Risk Of Spinal Cord Ischemia Research Articles

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.

Preoperative Spinal Drain Placement is Associated with Reduced Risk of Spinal Cord Ischemia in Patients Undergoing Thoracic Endovascular Aortic Repair for Aortic Dissection

Spinal cord ischemia (SCI) is a rare but serious complication of Thoracic Endovascular Aortic Repair (TEVAR). Several measures including spinal drain (SD) placement have been proposed to reduce the risk of SCI in TEVARs performed for aneurysms. However, there are no specific large-scale data on potential benefits of SD placement in Stanford Type B aortic dissection (TBAD). We aimed to assess the impact of preoperative SD placement on preventing SCI during TEVARs performed for TBAD. We included all TEVAR cases performed for TBAD in Vascular Quality Initiative (VQI) from 2012 to 2021. Patients with connective tissue disease, open conversion, rupture, proximal disease>zone 5, proximal landing zone <2 or SCI on presentation were excluded. One-to-one propensity score matching was used to balance patients on 34 dimensions by the nearest neighbor principle to compare patients based on preoperative SD placement. The primary outcome was SCI. Secondary outcomes included 30-day and 90-day mortality, perioperative complications, and 90-day2intervention. A total of 2,683 TEVARs were performed for TBAD with 1,227 (45.7%) undergoing preoperative SD placement. Propensity matching produced 672 well-matched pairs. In the matched cohort, SD placement was not associated with significant reduction in temporary SCI (3.0% vs. 3.7%, P=0.45). However, SD placement was associated with significant reduction of the risk of permanent SCI at discharge (1.3% vs. 3.4%, P=0.012). SD was also associated with lower risk of 30-day mortality (3.7% vs 6.4%, P=0.025) and shorter length of stay but not 90-day mortality or 90-day reintervention. Our study suggests that preoperative SD placement in patients undergoing TEVAR for TBAD is beneficial in reducing the risk of permanent SCI without increasing risks of perioperative complications. Further prospective studies are necessary to confirm these findings.

Prevention of Spinal Cord Injury during Thoracoabdominal Aortic Aneurysms Repair: What the Anaesthesiologist Should Know.

Thoraco-abdominal aortic repair is a high-risk surgery for both mortality and morbidity. A major complication is paraplegia-paralysis due to spinal cord injury. Modern thoracic and abdominal aortic aneurysm repair techniques involve multiple strategies to reduce the risk of spinal cord ischemia during and after surgery. These include both surgical and anaesthesiologic approaches to optimize spinal cord perfusion by staging the procedure, guaranteeing perfusion of the distal aorta through various techniques (left atrium–left femoral artery by-pass) by pharmacological and monitoring interventions or by maximizing oxygen delivery and inducing spinal cord hypothermia. Lumbar CSF drainage alone or in combination with other techniques remains one of the most used and effective strategies. This narrative review overviews the current techniques to prevent or avoid spinal cord injury during thoracoabdominal aortic aneurysms repair.

Con: Lumbar Drains Should Routinely Be Placed by a Landmark Approach and Not by Fluoroscopic Guidance for Elective Thoracic Aortic Repairs

SPINAL CORD ISCHEMIA (SCI) after thoracoabdominal aortic repair is a well-known complication of both open and endovascular surgery, with reported rates as high as 5%-to-21% after open repair. 1 Gravereaux EC Faries PL Burks JA et al. Risk of spinal cord ischemia after endograft repair of thoracic aortic aneurysm. Jour of Vasc Surg. 2001; 34: 997-1003 Abstract Full Text Full Text PDF PubMed Scopus (260) Google Scholar Resultant morbidity, including paraparesis and paraplegia, are devastating, and a fair amount of research has gone into developing strategies for mitigating SCI-related complications. Cerebrospinal fluid drainage (CSFD) with the placement of lumbar drains (LDs) is considered the current recommendation for both prevention and treatment of SCI in high-risk patients. 2 Coselli JS LeMaire SA Koksoy C et al. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. J Vasc Surg. 2002; 35: 631-639 Abstract Full Text Full Text PDF PubMed Scopus (520) Google Scholar ,3 Hiratzka LF Bakris GL Beckman JA et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010; 121: e266-e369 Crossref PubMed Scopus (1914) Google Scholar While there is some controversy over the utility of CSFD for endovascular repairs, it is still a widely accepted practice that is performed frequently for patients at high risk of developing SCI postrepair. 4 Isaak RS Furman W. Con: Patients at risk for spinal cord ischemia after thoracic endovascular aortic repairs should not receive prophylactic cerebrospinal fluid drainage. J Cardiothorac Vasc Anesth. 2015; 29: 1381-1383 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Protocols regarding the placement of LDs can vary by institution, whereby some centers may routinely use imaging guidance for the procedure. In this review, the authors examine the specifics of using fluoroscopic guidance for the preoperative placement of LDs in patients who are at a high risk of developing SCI after thoracoabdominal aortic repair. It is the authors’ belief that the universal use of fluoroscopic guidance is unnecessary, potentially harmful, confers additional expense, and is unsupported by the current body of evidence.

