Spinal Drainage Research Articles

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.

Surgical Treatment Methods of Post-coarctation Aneurysms of Aorta

Introduction. Aortal coarctation is one of the most studied conditions of heart congenital defects, which comprises from 7% to 10% of all congenital heart defects.
 During many years the various treatment strategies were used. Open surgical reconstructive intervention was first de-scribed in 1945, and this was, as a rule, resection of aortal narrowed portion.
 Although the treatment of coarctation is usually successful in a short-term perspective, there is a well-known fact of de-velopment of complications at the later stages, especially after surgical reconstruction, such as post-coarctation aneurysms.
 Objective. To analyze surgical methods of correction of coarctation.
 Materials and methods.in the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine during the period 1960–2017, 4245 patients were operated with native coarctation of aorta.
 Selective patients’ choice for this work was restricted only by such cases of aneurysm of descending aorta, for which the data were reliable. Considering the above, we will be limited by the period of observation, starting from 1995.
 Totally, 91 cases with aneurysm of descending aorta were included in this work, 85 (93.4%) of patients were re-operated, 6 (6.6%) of patients were not operated due to various reasons. The patient distribution by age and gender at the moment of correction of aortal coarctation showed that they included 68 (74.7%) males and 23 (25.3%) females in the ratio 2.9:1. The average patient age by that time was 14.7, ranging from 1 to 38 years.
 By the moment of discovery of post-coarctation aneurysm the patients’ age increased to an average 38.1, ranging from 21 to 60 years. The average time interval between the surgery of aortal coarctation and diagnosis of aneurysm of descending aorta was 22 years, ranging from 1 month to 45 years.
 The frequency of complications of aneurysm of descending aorta after surgery of aortal coarctation was different for various surgical methods. Among the aneurysms, which developed after coarctation correction, the most frequent were aneurysms after implantation of synthetic patch – 61(88.5%). The less frequent were aneurysms in 6 (8.7%) patients after implantation of tubular prostheses, and in 2 (2.8%) patients – after end-to-end anastomosis.
 Results and discussion. Till recent time the standard treatment practice was open surgical operation with direct access to proximal part of descending aorta by left-sided lateral.
 In our Department 85 surgical interventions were performed, including 69 surgeries by the traditional surgical method. From these patients, 7(10.1%) were operated two times, and 2(2.9%) – three times. In all 69(81.2%) cases, operated by open traditional surgical method, we performed vascular prosthesis implantation.
 Such operations require highly qualified anesthetic support with obligatory differential endobronchial intubation, cor-rection of disorders of respiratory and kidney functions, and compensation of present and possible blood loss [4]. Consider-ing high probability of uncontrolled hemorrhage at the stage of aneurysm mobilization, we installed temporary bypass graft – 75.3% or CPB pump – 24.7%, from ascending aorta or left atrium to descending aorta or femoral artery.
 Hospital mortality in this patient cohort was 5.9%.The use of endovascular treatment of thoracic aorta aneurysm increased considerably since Dake et al. in 1994 implanted the first stent-graft into thoracic aorta.
 In our Department, we performed 16(18.8%) of the procedures under general anesthesia with spinal drainage. For the patients, who require the covering of the zone of going of left subclavian artery or left common carotid artery, we perform extra-anatomic shunting 9(10.5%), or even subtotal debranching 2(0.2%), if there is no possibility to use individually pre-pared scalped stent-graft. The most common access is through common femoral artery by operative access 15(17.6%), or, more recently, by transcutaneous access 1(1.1%).

TAA 6. Staging Procedures, Cerebrospinal Fluid Drainage, Selective Neuromonitoring, and Use of Conduits During Complex Endovascular Aortic Repair in Patients With High Risk of Spinal Cord Injury

Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) and thoracoabdominal aortic aneurysm (TAAA) repair is a devastating complication. Outcomes improved significantly after 2015, when we revised our spinal cord protection strategy. This study describes a single experience of SCI prevention in patients who have had endovascular repair. A prospectively maintained database of patients having repair using standard, branched/fenestrated stent grafts at a single university center was reviewed. We optimized the implantation procedure, including the early restoration of pelvic and lower limb perfusion by precannulated devices and temporal conduits. The left subclavian artery was routinely revascularized before coverage. Procedures for extent thoracic and II and III TAAAs were staged. The aim was also to maintain controlled perfusion to the sac before complete exclusion. In cases of TEVAR, the first step was subclavian revascularization, then endograft deployment, and the next step was proximal occlusion of the left subclavian artery with a plug. For the TAAA, strategies used for staging included placement of the thoracic component; branch/fenestration device deployment, maintaining perfusion to the sac by delayed completion of either one of the stent graft side branches, perfusion branches, or contralateral iliac limb extension; and complete exclusion after side branch occlusion test and motor and somatosensory evoked potential monitoring (Fig). The current policy was to place a spinal drain; the mean arterial pressure is raised to >90 to 100 mm Hg, and the hemoglobin level is maintained at 10 g/dL. Twenty-nine patients (median age, 73 years; 24 male patients; 20 TEVARs and 9 branched/fenestrated endovascular aneurysm repairs) underwent endovascular repair. No death or neurologic symptoms or signs related to SCI were registered at 30 days. Temporary iliofemoral conduits were used in 16 limbs in 14 patients. One patient had a ≥75% decrease in motor and somatosensory evoked potential amplitude, and the complete exclusion of the sac was delayed for 2 more weeks. No patients developed late SCI or mortality. This series illustrates the importance of a dedicated institutional protocol aimed at ensuring the intraoperative maneuvers to avoid perioperative paraplegia. This study aimed to demonstrate the possible protective effects of ischemic preconditioning on the preservation of spinal cord function after segmental and sequential artery occlusion.

Total Endovascular Repair of the Aortic Arch: Initial Experience in the Netherlands

We report procedural and early results in the Netherlands of the Relay Branch device (Terumo Aortic, Sunrise, FL) for total endovascular repair of the aortic arch. Between 2014 and 2018, all consecutive patients who received the Aortic Relay double-branched stent graft in the Netherlands were included in a multicenter, retrospective registry. The Relay Branch device was used in 11 patients to treat saccular (n= 4), fusiform (n= 5), or false aneurysms (n= 2) in the aortic arch. Patients were deemed unfit or extreme high-risk for open (redo) surgery. The brachiocephalic trunk and left common carotid artery were branched using a retrograde approach in all cases. Additional surgical left subclavian artery revascularization was performed in 8 patients. The main device and the branches were successfully introduced, positioned, and deployed with complete exclusion of the aortic pathology in all patients (100% technical success). There was no retrograde type A dissection or conversion to open surgery. Two procedure-related deaths occurred, both caused by perioperative or postoperative strokes. There were 2 minor strokes with full recovery. One patient recovered from transient paraplegia after spinal fluid drainage. No permanent paraplegia was observed. Follow-up imaging showed persistent adequate exclusion of aortic arch pathology. Mean follow-up was 17 months (range, 3-42 months). Total endovascular aortic arch repair using the Relay Branch device is technically feasible and effective in excluding aortic arch pathology. The observed stroke rate in the initial experience, however, was considerable. Although appealing, this new less-invasive technique should be carefully introduced and its progress thoroughly evaluated.

Cervical spinal dural fistulas leading to remote thoracolumbar myelopathy: A diagnostic pitfall.

Spinal dural arteriovenous fistulas (SDAVFs) are abnormal connections between 1 or more radiculomeningeal arteries and a single radiculomedullary vein draining into the perimedullary venous system. SDAVFs present in older patients with a progressive myelopathy caused by diffuse spinal venous hypertension. The discrepancy between the focal nature of the arteriovenous shunt and the extent of the induced myelopathy is a classic feature of SDAVFs related to the coexistence of diffuse spinal venous drainage impairment. We describe 3 cases of cervical SDAVFs (at C1, C4, and C7) presenting with a myelopathy that spared the cervical spinal cord and, in 2 instances, the upper thoracic cord. This is to our knowledge the first observations of cervical SDAVFs with MRI showing absent or subtle flow voids and presenting remote thoracolumbar myelopathy without cervical cord involvement. A considerable distance may separate low-flow spinal arteriovenous fistulas from the spinal cord damage they produce. These observations emphasize the importance of performing a complete spinal angiogram when investigating a vascular myelopathy of any location and extent.

Microsurgical resection of ossification of the posterior longitudinal ligament in the thoracic spine via the transthoracic approach without spinal fusion: case series and technical note.

