fenestrated and/or branched EVAR (F/B EVAR) in order to prevent spinal cord ischemia (SCI). Endpoints included technical success and early outcomes in terms of morbidity, mortality and patency of the implanted stents. ResultsBetween May 2014 and June 2019 prophylactic HA stenting was performed in 36 consecutive patients with significant HA stenosis during F/B EVAR to prevent SCI. 69.4% of patients presented with asymptomatic, 25% with symptomatic and 5.6% with ruptured aortic aneurysms. 55.6% were treated for thoracoabdominal aortic aneurysms, 44.4% for pararenal abdominal aortic aneurysms. In 13.9% aortic coverage was limited to the abdominal aorta. In 86.1% the aortic coverage was in the thoracoabdominal aortic segment. Unilateral HA stenting was performed in 91.7%, whereas 8.3% underwent bilateral stenting. Technical success was 100%. The primary patency of the implanted stents after a median follow-up time of 9.5 months was 97.5%. One intraprocedural bleeding from an HA branch occurred and was successfully treated by coil embolization. No further procedure-related complications occurred. 11.1% of the patients developed SCI. ConclusionsHA stenting is feasible and safe with high rates of technical success and short-term patency.

Spinal Cord Ischemia Prevention Through Hypogastric and Inferior Mesenteric Artery Preservation During Complex Endovascular Aortic Procedures

Endovascular procedures have been widely accepted as safe treatment in patients with thoracoabdominal aortic aneurysms (TAAAs). Spinal cord ischemia (SCI) is the most dreaded complication. Its incidence is estimated in 3.9% of patients undergoing thoracoabominal procedures. As reported in American and European guidelines, spinal fluid drainage, mean arterial pressure above 100 mm Hg, hemoglobin above 10 g/dL, transcutaneous oxygen measurement above 95%, staged procedures, and collateral networks preservation are recognized as possible preventive strategies.

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.

Management of Descending Thoracic Aortic Diseases: Similarities and Differences Among Cardiovascular Guidelines

Cardiovascular societies have developed recommendations regarding the management of thoracic aortic diseases. While improvements in treatment have been observed during the past decade in regard to patient selection, thoracic endovascular aortic repair (TEVAR) and associated techniques, and high-volume centralization, the broad expansion of TEVAR has raised considerations about its indications, appropriateness, limitations, and application. The aim of this systematic review was to assess the similarities and differences among current cardiovascular societies’ guidelines for the management of thoracic aortic diseases. The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched from January 2009 to May 2020. The initial search identified 990 articles. After exclusion of duplicate or inappropriate articles, the final analysis included 5 articles from cardiovascular societies published between 2010 and 2020. Selected controversial topics were analyzed, including diagnosis, imaging, spinal cord ischemia prevention, and management of the most important thoracic aortic pathologies. The analysis included data concerning the therapeutic approach in acute and chronic type B aortic dissection, penetrating aortic ulcer, intramural hematoma, thoracic aortic aneurysm, and traumatic aortic injury, as well a discussion of inflammatory aneurysms, aortitis, and genetic syndromes. The review presents consistent and controversial recommendations, as well as “gray zone” issues that need further investigation. There was significant overlap and agreement among the 5 societies regarding the management of thoracic aortic diseases. Especially in dissection and aneurysm management, TEVAR has established its role as the treatment of choice. However, robust evidence is still needed in many aspects of the management of thoracic aortic pathologies.

Permissive Hypertension and Collateral Revascularization May Allow Avoidance of Cerebrospinal Fluid Drainage in Thoracic Endovascular Aortic Repair

The utility of cerebrospinal fluid drainage (CSFD) for prevention of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) remains unclear. We previously published our institutional algorithm restricting preoperative CSFD to patients deemed high risk for SCI. Since that publication, our algorithm has evolved with preoperative CSFD avoided in all patients undergoing isolated descending TEVAR with or without arch involvement (+/- arch TEVAR). This study evaluated the updated algorithm in a contemporary cohort. Patients who underwent TEVAR for descending aortic+/-arch pathology between February 2012 and September 2018 at a single center were identified from an institutional aortic surgery database. The algorithm includes left subclavian artery (LSA) revascularization in cases of coverage with no preservation of antegrade flow, permissive hypertension, and use of evoked potential monitoring. The primary end points were SCI or postoperative CSFD. During the study interval, 225 patients underwent descending+/- arch TEVAR. CSFD was used before TEVAR in 2 patients (0.9%) in violation of the algorithm, and they were excluded from the study cohort. Endograft coverage below T6 occurred in 81%. The LSA was fully covered in 100 patients (47%), all of whom underwent LSA revascularization. Following the updated algorithm, the incidence of temporary or permanent SCI was 0%. No patient required postoperative CSFD. A restrictive lumbar CSFD algorithm, including permissive hypertension and LSA revascularization in the setting of descending+/- arch TEVAR, appears safe, with a 0% incidence of SCI in 223 consecutive patients treated during a 6.5-year interval. We recommend consideration of further prospective study to evaluate this algorithm.