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

Spinal Cord Ischemia following Simultaneous EVAR and TEVAR for Concomitant Thoracic and Abdominal Aortic Aneurysms

In patients with abdominal aortic aneurysms, 10-20% has concomitant thoracic aortic pathologies. These are typically managed with staged endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR) due to a perceived higher risk of spinal cord ischemia from a simultaneous intervention. We aimed to determine the outcomes of patients undergoing simultaneous EVAR and TEVAR for concomitant aneurysms. A retrospective cohort study was performed using the Vascular Quality Initiative registry from December 2003 to January 2021. Patients undergoing same day EVAR and TEVAR were included and analyzed in accordance with the Society for Vascular Surgery reporting standards. Primary outcomes were technical success and spinal cord ischemia. Simultaneous EVAR and TEVAR were performed in 25 patients. Median age was 75.0 (interquartile range [IQR], 63.0-79.0) years and 20 (80.0%) patients were male. Two (4.0%) patients were symptomatic and 4 (16.0%) presented with rupture. Median maximum infrarenal and thoracic aortic diameter was 57.0 (IQR, 52.0-65.0). Infrarenal aortic neck length was 15.0mm (IQR, 10.0-25.0), and diameter was 27.0mm (IQR, 24.5-30.0). Median procedure time was 185.0min (IQR, 117.8-251.3), fluoroscopy time 32.7min (IQR, 21.8-63.1), and contrast volume 165mL (IQR, 115.0-207.0). There were 3 (12.0%) Type Ia endoleaks and 3 (12.0%) Type II endoleaks in EVAR's, with 1 (4.0%) Type Ia and 1 (4.0%) Type II endoleak in TEVARs. In-hospital mortality occurred in 3 (12.0%) patients (1 elective, 2 ruptures). Spinal cord ischemia occurred in 1 (4.0%) patient. This patient had a symptomatic aneurysm. Thoracic coverage extended from Zone 4 to Zone 5 and an emergent spinal drain was placed postoperatively. Symptoms were present on discharge. There was 1 (4.0%) conversion to open repair which occurred in a ruptured aneurysm. Technical success was achieved in 19 (76.0%) patients, however when excluding ruptured aneurysms, was achieved in 17 (81.0%) patients. Follow-up data was available for 19 (76.0%) patients at a median of 426.0 (IQR, 329.0-592.5) days postoperatively. A total of 3 (12.0%) patients died during the late mortality period, at a mean of 509.0 (±503.7) days. Median change in abdominal and thoracic aortic sac diameter was -1.35mm (IQR, -11.5 to 2.5) and 8.0 (IQR, -10.5 to 12.0), respectively. Simultaneous EVAR and TEVAR for concomitant abdominal and thoracic aortic aneurysms can be performed with low rates of spinal cord ischemia. Short- and mid-term outcomes are acceptable.

Evaluating the risk of spinal cord ischemia in zone 2 frozen elephant trunk replacement

BackgroundThe appropriate stent length in frozen elephant trunk replacements (FET) remains debated relative to the risk for paraplegia. However, landing the distal end of the stent beyond the curve of the arch facilitates distal reintervention, which is commonly beyond the 10 cm stent coverage when deployed proximal to the left subclavian artery. The aim of this study was to evaluate outcomes following the use of 15 cm stent grafts in zone 2 (z2, distal to the left common carotid). MethodsUsing our single institution-maintained database, 103 zone 2 FET performed from 2016 to 2020 were reviewed. ResultsOf the 103 z2, a 15 cm stent graft was used in 51 operations. The indications for FET included acute and chronic aortic dissection, arch aneurysms, and pseudoaneurysms. The incidence of SCI was 0%. Seven deaths (13.7%) occurred. ConclusionsThe data demonstrates the incidence of post-operative paraplegia to be 0% with 15 cm z2 FET. The understanding of SCI in FET should not only include the stent length but also from where it begins.