Surgical management of thoracic ossification of the posterior longitudinal ligament (OPLL) remains challenging because of the anatomical complexity of the thoracic spine and the fragility of the thoracic spinal cord. Several surgical approaches have been described, but it remains unclear which of these is the most effective. The present study describes the microsurgical removal of OPLL in the middle thoracic level via the transthoracic anterolateral approach without spinal fusion, including the surgical outcome and operative tips. Between 2002 and 2017, a total of 8 patients with thoracic myelopathy due to OPLL were surgically treated via the transthoracic anterolateral approach without spinal fusion. The surgical techniques are described in detail. Clinical outcome, surgical complications, and the pre- and postoperative thoracic kyphotic angle were assessed. The mean patient age at the time of surgery was 55 years (range 47-77 years). There were 5 women and 3 men. The surgically treated levels were within T3-9. The clinical symptoms and Japanese Orthopaedic Association (JOA) score improved postoperatively in 7 cases, but did not change in 1 case. The mean JOA score increased from 6.4 preoperatively to 7.5 postoperatively (recovery rate 26%). Intraoperative CSF leakage occurred in 4 cases, and was successfully treated with fibrin glue sealing and spinal drainage. The mean follow-up period was 82.6 months (range 15.3-169 months). None of the patients had deterioration of the thoracic kyphotic angle. Anterior decompression is the logical and ideal procedure to treat thoracic myelopathy caused by OPLL on the concave side of the spinal cord; however, this procedure is technically demanding. Microsurgery via the transthoracic anterolateral approach enables direct visualization of the thoracic ventral ossified lesion. The use of microscopic procedures might negate the need for bone grafting or spinal instrumentation.

Stepwise Algorithm for Skull Base Reconstruction in Endoscopic Endonasal Surgery: From the Simple to the Complex

Abstract INTRODUCTION The most frequent complication of endoscopic endonasal surgery (EES) is postoperative cerebrospinal fluid (CSF) leak. This study was designed to develop a step-wise algorithm for EES reconstruction across the spectrum of skull base defects: from free mucosal graft for uncomplicated pituitary adenomas to free flaps in complex cases with recurrent leaks. METHODS All patients with skull base pathologies who underwent EES between January 2017 and December 2018 were included and retrospectively analyzed. Tumor location, reconstruction method and postoperative CSF leak were reviewed and a step-wise algorithm based on size and location of defect was developed. RESULTS Location of skull base defects was categorized as follows: anterior fossa, suprasellar, sellar and posterior fossa. For all nonsellar sites, we performed a multilayer (collagen matrix + /- fascia lata + /− fat graft + vascularized flap) reconstruction. The nasoseptal flap (NSF) was the first choice for vascularized reconstruction when available. For all sellar lesions we employed a free mucosal graft unless a high-flow CSF leak was present, in which case a single-layer reconstruction with NSF was performed. When the NSF was not available, alternative local (lateral nasal wall flap) and regional (extracranial pericranial flap) pedicled flaps were successful choices. When patients failed multiple attempts at repair, regional or microvascular free flaps were options. Lumbar spinal drainage was employed for large anterior and posterior fossa defects and during secondary repair of postoperative CSF leaks. Of 347 patients, 4.6% had a postoperative CSF leak. Of 158 patients with an intraoperative leak (45.5%), 10.1% developed a postoperative CSF leak: 7.8% for sellar/suprasellar defects and 13% for anterior/posterior fossa defects. CONCLUSION This algorithm provides a standardized, stepwise approach to the reconstruction of all skull base defects after EES based on location.

Hydrocephalus after foramen magnum decompression for Chiari I malformation successfully treated with the aspiration of pseudomeningocele: a case report

BackgroundPseudomeningocele or cerebrospinal fluid leakage is one of the most common complications of foramen magnum decompression with duraplasty for Chiari I malformation. Usually, cerebrospinal fluid leakage is treated with lumbar drainage and/or secondary suture. However, if hydrocephalus occurs, spinal drainage may cause brain herniation.Case presentationA 54-year-old Japanese woman presented to our hospital with a 10-month history of bilateral finger extension weakness and clumsiness. Magnetic resonance imaging showed displacement of her cerebellar tonsils below the foramen magnum level, with syringomyelia presenting from the C4 to T8 level. Suboccipital craniectomy and C1 laminectomy with duraplasty were performed under general anesthesia. At 1 month after discharge, she again presented to our hospital due to severe headache and nausea. Magnetic resonance imaging of her cervical spine showed pseudomeningocele compressing her cerebellum and spinal cord. Magnetic resonance imaging of her brain also showed ventriculomegaly. Pseudomeningocele aspiration was performed, with 25 ml of fluid removed under X-ray control. Immediately after aspiration her headache and nausea decreased, and she reported improvement in her symptoms with increasing bilateral finger extension strength and decreasing bilateral upper extremity numbness at her 1-year follow-up.ConclusionsAlthough there is a considerable risk of meningitis with the aspiration procedure of pseudomeningocele, an aspiration procedure may be an easy and effective treatment option for postoperative hydrocephalus after suboccipital craniotomy with duraplasty in a patient treated for Chiari I malformation.