Epidural Corticosteroids, Lumbar Spinal Drainage, and Selective Hemodynamic Control for the Prevention of Spinal Cord Ischemia in Thoracoabdominal Endovascular Aortic Repair: A New Clinical Protocol.

In patients undergoing thoracoabdominal aorta repair, spinal cord ischemia (SCI) remains one of the most common and important complications resulting in transient paraparesis through to permanent flaccid paraplegia. In this manuscript, after a brief introduction to spinal cord ischemia complication and its prevention in thoracoabdominal endovascular aortic repair (TEVAR), we propose a new clinical protocolpotentially able to prevent such complication. The proposed protocol suggests the use of high dosages of corticosteroids by epidural route, along with drainage of cerebrospinal fluid and controlled vascular hypertension, to reduce the incidence of SCI in TEVAR. Moreover, we paid particular attention to the control of the hemodynamic parameters to obtain adequate peripheral tissue perfusion (oxygen delivery), including in the spinal cord. We applied this new protocol in 50 consecutive patients treated with TEVAR for thoracoabdominal aortic aneurysms (TAAs); 47 patients completed the procedure: 27 patients Crawford typeI and 20 Crawford typeII. Three patients died during surgery because of untreatable aneurysm rupture. The results show that in all patients there were no cases of SCI, after 5days from TEVAR. To the best of our knowledge, there are no clinical studies on the use of epidural corticosteroids in patients undergoing treatment of aortic syndrome (both in "open surgery" and endovascular aortic repair). This initial study on 50 consecutive patients has shown that the clinical protocol used could be of great interest to prevent one of the worse complications of TEVAR. Its limitations are the low number of patients studied till now, and the non-randomized protocol adopted. Further studies would be necessary. Our experience and the results obtained with this new perioperative protocol with epidural corticosteroid and accurate hemodynamic control have been encouraging and it seems a valid proposal to be explored in future by well-structured prospective, randomized protocols.

IFT12. Hemorrhagic Complications of Two Stages Procedure for Prevention of Spinal Cord Ischemia in Fenestrated/Branched Endovascular Repairs for Thoracoabdominal Aneurysm

IFT12. Hemorrhagic Complications of Two Stages Procedure for Prevention of Spinal Cord Ischemia in Fenestrated/Branched Endovascular Repairs for Thoracoabdominal Aneurysm

Staged procedures for prevention of spinal cord ischemia in endovascular aortic surgery.

BackgroundSpinal cord ischemia with development of paraplegia is the most relevant complication of thoracoabdominal aortic surgery caused by compromising the segmental arteries. To prevent this devastating complication in endovascular aortic surgery, staging procedures have been developed to reinforce collateral blood flood to the spinal cord.ResultsIn patients with a medium to high risk for spinal cord ischemia, staged aortic repair is recommended. The classical staged repair is the two-step repair with delayed implantation of the aortic stent grafts. Additionally, more recent methods for short-term salvage of segmental artery perfusion by leaving an endoleak have been developed. Perfusion branches, delayed bridging stents as well as the open branch technique are among these methods. The latest option of staged repair is minimally invasive segmental artery embolization.ConclusionBesides the nonsurgical options for monitoring and therapy of spinal cord ischemia, various staging procedures are available, which can be implemented depending on the patient and the aortic anatomy. Evidence that underlines staged repair for endovascular treatment of thoracoabdominal aortic pathologies is mostly based on retrospective studies.

Temporary Aneurysm Sac Perfusion as an Adjunct for Prevention of Spinal Cord Ischemia After Branched Endovascular Repair of Thoracoabdominal Aneurysms

Temporary Aneurysm Sac Perfusion as an Adjunct for Prevention of Spinal Cord Ischemia After Branched Endovascular Repair of Thoracoabdominal Aneurysms

Editor's Choice – Temporary Aneurysm Sac Perfusion as an Adjunct for Prevention of Spinal Cord Ischemia After Branched Endovascular Repair of Thoracoabdominal Aneurysms