The Colt Device for Treating Thoraco-Abdominal Aneurysms - Concept and Clinical Results.

To report results of application a new stent graft design for the treatment of patients with thoraco-abdominal aneurysms (TAAAs), which was co-invented by a vascular surgeon. This is a retrospective observational study. The Colt is a self-expanding stent graft, composed of nitinol metal stents creating a special exoskeleton with asymmetric springs covered with polyester material. The Colt device offers some advantages over existing stent graft options. The main body is available in two different diameters on both ends and in three different lengths. It has four branches pointing downward and coming from the main stent graft at two levels. It offers the physician an opportunity to decide which branch to choose for the target vessel. It may be implanted alone or extended proximally and distally. Balloon expandable and/or self-expanding stent grafts are used to create the visceral branches. In complex extensive aneurysms, the procedure is divided into two or three stages to minimize the risks of spinal cord ischemia. Between August 2015 and December 2021, twenty-two Colt stent grafts were implanted in twenty males and two females (aged 56-81) with TAAAs (eight Type II; twelve Type III; two Type IV). The mean aneurysm diameter was 73.4 mm (range 64-83). All patients were asymptomatic. Eighty-five target vessels were reconstructed using either self-expanding or balloon-expandable stent grafts. Fourteen bifurcated, six custom-made tubes and two aortouniiliac (AUI) stent grafts were used as distal extensions to the Colt device. Completion angiography revealed no type I endoleaks. Five patients had Type II endoleaks which were treated conservatively. There were no intraoperative deaths. One patient died on the 7th postoperative day from multiorgan failure. We did not observe any other complications within 30 days after implantation. One patient died from Covid-19 two months after discharge. Follow-up ranged from three to 75 months. There was no migration or dislocation of the docking station or proximal and distal extensions. All Colt device prostheses remained patent, however, two branches leading to the coeliac trunk were found occluded at the time of the 12-month CTA, without any symptoms. In two patients, there were late problems with three renal bridging stent grafts. One of the Type II endoleaks resolved spontaneously after one year, while four others remain under observation. No patient had an increase in sac diameter. Results from the current series are promising. The Colt stent graft can be applied to a large variety of TAAA anatomies, which may facilitate the development of new "off-the-shelf" devices in the future.

Spinal Drain Complications for Advanced Aortic Surgery at a University Hospital Center in Montreal, Canada

Spinal drains (SD) are an important component of spinal cord protection for patients undergoing complex aortic surgery. However, SDs are not benign and can lead to important complications such as intracranial hemorrhage and spinal hematomas. We sought to evaluate the outcomes of SD placement, including drain-related complications and spinal cord ischemia at a university hospital center in Montreal, Canada. Patients who underwent SD placement between 2014 and 2020 were identified using procedure codes. A retrospective chart review was then performed to identify patient demographics, comorbidities, characteristics of the index surgery, postoperative outcomes, and SD-related complications. Seventy-nine patients underwent preoperative SD placement. Sixty-six percent of patients were male and the mean age at the time of procedure was 66 years. Fifty-seven percent of patients presented with isolated thoracic aortic aneurysms and 43% presented with thoracoabdominal aortic aneurysms. Thirty-eight patients (48.1%) underwent advanced endovascular repair. Intraoperative drain placement was obtained with an average of 1.3 attempts, however this increased to 1.8 attempts in patients who experienced SD-related events (P = .032). Multiple attempts at placement was associated with an increase in SD events (P = .004). Ten patients (12.7%) experienced intraoperative SD events, including 6 patients (7.6%) who reported transient paresthesia requiring drain removal and new drain placement, 3 patients (3.8%) who had a bloody spinal tap, causing 1 drain placement to be aborted, and 1 patient who developed a hematoma at the drain insertion site and subsequently had their drain removed. Of the patients who experienced intraoperative SD events, three (3.8%) developed postoperative SD complications in addition to seven patients (8.9%) who developed new drain-related complications. Four patients (5.1%) had bloody drain output, two patients (2.5%) had a cerebrospinal fluid leak, two patients (2.5%) experienced intracerebral hemorrhages without long-term sequelae, one of the placed drains malfunctioned, and one patient had prolonged bleeding around the drain site. Spinal cord ischemia occurred in five patients (6.3%) total, two of whom experienced permanent disability. Of the five cases of SCI, three (3.8%) occurred in patients who had experienced SD complications. Postoperative SD-related complications occurred in 12.7% of patients undergoing aortic surgery, were more likely to occur when multiple attempts at SD placement occurred, and were associated with an increased risk of spinal cord ischemia. Lack of vascular-specialized anesthesiologists, participation of residents in SD placement and difficult patient anatomy may all have contributed to increasing the number of attempts required for SD placement.