Outcomes of a Spinal Drain and Intraoperative Neurophysiologic Monitoring Protocol in Thoracic Endovascular Aortic Repair

Adjuncts for early detection and treatment of spinal cord ischemia (SCI) in thoracic aortic surgery are supported by robust clinical experience in open repair. The utility of cerebrospinal fluid (CSF) drainage and neurophysiologic monitoring (NPM) in thoracic endovascular aortic repair (TEVAR) is less clear. The purpose of this investigation is to determine the influence of a selective institutional spinal cord protection protocol using prophylactic NPM and CSF on outcomes for standard TEVAR. Patients undergoing standard TEVAR entered into a prospectively maintained database from a single institution from 2007 to 2016 were retrospectively reviewed. Preoperative characteristics, aneurysm extent, and etiology were reviewed. Utilization of CSF drains including volume of fluid removed, duration of drainage, and catheter-related complications were collected. NPM data were reviewed to determine the influence on intraoperative management. Exact logistic regression was used to identify independent predictors of SCI. Of 223 patients undergoing TEVAR, 130 met inclusion criteria for the study. CSF drains were used in 71 patients (54.6%), and 56 of 130 (43%) had NPM. SCI occurred in 7 patients (5.4%), of whom 5 had partial or complete recovery. Median time to symptoms of SCI was delayed in all cases (median 52hr, range 8-312), and none of the 4 of 7 patients with adjunct NPM demonstrated intraoperative changes. Intraoperative changes in NPM occurred in 26 (46%), and represented unilateral leg ischemia in all but 2 cases. In both patients, changes consistent with SCI were associated with intraoperative hypotension and resolved with blood pressure augmentation. Neither patient developed postoperative SCI. Median length of stay (22 vs. 9days, P=0.012), operative room time (262 vs. 209, P=0.040), and perioperative mortality (28.6% vs. 4.1%, P=0.046) were significantly higher for patients with SCI versus those without. Length of aortic coverage was found to be the sole independent predictor of SCI (odds ratio 8.2, P=0.026). Complications related to CSF drainage occurred in 4 patients (5.6%) with major complications occurring in 2 patients (2.8%), including 1 with an intrathecal hematoma and permanent bilateral paraparesis. Selective use of prophylactic CSF drainage in TEVAR was associated with moderate risk and questionable benefit. The use of neurophysiological monitoring allowed for early detection and treatment of spinal ischemia, but its utility is limited by logistical factors and to the minority of patients with intraoperative spinal ischemic events.

073 Acute spinal infarction: treatment and outcomes with and without hyperbaric oxygen therapy at fiona stanley hospital

IntroductionSpinal cord infarction is a potentially devastating disorder commonly presenting with anterior spinal artery syndrome developing over minutes to hours, accounting for an estimated 1% of stroke presentations. Aetiologies range from aortic surgical complications, systemic hypotension and other rare causes including fibrocartilaginous embolism and vascular malformations. Diagnosis is clinical combined with restriction on diffusion-weighted MRI. There are no specific treatment guidelines. The evidence for hyperbaric oxygen therapy (HBOT) in acute spinal infarction is mixed. This case series describes ten cases of acute spinal infarction at Fiona Stanley Hospital (FSH), half of which received HBOT.MethodsData for all MRI-proven spinal cord infarctions at FSH between 2014 and 2018 were reviewed.ResultsTen patients, median age 55years (31–74), 60% male. Aetiologies: three fibrocartilaginous emboli, five likely atheroembolic disease, one antiphospholipid syndrome, one cryptogenic. Sixty percent presented with flaccid paraplegia ranging from levels C4 to T11. Five patients received HBOT within a median time of 31 hours from symptom onset, with average 15 treatments. Three patients received triple therapy of HBOT, pentoxyfiline and high-volume lumbar-puncture drainages and had median MRC muscle power of 5- on discharge, compared with 2+ power in those who did not. Nine required inpatient rehabilitation, of average eight weeks’ duration, with median disability at discharge of 3 on the Modified Rankin Scale.ConclusionSpinal infarctions can be severely disabling. Fibrocartilaginous embolism may be more common than previously thought. More research is needed on the role of acute triple therapy with pentoxyfiline, spinal drains and HBOT given the marked difference in this case series.