To report experience with the concept of temporary aneurysm sac perfusion (TASP) and second stage side branch completion to prevent severe spinal cord ischemia (SCI) after branched endovascular aortic repair (bEVAR) for thoracoabdominal aortic aneurysm (TAAA). Patients were treated for TAAA with bEVAR between January 2009 and September 2012. TASP was performed by non-completion of side branches to one of the reno-visceral arteries, distal aortic or iliac extensions with secondary side branch completion. Primary endpoints of the study were overall technical success, side branch patency, perioperative mortality, and the rate of severe SCI. Eighty-three patients were treated for TAAA with branched aortic stent grafts with (n = 40) or without (n = 43) TASP. Overall technical success, including aneurysm exclusion, absence of persistent type I or III endoleak, TASP side branch patency, and secondary side branch completion was 35/40 (88%). Secondary TASP side branch completion was performed after a median of 48 days (range 1-370 days). The rate of early re-interventions for reno-visceral side branch complications was 8/283 (3%) and 6/83 (7%) for perioperative mortality, with three patients in both groups. Severe SCI or paraplegia was observed in 11/83 (13%) of the patients and reduced in the TASP group (2/40) compared with the non-TASP group (9/43; p = .03), especially in Crawford I-III aneurysms (1/29 vs. 7/24; p = .01). However, one TASP patient died 4 months after bEVAR during the TASP interval from suspected aorto-bronchial fistula. The concept of TASP after bEVAR for TAAA is feasible and seems to reduce the risk of SCI. Early side TASP branch completion within 4 weeks is recommended to reduce the risk of rupture, although, according to the individual clinical presentation, a longer TASP interval might improve neurological rehabilitation from SCI.

Paraplegia prevention by oral pretreatment with memantine in a rabbit model

To evaluate the role of memantine (N-methyl-d-aspartate receptor antagonist) pretreatment for the prevention of spinal cord ischemia after infrarenal aortic clamping in a rabbit model. Thirty New Zealand White rabbits were divided into 5 different groups of 6 rabbits. Groups 60-7 and 60-5 received oral memantine 60 mg once a day for 7 and 5 days, respectively, and groups 30-5 and 30-3 received oral memantine 30 mg once a day for 5 and 3 days, respectively, all before surgery. Group C (control) received normal feeds without memantine. A paraplegic model was created by clamping both the aorta and the inferior vena cava infrarenally and just proximal to their bifurcations for 45 minutes. The modified Tarlov score, motor evoked potential (MEP), serum memantine concentration, and histopathology of the spinal cord were evaluated. The mean modified Tarlov scores were 4.2±1.3, 4.3±1.0, 4.2±1.3, 4.3±1.2, and 0.8±1.6 in groups 60-7, 60-5, 30-5, 30-3, and C, respectively at 6, 24, 48, and 72 hours (P<.009 for individual groups vs control). Percentage amplitude loss of MEP by the end of surgery was 29.5%±46.3%, 11.9%±28.0%, 30.0%±46.8%, 16.7%±40.8%, and 81.8%±40.3% for the 5 groups, respectively (P=.049). After declamping, MEP reappeared in 83%, 100%, 83%, 83%, and 33% of cases in the 5 groups, respectively (P=.073). The serum memantine level was similar in the 4 memantine groups. Spinal cords were normal in most of the rabbits in groups 60-7, 60-5, 30-5, and 30-3, but severely ischemic in most of the rabbits in group C (P=.041). Oral memantine pretreatment is protective against spinal cord ischemia, and can be an additional strategy for the prevention of paraplegia during thoracoabdominal aortic surgeries.

Changes of cerebrospinal fluid pressure after thoracic endovascular aortic repair

Background Decreasing the intracranial pressure has been advocated as one of the major protective strategies to prevent spinal cord ischemia after endovascular aortic repair. However, the actual changes of cerebrospinal fluid (CSF) pressure and its relation with spinal cord ischemia have been poorly understood. We performed CSF pressure measurements and provisional CSF withdrawal after thoracic endovascular aortic repair, and compared the changes of CSF pressure in high risk patients and in patients with new onset paraplegia and paraparesis. Methods Four hundred and nineteen patients were evaluated for the risk of spinal cord ischemia after thoracic endovascular aortic repair. Patients with identified risk factors before the procedure constituted group H and received prophylactic sequential CSF pressure measurement and CSF withdrawal. Patients who actually developed spinal cord ischemia constituted group P and received rescue CSF pressure measurements and CSF withdrawal. Results Among the 419 patients evaluated, 17 were graded as high risk. Four patients actually developed spinal cord ischemia after endovascular repair. The incidence of spinal cord ischemia in this investigation was 0.9%. The patients who actually developed spinal cord ischemia had no identified risk factors and had elevated CSF pressure, ranging from 15.4 to 30.0 mmHg. Six of the 17 patients graded as high risk had elevated CSF pressure: &gt;20 mmHg in two patients and &gt;15 mmHg in four patients. Sequential CSF pressure measurements and provisional withdrawal successfully decrease CSF pressure and prevented symptomatic spinal cord ischemia in high-risk patients. However, these measurements could only successfully reverse the neurologic deficit in two of the patients who actually developed spinal cord ischemia. Conclusions Cerebrospinal fluid pressure was elevated in patients with spinal cord ischemia after thoracic endovascular aortic repair. Sequential measurements of CSF pressure and provisional withdrawal of CSF decreased CSF pressure effectively in high risk patients and provided effective prevention of spinal cord ischemia. Risk factor identification and prophylactic measurements play the key role in prevention of spinal cord ischemia after thoracic endovascular aortic repair.