Our experience with 1000 recent thoracoabdominal aneurysm repairs, including endovascular stenting

ObjectiveManaging patients with thoracoabdominal aneurysms is demanding yet fascinating, and requires a team effort. This invited talk presents lessons learned as our history with open and endovascular procedures evolved for 2578 descending and thoracoabdominal repairs over the past 20 years. MethodsBeginning in 1985 with an analysis of 596 traumatic aortic ruptures and the risk of spinal cord ischemia, the evolution of research and procedures for thoracoabdominal aneurysms progressed. The focus of these studies, medication trials, and procedure adjustments was on lowering the risk of spinal cord ischemia. ResultsBetween January 2002 and December 2021, 2578 aneurysm repairs were performed. The respective mortality rates were 6.8% and 4.0% for all patients treated. The permanent spinal cord ischemia rates were 1.3% for open descending thoracic aortas and 4.9% for open thoracoabdominal aneurysms. A detailed analysis of open and thoracoabdominal repairs showed better long-term outcomes with open repairs. ConclusionsThrough multiple randomized trials and innovations with procedures and techniques, the risk of death and spinal cord ischemia have been reduced. Long-term survival has also been improved. The pursuit of reducing the risks of descending and ascending thoracoabdominal repairs is a fascinating endeavor that has resulted in better patient outcomes. Nevertheless, this is a journey, and there will always be more room to achieve even better results.

Staging Endovascular Thoracic and Thoracoabdominal Aortic Aneurysm Repairs and the Risk of Post-operative Spinal Cord Ischemia

Staged aortic aneurysm repair is one method used to decrease the risk of spinal cord ischemia (SCI) following endovascular aortic intervention. Sequential sacrifice of arteries perfusing the spine may allow for improved spinal perfusion through the development of collateral networks over time. To evaluate the impact of staging endovascular aortic aneurysm repairs on SCI, we conducted a conservative analysis of Vascular Quality Initiative (VQI) data. De-identified VQI data were queried for cases of endovascular thoracic and thoracoabdominal aneurysm repairs from year 2014 to 2019. Cases were selected based on inclusion criteria: aneurysmal disease, no ruptures, no prior aortic surgeries, no retreatments, and only cases with complete data on aortic zones and SCI. Chi-square, Student's t-tests, and Mann-Whitney U tests were used for univariable analyses, as appropriate. Logistic regression analyses were used to identify independent predictors of outcome. There were 116 staged aortic repairs (SARs) (8.2%) performed out of a total of 1421 endovascular aortic repairs that fit study criteria. The overall rate of SCI within the study cohort was 3.4% (n=48). The distribution of SARs and SCI events according to aortic zone coverage are displayed in Table1. Patients who underwent staged endovascular aortic repairs had higher rates of SCI, pre-op spinal drain placement, non-African-American race, COPD, smoking history, positive stress tests, aspirin and statin use, increased estimated blood loss, physician-modified endografts, number of aortic zones covered, lower pre-op hemoglobin levels, larger aneurysm sac size, fusiform aneurysms, and longer total procedure times, Table2. After adjusting for factors associated with SCI, a priori, and factors with a P<0.1 univariable analysis, SAR was not associated with SCI (odds ratio [OR]=1.86, 95% confidence interval [CI]=0.77-4.50, P=0.17). Of the six factors associated with SCI on univariable analysis, only procedure time ≥6hours (OR=2.49, 95% CI=1.09-5.70, P=0.031) and the number of aortic zones covered (OR=1.15, 95% CI=1.00-1.32, P=0.047) were predictive of SCI. Staged repairs had a lower proportion of permanent SCI (38%, 3 of 8 cases) compared with repairs that were not staged (68%, 27 of 40 cases), with a relative risk reduction of 44% for those who developed SCI, P=0.21. In a large national data set, SARs were performed for patients with more extensive aortic disease. SARs were only performed in about 8% of cases and the rate of SCI remained low. After adjusting for baseline comorbidities, extent of aortic disease, and other factors that may potentiate SCI, staged aortic aneurysm repair had a similar risk of SCI compared with non-staged repairs. However, there was a trend toward decreased permanent SCI risk in the SAR group.