“Sacral Vein Sign” on MRI with Typical Findings of Spinal Arteriovenous Fistula Suggests a Pelvic Arteriovenous Fistula with Retrograde Spinal Venous Drainage (P2.7-003)

“Sacral Vein Sign” on MRI with Typical Findings of Spinal Arteriovenous Fistula Suggests a Pelvic Arteriovenous Fistula with Retrograde Spinal Venous Drainage (P2.7-003)

False lumen embolization in chronic aortic dissection promotes thoracic aortic remodeling at midterm follow-up

ObjectiveFailure of thoracic endovascular aortic repair (TEVAR) in chronic aortic dissections can be partially explained by retrograde false lumen (FL) flow through distal re-entry tears. After implantation of a thoracic stent graft, FL thrombosis occurs in less than 50% of the cases. The objectives of this study were to describe the feasibility and outcomes of FL embolization in patients with chronic aortic dissections. MethodsBetween June 2015 and January 2018, 27 patients (mean age, 61 ± 14 years) with chronic aortic dissection underwent FL embolization as an adjunct during or after TEVAR placement procedure. Indications for embolization were (1) symptomatic chronic aortic dissections with pain or rapid growth of aortic diameter (≥5 mm/y) requiring rapid exclusion of the aneurysm, (2) aneurysmal dilatation with persistent FL retrograde flow after TEVAR, and (3) large FL aneurysms (≥55 mm) that might lead to persistent retrograde flow. Twenty patients presented with type B chronic aortic dissections (74.1%) and seven presented a residual type A chronic aortic dissections (25.9%). Eight patients had a previous aortic arch replacement (29.6%). Six patients had previous repair with TEVAR (22.2%). The delay between the onset of dissection and the first endovascular repair was 47 months (range, 3-144). Spinal fluid drainage was used in 74.1% of cases (20/27 patients). Embolization devices included coils and vascular plugs. ResultsThe technical success rate was 100% (27/27). Complete spinal cord ischemia was observed in one patient (3.7%). There was one hospital death from pneumonia after zone 1 supra-aortic trunk debranching with TEVAR and embolization. After the index procedure, FL thrombosis was observed in 81.5% of patients (22/27) on late phase computed tomography angiography. Five patients required two or more embolization procedures, leading to a high rate of complete FL thrombosis (92.6%). One patient presented a type IB endoleak and one patient presented a type II endoleak. Radiologic follow-up was 20 ± 10 months. The maximum thoracic aortic diameter significantly decreased from 63 mm to 54 ± 10 mm (P < .001). ConclusionsEmbolization of the FL of chronic aortic dissections is technically feasible with a low morbidity rate. The FL thrombosis is observed in the majority of case and promotes favorable thoracic aortic remodeling. Longer follow-up is needed to confirm these good results on the thoracic aorta and this technique may, therefore, improve the results of TEVAR in chronic aortic dissections.

Stenting of superior mesenteric and celiac arteries does not increase complication rates after fenestrated-branched endovascular aneurysm repair

ObjectiveThis study compared complications in patients undergoing fenestrated-branched endovascular aneurysm repair (F-BEVAR) without and with stenting of the superior mesenteric artery (SMA) or celiac artery (CA), with particular attention to the length of coverage above the CA. MethodsA retrospective review was performed of a prospectively maintained database of patients treated with F-BEVAR for thoracoabdominal aortic aneurysms between July 2012 and May 2017. Data included demographics, risk factors, comorbidities, preoperative aneurysm characteristics, procedural data, and outcomes. Patients were grouped as follows: group 1, no SMA or CA stent; group 2, SMA or CA stent and <5 cm of coverage above the CA; and group 3, SMA or CA stent and ≥5 cm of coverage above the CA. Complications measured included death, myocardial infarction, respiratory failure, stroke or transient ischemic attack, paraplegia, acute kidney injury, mesenteric ischemia, and vascular complications. Individual and composite complications were compared between groups. ResultsThere were 223 patients who had data analyzed (group 1, 53 [24%]; group 2, 101 [45%]; and group 3, 69 [31%]). Mean age was 72 years (76% male). There was no difference in patients' characteristics between groups, except for hypertension (less common in group 2) and history of previous aortic surgery (more common in group 3). Group 2 (15%) and group 3 (90%) had higher spinal drain use than group 1 (2%; P < .0001). Mean operative time was longer in groups 2 and 3 compared with group 1 (group 1, 224 minutes; group 2, 253 minutes; and group 3, 313 minutes; P < .0001). Group 1 had more intraoperative complications, without difference in the technical success and mortality rates. Failure to deliver a bridging stent occurred in only 3 of 695 vessels (0.4%) intended, without difference between groups (P = .79). The incidence of major complications (individually and composite analysis) was similar between groups. On 30-day computed tomography angiography, there was no difference in type I or type III endoleaks (2%, 3%, and 6%) and branch patency (98%, 99%, and 99%) for groups 1, 2, and 3, respectively. At 3 years of follow-up, there was no difference in survival, stent patency, and branch instability. Group 3 had a higher reintervention rate compared with groups 1 and 2 (P < .0001); however, there was no difference between groups 1 and 2 (P = .31). ConclusionsPatients who needed SMA or CA incorporation with stents during F-BEVAR for aortic repair had more complex procedures, as assessed by operative time, brachial access, number of vessels incorporated, and spinal drain use. However, the extension of the repair did not affect the outcomes, demonstrated by similar mortality and morbidity rates between groups.