Spinal Cord Ischemia After Thoracic Stent-Grafting: Causes Apart From Intercostal Artery Coverage

Examination of a large collective combined with individual case analyses may give new insights into mechanisms and prevention of spinal cord ischemia (SCI) after thoracic endovascular repair. In an 11-year period, stent-grafts were implanted in 406 patients for various aortic pathologic conditions. The mean age was 63 years (15-91 years) and 300 (74%) patients were men; 58 patients underwent staged thoracic stent-graft procedures. The length of aorta covered was between 75 and 584 mm (mean, 204 mm). Thoracoabdominal branched or fenestrated stent-grafts were implanted in 11 patients. The left subclavian artery was occluded in 161 patients (39%); this occurred in half of them (n = 78) after protective revascularization. Prophylactic cerebrospinal fluid (CSF) drainage was used selectively in 4 cases; no neuromonitoring was used. The incidence of SCI was 2.7% (n = 11); 6 patients (1.5%) had major permanent deficits. Conditions that had a potential influence on SCI were analyzed. Statistical correlation was found for previous conventional or endovascular abdominal aortic aneurysm repair (odds ratio [OR], 4.8), coverage of the entire descending thoracic aorta (OR, 3.6), and implantation of thoracoabdominal branched and fenestrated stent-grafts (OR, 9.5). Individual analyses revealed other conditions that might have played a role, such as embolization into the segmental arteries, severe visceral ischemia, profound hemorrhagic shock, and heparin-induced thrombocytopenia. The incidence of SCI is unexpectedly low despite extensive sacrifice of intercostal arteries. Extended coverage of the thoracic and thoracoabdominal aorta seems to have a higher risk, but other factors may contribute to the individual disaster.

Results With Selective Preoperative Lumbar Drain Placement for Thoracic Endovascular Aortic Repair

The optimal use of lumbar cerebrospinal fluid drainage for the prevention of spinal cord ischemia (SCI) with thoracic endovascular aortic repair (TEVAR) remains unclear. Here, we report our experience with selective preoperative lumbar drain placement with TEVAR. Between May 2002 and January 12, 381 TEVAR procedures were performed at a single referral institution. Preoperative lumbar drains were placed selectively in patients considered high-risk for SCI due to planned long-segment aortic coverage with a history of prior aortic intervention or planned hybrid Crawford extent I to III thoracoabdominal aortic aneurysm repair. Preoperative lumbar drains were placed in 81 patients (21%); of these, drain placement in 38 (47%) was for procedures involving long-segment descending thoracic aortic coverage in the setting of prior descending thoracic or infrarenal aortic repair, and in 43 (53%) was for hybrid thoracoabdominal aortic aneurysm repair. SCI occurred in 12 patients (14.8%) who received a preoperative lumbar drain, transient in 6 (7.4%) and permanent in 6 (7.4%), whereas SCI occurred in 13 patients (4.3%) who did not receive a preoperative lumbar drain, 12 transient (4.0%) and 1 permanent (0.3%). A lumbar drain complication occurred in 9 drain patients (11.1%), although none resulted in permanent disability. Age, postoperative hypotension, and the number of endografts implanted were independently associated with SCI. Preoperative lumbar drain placement was not associated with reduced SCI. Restricted use of preoperative lumbar drains for patients at high-risk of SCI undergoing TEVAR appears safe and leads to low rates of SCI in nondrained patients. However, the utility of preoperative lumbar drains in preventing SCI with TEVAR remains questionable and should be weighed against the risk of drain complications.

A Case of Difficulty Predicting Neurological Deficit During Thoracoabdominal Aortic Surgery

Perioperative spinal cord injury associated with thoracoabdominal aorta (TAAA) surgery is a devastating complication. With variable results, the intraoperative use of neurophysiologic monitoring has been employed for the diagnosis and prevention of spinal cord ischemia. We present a case report of a patient undergoing TAAA surgery with the use of evoked potential monitoring. Intraoperatively, both sensory and motor evoked potentials were utilized and consequently the patient experienced changes in monitoring consistent with a new neurologic deficit. However, postoperatively these changes in evoked potentials never manifested in neurologic injury. We examine the utility of neurophysiologic monitoring as it pertains to TAAA surgery.