Preoperative Spinal Drain Placement Is Associated With Reduced Risk Of Spinal Cord Ischemia In Patients Undergoing Thoracic Endovascular Aortic Repair For Aortic Dissection

<h3>INTRODUCTION</h3> Spinal cord ischemia (SCI) is a rare but serious complication of TEVAR. A number of measures including spinal drain (SD) placement have been proposed to reduce the risk of SCI in TEVARs performed for aneurysms. However, there is no specific data on potential benefits of SD placement in aortic dissection (AD). We aimed to assess the impact of preoperative SD placement on preventing SCI during TEVARs performed for AD. <h3>Methods</h3> We included all TEVAR cases performed for AD in VQI from 2012 to 2021. Patients with connective tissue disease, open conversion, rupture, proximal disease > zone 5, or SCI on presentation were excluded. One-to-one propensity score matching was used to balance patients on 37 dimensions by the nearest neighbor principle to compare patients based on preoperative SD placement. The primary outcome was SCI. Secondary outcomes included 30-day and 90-day mortality, perioperative complications, and 90-day re-intervention. <h3>RESULTS</h3> A total of 2970 TEVARs were performed for AD with 1373 (44.9%) undergoing preoperative SD placement. Propensity matching produced 924 well-matched pairs. In the matched cohort, SD placement was not associated with significant reduction in temporary SCI (2.7 vs. 1.9%, p=0.28). However, SD placement was associated with significant reduction of the risk of permanent SCI at discharge (1.4% vs. 2.7%, p=0.049). SD was also associated with lower risk of 30-day mortality (3.6% vs 6.0%, p=0.016) and longer length of stay but not perioperative complication or 90-day mortality or 90-day re-intervention. <h3>CONCLUSION</h3> Our study suggests that preoperative SD placement in patients undergoing TEVAR for AD is beneficial in reducing the risk of permanent SCI without increasing risks of perioperative complications. Further prospective studies are necessary to confirm these findings.

Early Results and Technical Tips of Combining Iliac Branch Endoprostheses with Fenestrated Aortic Stent Grafts during Endovascular Repair of Complex Abdominal and Thoracoabdominal Aortic Aneurysms

Concomitant iliac artery aneurysms can pose challenges during repair of complex abdominal and thoracoabdominal aortic aneurysms. In fenestrated aortic aneurysm repairs (FEVAR), preservation of internal iliac perfusion is important to minimize risk of spinal cord ischemia. Currently, most commonly used fenestrated stent grafts and the only approved iliac branch devices are manufactured by different companies in the United States. We report our experience with combining Iliac Branch Endoprosthesis (IBE) (W.L. Gore and Associates, Flagstaff, AZ) and fenestrated stent grafts, using the Zenith platform (Cook Medical, Bloomington, IN). Retrospective review of consecutive patients who underwent FEVAR at a single institution from September, 2015 to June, 2020 was performed. Patients were deemed high-risk for open repair. Fenestrated aortic components implanted were either physician-modified or custom manufactured. Cases in which IBEs were deployed during FEVAR were specifically reviewed. Anatomic details were obtained from preoperative CT scans. Postoperative outcomes such as mortality, technical success, major adverse events, limb patency, limb-related endoleaks and re-intervention rates were assessed. During the study period, 171 patients underwent FEVAR at our institution. Among those, 15 patients had unilateral IBE implantation during FEVAR, while one received bilateral IBE implantation. Fourteen cases involved physician-modified fenestrated endograft, and Zenith Fenestrated (Cook Medical, Bloomington, IN) in combination with Excluder bifurcated main body and IBE (W.L. Gore and Associates, Flagstaff, AZ). Mean operative, and fluoroscopy times were 340.2 minutes, and 65.4 minutes respectively. A total of 67 viscerorenal target vessels (mean=3.9, range =_3-5) and 15 internal iliac arteries were incorporated, with a mean of 160 cc contrast used. Completion angiograms were free of type 1 and type 3 endoleaks. Technical success was 100%. There was no perioperative mortality. One patient developed spinal cord ischemia post-operative day two with neurological recovery. At mean follow-up of 430 days, overall survival was 100% with no aneurysm-related mortalities. Limb patency remained 100%. There were no type 3 endoleaks while one patient had a type 1B endoleak that is currently being monitored. There was one re-intervention for type 1C renal branch graft endoleak. Combining IBE with FEVAR allows internal iliac preservation during endovascular repair of complex abdominal aortic aneurysms, with encouraging early results.