Efficacy of three-dimensional rotational fluoroscopic unit guidance for lumbar cerebrospinal fluid drainage among patients with unsuccessful initial attempt at bedside.

Lumbar cerebrospinal fluid drainage has been widely performed in patients at the bedside; however, technical failure can occasionally occur as a result of blind maneuvering. Herein, we present the use of rotational fluoroscopic unit-guided lumbar drainage for patients with an unsuccessful initial attempt at bedside. In four of the 24 patients with aneurysmal subarachnoid hemorrhage, initial lumbar drainage could not be performed at bedside. Thus, a three-dimensional rotational technology guided by a high-quality fluoroscopic unit was used. After a cone-beam computed tomography scan was performed, an accurate puncture point and a target thecal sac were identified using the software. The fluoroscopic unit helped us to identify the puncture point and trajectory with a laser pointer on the patient. A needle was inserted along the tract until the cerebrospinal fluid was collected. The lumbar drainage tube was successfully inserted with a single puncture in all four patients. Rotational fluoroscopic technology helps to identify a suitable puncture point, trajectory and target site for lumbar spinal drainage. Our technique is considerably useful in an era wherein minimally invasive procedures are preferred.

Association of preoperative spinal drain placement with spinal cord ischemia among patients undergoing thoracic and thoracoabdominal endovascular aortic repair

ObjectiveSpinal cord ischemia (SCI) is among the most devastating complications of thoracic endovascular aortic repair (TEVAR). Spinal fluid drainage has been proposed as a viable means to reduce SCI, but few data exist to support its routine use. This study investigated the association of preoperative spinal fluid drainage with the risk of SCI after TEVAR. MethodsThe Vascular Quality Initiative TEVAR module was queried for adult patients (≥18 years) undergoing TEVAR (coverage of zones 0-5) between September 2014 and March 2018 (inclusive). Patients with preoperative spinal malperfusion, aortic rupture on presentation, and connective tissue disorders were excluded. One-to-one propensity matching was used to balance patients on 44 separate dimensions by the nearest neighbor principle to compare those with vs those without preoperative spinal drainage. The primary end point was SCI still present at the time of discharge. Secondary outcomes were 30-day mortality and prolonged intensive care unit stay (>7 days). ResultsAmong 4287 patients who underwent TEVAR (mean age, 67.1 [standard deviation, 13.7] years; 1665 [38.8%] women and 2622 [61.2%] men), 2076 had a spinal drain placed. Propensity matching yielded 1292 pairs with adequate covariate balance (all 44 absolute standardized differences <0.1). In the 2584 propensity-matched patients, spinal drain placement was associated with a reduced risk of SCI (1.5% vs 2.5%; risk-adjusted odds ratio [OR], 0.47; 95% confidence interval [CI], 0.24-0.89; P = .02). The rates of 30-day mortality (4.5% vs 5.0%; risk-adjusted OR, 0.67; 95% CI, 0.44-1.01; P = .05) and prolonged intensive care unit stay (7.0% vs 5.7%; risk-adjusted OR, 1.10; 95% CI, 0.84-1.45; P = .48) did not differ on the basis of spinal drain placement. The crossover rate was 10% (127/1292), and those with postoperative drain placement had a 20% (26/127) SCI rate on discharge. ConclusionsAmong patients undergoing thoracic and thoracoabdominal endovascular aortic repair, preoperative placement of a spinal drain, compared with no drain, was associated with reduced risk of SCI. Cerebrospinal fluid drainage as a rescue measure does not provide the same protection offered by routine preoperative placement. Further investigation, including randomized controlled trials, is needed to more definitively determine the role for spinal drainage in TEVAR.

Outcomes and complications after fenestrated-branched endovascular aortic repair

ObjectiveTo report the outcomes of patients enrolled in a physician-sponsored investigational device exemption trial for endovascular treatment of complex thoracoabdominal aortic aneurysms with fenestrated and/or branched devices. MethodsThis study represents a retrospective analysis of a prospectively maintained database of patients enrolled in a physician-sponsored investigational device exemption trial for endovascular treatment of complex thoracoabdominal aneurysms between July 2012 and July 2017. Subjects included high-risk patients for open repair and patients with unsuitable anatomy for either standard endovascular aneurysm repair or Zenith (Cook Medical, Bloomington, Ind) fenestrated device. Aneurysm classification was based upon Crawford classification. We included the pararenal and paravisceral aneurysms in the type IV aneurysm group, because the repair of these aneurysms usually involved treatment of all four visceral branches. The endografts implanted were custom manufactured devices or off-the-shelf devices based on the Cook Zenith platform. Variables analyzed included preoperative demographics and comorbidities, anatomic aneurysmal characteristics, procedural details, and perioperative complications. ResultsOne -hundred fifty patients with a mean age of 71 ± 7.9 years were treated; 69% were male. Tobacco use (93%) and hypertension (91%) were the most common risk factors. Fifty-seven patients (38%) had a history of previous aortic repair. The mean aneurysm diameter was 62 ± 12 mm and 14 (9%) aneurysms were associated with chronic dissection. A total of 573 visceral vessels were incorporated (celiac artery/superior mesenteric artery [287 vessels], renal arteries [275 vessels], and 11 additional vessels) and 539 were stented. The celiac artery/superior mesenteric artery received a fenestrated design in 76.1% of cases. Branch designs were used in the renal artery in 13.2%, with the remainder treated with fenestrations. Spinal cord drainage was used in 51% of patients (76/150). The mean operative time, fluoroscopy time, and estimated blood loss were 283 ± 89 minutes, 83 ± 38 minutes, and 417 ± 404 mL, respectively. There were five patients (3.3%) with intraoperative complications, resulting in one intraoperative death. The early mortality was 2.7% (4/150). Major complications included respiratory failure in 7% (10/150), stroke and myocardial infarction in 0.7% each (1/150), and paraplegia in 2.7% (4/150). Acute kidney injury occurred in 4.7% of patients (7/150), two of whom required temporary dialysis. Thirty-nine percent of patients experienced at least one complication. Early branch vessel patency was 99.8% (525/526). Survival, primary, and primary-assisted branch patency at 2 years of follow-up were 79%, 97%, and 99%, respectively. ConclusionsEndovascular repair of complex aneurysms is safe and effective when performed in a high-volume center experienced in aortic disease management. Branch vessels patency and the low incidence of paraplegia and mortality support expanded use to treat most complex thoracoabdominal aortic aneurysms.

Association of Preoperative Spinal Drainage Placement With Spinal Cord Ischemia Among Patients Undergoing Thoracic Endovascular Aortic Repair

Association of Preoperative Spinal Drainage Placement With Spinal Cord Ischemia Among Patients Undergoing Thoracic Endovascular Aortic Repair

Resection of a Dumbbell Skull Base Meningioma by a Combined Two-Staged Retrosigmoid and Transzygomatic Transcavernous Approach.

This case describes a 32-year-old male with 2 months of headache accompanied with slight right-hand hemiparesis. During a physical examination, he was also detected left facial hypoesthesia. An enhanced magnetic resonance imaging (MRI) showed a large size lesion on the region of the left cerebellopontine angle, with large displacement of the brainstem and cerebellum. The tumor extended to the cavum of Meckel, displacing and pushing the left cavernous sinus upward. After analyzing the anatomical characteristics of the tumor, surgery was decided in two steps. Since the symptoms were mostly produced by the tumor part located in the posterior fossa, a decision was made to first resect that part of the tumor. With the patient in a semisitting position, we performed a left retrosigmoid craniotomy, exposing the transverse and sigmoid sinus edges. Using microsurgical technique, and ultrasonic aspirator, the complete removal of the lesion located in the posterior fossa was achieved. The patient presented a very good postoperative period, without a new neurological deficit. A month after the surgery, the patient no longer suffered from headaches or hemiparesis, but continued the left facial hypoesthesia. The pathology reported clear cell meningioma. Another month later, a transcygomatic approach plus peeling of the cavernous sinus was performed with the patient in the supine position and head rotated to the right side. Spinal drainage was previously placed. The total resection of the tumor was achieved without any surgical complication. The patient presented an excellent postoperative condition without new neurological deficit. The pathologist confirmed the diagnosis of clear cell meningioma. The link to the Video can be found at: https://youtu.be/SmRy5HiJYJI .