Prior infrarenal aortic surgery is not associated with increased risk of spinal cord ischemia after thoracic endovascular aortic repair and complex endovascular aortic repair

ObjectivePatients with prior infrarenal aortic intervention represent an increasing demographic of patients undergoing thoracic endovascular aortic repair (TEVAR) and/or complex EVAR. Studies have suggested that prior abdominal aortic surgery is a risk factor for spinal cord ischemia (SCI). However, these results were largely based on single-center experiences with limited multi-institutional and national data that had assessed the clinical outcomes for these patients. The objective of the present study was to evaluate the effect of prior infrarenal aortic surgery on the occurrence of SCI. MethodsThe Society for Vascular Surgery Vascular Quality Initiative database was retrospectively reviewed to identify all patients aged ≥18 years who had undergone TEVAR and/or complex EVAR from January 2012 to June 2020. Patients with previous thoracic or suprarenal aortic repair were excluded. The baseline and procedural characteristics and postoperative outcomes were compared between TEVAR and/or complex EVAR with and without previous infrarenal aortic repair. The primary outcome was postoperative SCI. The secondary outcomes included postoperative hospital length of stay, bowel ischemia, renal ischemia, and 30-day mortality. Multivariate regression was used to determine the independent predictors of postoperative SCI. Additional analysis was performed of the patients who had undergone isolated TEVAR. ResultsA total of 9506 patients met the inclusion criteria: 8691 (91.4%) had not undergone prior infrarenal aortic repair and 815 (8.6%) had undergone previous infrarenal aortic repair. Patients with previous infrarenal repair were older with an increased prevalence of chronic kidney disease (P = .001) and cardiovascular risk factors, including hypertension, chronic obstructive pulmonary disease, and positive smoking history (P < .001). These patients also presented with a larger maximal aortic diameter (6.06 ± 1.47 cm vs 5.15 ± 1.76 cm; P < .001) and required more stent-grafts (P < .001) with increased intraoperative blood transfusion requirements (P < .001), and longer procedure times (P < .001). Univariate analysis demonstrated no differences in postoperative SCI, postoperative hospital length of stay, bowel ischemia, or renal ischemia between the two groups. The 30-day mortality was significantly higher in patients with prior infrarenal repair (P = .001). On multivariate regression, prior infrarenal aortic repair was not a predictor of postoperative SCI. In contrast, aortic dissection (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.26-2.16; P < .001), number of stent-grafts deployed (OR, 1.45; 95% CI, 1.30-1.62; P < .001), and units of packed red blood cells transfused intraoperatively (OR, 1.33; 95% CI, 1.03-1.73; P = .032) were independent predictors of postoperative SCI. ConclusionsAlthough the patients in the TEVAR and/or complex EVAR group with prior infrarenal aortic repair constituted a sicker cohort with higher 30-day mortality, the rate of SCI was comparable to that of the patients without prior repair. Previous infrarenal repair was not associated with the risk of SCI.

Prior Infrarenal Aortic Surgery Is Not Associated With Increased Risk of Spinal Cord Ischemia After Thoracic Endovascular Aortic Repair

Patients with prior infrarenal aortic intervention represent an increasing demographic of patients undergoing thoracic endovascular aortic repair (TEVAR). Studies have suggested that prior abdominal aortic surgery is a risk factor for spinal cord ischemia (SCI) after TEVAR. However, these Results were largely based on single-center experiences, and limited national data assessing the postoperative outcomes for these patients are available. The Objective of our study was to evaluate the effect of prior infrarenal aortic surgery on SCI after TEVAR.

Staged Endovascular Repair of Thoracoabdominal Aortic Aneurysms Does Not Confer Protection Against Spinal Cord Ischemia

Staged aortic aneurysm repair is one method used to decrease the risk of spinal cord ischemia (SCI) after endovascular aortic intervention. Sequential sacrifice of the arteries perfusing the spine might allow for improved spinal perfusion through the development of collateral networks over time. To evaluate the effect of staging endovascular aortic aneurysm repairs on SCI, we conducted a conservative analysis of Vascular Quality Initiative data.