Risk of spinal cord ischemia after fenestrated or branched endovascular repair of complex aortic aneurysms

ObjectiveThe aim of our study was to analyze the incidence of spinal cord ischemia (SCI) in patients presenting with complex aortic aneurysms treated with endovascular aneurysm repair (EVAR) and to identify risk factors associated with this complication. MethodsA retrospective study was undertaken of prospectively collected data including patients presenting with complex aortic aneurysm (pararenal abdominal aortic aneurysm and thoracoabdominal aortic aneurysm) treated with fenestrated EVAR (F-EVAR) or branched EVAR (B-EVAR). The primary end point was the incidence of SCI and the assessment of any associated factors. ResultsBetween January 2011 and August 2017, a total of 243 patients (mean aneurysm diameter, 65.2 ± 15.3 mm; mean age, 72.4 ± 7.5 years; 73% male) were treated with F-EVAR or B-EVAR. Asymptomatic patients were treated in 73% of the cases (177/243, in contrast to 27% urgent), and 52% (126/243) were treated for thoracoabdominal aortic aneurysm (in contrast to 48% for pararenal abdominal aortic aneurysm). F-EVAR (mean number of fenestrations, 3.3/case) and B-EVAR (mean number of branches, 3.7/case) were undertaken in 67% (164/243) and 33% (79/243), respectively. The total incidence of SCI was 17.7% [43/243; paraplegia in 4% (10/243) and paraparesis in 13.7% (33/243)]. Most of the patients with SCI presented with immediate postoperative symptoms (72% [31/43]). A spinal drain was preoperatively placed in 53% (130/243) and was associated with the prevention of SCI (SCI with spinal drainage, 12% [16/130]; SCI without spinal drainage, 24% [27/113]; P = .018). The 30-day mortality rate was 9% (21/243). After multiple logistic regression analysis, SCI was associated with preoperative renal function (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m2: odds ratio [OR], 2.43; 95% confidence interval [CI], 1.18-4.99; P = .016) and the number of vertebral segments covered (SCI with higher position of proximal stent in terms of vertebra: OR, 1.2; 95% CI, 1.1-1.3; P = .000). A similar outcome was derived when the height of the proximal end of the stent graft was replaced by the total length of aortic coverage (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m2: OR, 2.36 [95% CI, 1.11-5.00; P = .025]; SCI with longer length of aortic coverage: OR, 1.01 [95% CI, 1.003-1.009; P = .000]). ConclusionsThe majority of SCI incidence after F-EVAR or B-EVAR of complex aortic aneurysms is manifested immediately postoperatively. The use of preoperative spinal drainage may prevent SCI. Patients with GRF <60 mL/min/1.73 m2 and with longer aortic stent graft coverage are at higher risk of SCI.

Spinal Cord Ischaemia in Endovascular Thoracic and Thoraco-abdominal Aortic Repair: Review of Preventive Strategies

Introduction: The incidence of spinal cord ischaemia (SCI) and subsequent paraplegia after thoracic endovascular aneurysm repair (TEVAR) and thoraco-abdominal endovascular aneurysm repair is estimated to be between 2.5% and 8%. The aim of this review is to provide an overview of SCI preventive strategies in TEVAR and thoraco-abdominal repair and recommend an optimal strategy. Methods: Medline, Embase, and the Cochrane Library were searched for studies on TEVAR, thoraco-abdominal endovascular repair, and the use of SCI preventive measures. The review was reported according to the PRISMA statement. Results: The final analysis included 43 studies (7168 patients). All studies are cohort studies (non-comparative cohorts n = 37, comparative cohorts n = 6) and largely performed retrospectively (n = 27). The included studies had an average MINORS score of 9 (range 6-13) for non-comparative studies and 15.5 (range 12-18) for comparative studies. Transient SCI occurred in 5.7% (450/7,168, 95% CI 4.5-6.9%), permanent SCI in 2.2% (232/7,168, 95% CI 1.6-2.8%). There was a trend towards increased SCI incidence for more cohorts. Avoidance of hypotension resulted in a slightly lower permanent SCI rate 1.8% (102/4216, 95% CI 1.2-2.3%) than the overall cohort. A very low SCI estimate (transient and permanent) was found in the subgroup of studies (2 studies, n = 248) using (mild) peri-operative hypothermia (transient SCI 0.8%, permanent SCI 0.4%). In the subgroup using temporary permissive endoleak, there was a transient SCI estimate (15.4%), with a permanent SCI estimate of 4.8%. The remaining preventive measures did not significantly impact transient or permanent SCI estimates. Conclusion: Low overall transient and permanent SCI rates are achieved during endovascular thoracic and thoraco-abdominal aortic repair. Based on the presented data, the use of selective spinal fluid drainage in high risk patients seems justified. Peri-operative hypotension should be avoided and treated where possible. The use of mild hypothermia is promising in small cohorts, but requires further evaluation. Further high quality data are essential to establish a definitive preventive strategy.