“Awake” Spinal Cord Monitoring Under Local Anesthesia and Conscious Sedation in Fenestrated and Branched Endovascular Aortic Repair

Introduction Endovascular repair of thoracoabdominal aortic aneurysms carries a risk of spinal cord ischemia, the causes of which remain uncertain. We hypothesized that local anesthesia (LA) with conscious sedation could abrogate the potential suppressive cardiovascular effects of general anesthesia (GA) and facilitate intraoperative monitoring of neurological function. Here, we examine the feasibility of this technique during fenestrated (FEVAR) or branched endovascular aortic repair (BEVAR). Materials and Methods Consecutive patients undergoing FEVAR or BEVAR under LA and conscious sedation by a team at a single center were analyzed. Patients received conscious sedation using intravenous remifentanil and propofol infusions in conjunction with a local anesthetic agent. No patient had a prophylactic spinal drain inserted. Outcome measures included conversion to GA, need for vasopressors and/or spinal drainage, length of stay, complications, and patient survival. Results A total of 44 patients underwent FEVAR or BEVAR under LA and conscious sedation. The cohort included thoracoabdominal aortic aneurysms (n=41) and pararenal aneurysms treated with endografts covering the supraceliac segment (n=3). Four patients (9%) required conversion to GA at a median operative duration of 198 minutes (range 97–495 minutes). Vasopressors were required intraoperatively in 3 of the cases that were converted to GA. No patient developed spinal cord ischemia and none had insertion of a spinal drain. The median hospital length of stay was 4 days (range 2–41 days). Postoperative delirium and hospital-acquired pneumonia was seen in 7% of patients. All patients survived to 30 days, with 95% alive at a median follow-up of 15 months (range 3–26 months). Conclusion LA and conscious sedation is a feasible anesthetic technique for the endovascular repair of thoracoabdominal aortic aneurysms.

Staged endovascular treatment of aneurysmal progressive development of an intercostal arteries island reimplanted with the loop-graft technique.

A staged endovascular strategy was used to treat the aneurysmal evolution of the aortic island including intercostal arteries reimplanted in a loop-graft, following thoraco-abdominal aortic open repair in a young patient diagnosed with Marfan syndrome. First, selective coil embolization of patent intercostal arteries was performed in 2 separate sessions, to minimize the risk of spinal cord ischaemia. Then, the aneurysm was successfully excluded occluding the loop graft with 2 PTFE-membrane vascular plugs.

Effect of cerebrospinal fluid pressure elevation on spinal cord perfusion during aortic cross-clamping with distal aortic perfusion.

Distal aortic perfusion (DaP) is a widely accepted protective adjunct facilitating early reinstitution of visceral perfusion during extended thoracic and thoraco-abdominal aortic repair. DaP has also been suggested to secure distal inflow to the paraspinal collateral network via the hypogastric arteries and thereby reduce the risk of spinal cord ischaemia. However, an increase in cerebrospinal fluid (CSF) pressure is frequently observed during thoracoabdominal aortic aneurysm repair. The aim of this study was to evaluate the effects of DaP on regional spinal cord blood flow (SCBF) during descending aortic cross-clamping and iatrogenic elevation of cerebrospinal fluid pressure. Eight juvenile pigs underwent central cannulation for cardiopulmonary bypass according to our established experimental protocol followed by aortic cross-clamping of the descending thoracic and abdominal aorta-mimicking sequential aortic clamping-with the initiation of DaP. Thereafter, CSF pressure elevation was induced by the infusion of blood plasma until baseline CSF pressure was tripled. At each time-point, microspheres of different colours were injected allowing for regional SCBF analysis. DaP led to a pronounced hyperperfusion of the distal spinal cord [SCBF up to 480%, standard deviation (SD): 313%, compared to baseline]. However, DaP provided no or only limited additional flow to the upper and middle segments of the spinal cord (C1-Th7: 5% of baseline, SD: 5%; Th8-L2: 24%, SD: 39%), which was compensated by proximal flow only at C1-Th7 level. Furthermore, DaP could not counteract an experimental CSF pressure elevation, which led to a further decrease in regional SCBF most pronounced in the mid-thoracic spinal cord segment. Protective DaP during thoraco-abdominal aortic repair may be associated with inadequate spinal protection particularly at the mid-thoracic spinal cord level ('watershed area') and result in the adverse effect of a potentially dangerous hyperperfusion of the distal spinal cord segments.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.