Spinal Drainage Research Articles

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.

O060 Staged hybrid single lumen reconstruction (TIGER) in management of chronic symptomatic complex type B aortic dissection

Abstract Introduction We aim to report an innovative technique - Staged Hybrid Single Lumen Reconstruction (TIGER) in the management of chronic symptomatic complex type B aortic Dissection (CS -TBAD). TIGER technique was adopted as a tool for total aortic remodelling with true lumen expansion, false lumen regression and complete thrombosis with stabilization of overall aortic diameter. Methods Aortic dissection cases (n = 5) were managed by the TIGER technique, which included creating a single lumen from the supra celiac, infra-diaphragmatic aorta to both common iliac arteries with open surgical patching of the visceral arteries; followed by TEVAR three months later (mean follow-up 16 months). All had aneurysmal dilation, while 60% had acute pan aortic dissection and 40% CS-TBAD. Results Sixty percentages of the patients required a left subclavian artery chimney graft, while 20% required bilateral subclavian to carotid artery transposition. No spinal drainage was needed and all patients had intra-operative trans-oesophageal ECHO for wire guidance. There was no aortic rupture or retrograde type A dissection, and renal, visceral, cardiac, pulmonary, or spinal complications. All, but one patient, went off their antihypertensive medication. 100% of the patients maintained normal eGFR postoperatively with accelerated aortic modulation. Conclusion Our experience showed that TIGER is effective at the semi acute stage to initiate remodelling and prevent malperfusion, facilitating straightforward TEVAR at stage two, which was made easier by avoiding visceral branch stenting. Moreover, the stented aortic segment's length was decreased, avoiding critical shattering, branch dislodgment, and visceral compromise, including spinal ischaemia and negative cardiovascular consequences. Take-home message Staged Hybrid Single Lumen Reconstruction (TIGER) is an effective technique in the management of chronic symptomatic complex type B aortic dissection at the semi acute stage to initiate remodelling and prevent malperfusion, facilitating a straightforward thoracic endovascular aortic repair (TEVAR) made easier by avoiding visceral branch stenting.

Low Psoas Muscle Area is Associated with Increased Mortality and Spinal Cord Injury After Complex Endovascular Aortic Aneurysm Repair

Low psoas muscle area (PMA) is associated with worse post-operative outcomes. Our objective was to evaluate the association of PMA and postoperative outcomes in patients undergoing fenestrated/branched endovascular aneurysm repair (F/BEVAR). Patient characteristics, anatomical and clinical information, and post-operative outcomes were collected from patients undergoing F/BEVAR between 2005-February 2019 who were deemed too high-risk for open repair. PMA was measured using a validated web-based software (coreslicer.com). Post-operative outcomes were compared between patients with low PMA (lowest quartiles) and high PMA (highest quartiles). We included 129 patients with a mean age of 74.6 ± 8.1, 81.4% male, and a mean follow-up of 29.4 ± 32.2 months. Patients in the low PMA group were more likely to be female (33.8% vs. 3.1%, P < 0.0001), less likely to have hypertension (72.3% vs. 87.5%, P = 0.03), dyslipidemia (63.1% vs. 78.1%, P = 0.06), and a trend towards a greater history of endovascular aneurysm repair (4.6% vs. 0%, P = 0.08). There were no significant differences in aneurysm or device characteristics between groups. In a multivariate model including age, sex, aneurysm type, and presence of prophylactic spinal drain, the low PMA group had a significantly increased risk of spinal cord injury (odds ratio 12.7, 95% CI 1.1-143.6). There were no significant differences in other 30-day outcomes. When compared to the highest quartile, the lowest PMA quartile patients had a hazard ratio of 4.6 (95% CI 1.2-17.6) for mortality during follow-up in a model with age, sex, and aneurysm type. For each 1 cm2 increase in PMA, the HR was 0.90 (95% CI 0.82-0.99) for mortality during follow-up. In high-risk patients undergoing F/BEVAR low PMA is associated with spinal cord injury and mortality during follow-up. We found no association between PMA and 30-day mortality. PMA measurement is a simple method to assess for sarcopenia and frailty and may be useful for risk stratification pre-operatively.

The neurosurgical management of sinonasal malignancies involving the anterior skull base: a 28-year experience at The MD Anderson Cancer Center.

Sinonasal malignancies that extend to the anterior skull base frequently require neurosurgical intervention. The development of techniques for craniofacial resection revolutionized the management of these neoplasms, but modern and long-term data are lacking, particularly those related to the incorporation of endoscopic techniques and novel adjuvant chemotherapeutics into management schema. The present study was performed to better define the utility of surgical management and to determine factors related to outcome. Patients who underwent surgery between 1993 and 2020 were included in this retrospective cohort study. Only patients with greater than 6 months of clinical and radiological follow-up were included. Outcome measures included progression, survival, and treatment-related complications. Two hundred twenty-five patients were included. The mean clinical follow-up was 6.5 years. The most common histological diagnosis was olfactory neuroblastoma (33%). Overall, metastatic disease and brain invasion were present in 8% and 19% of patients, respectively, at the time of surgery. A lumbar drain was used in 54% of patients. When stratified by decade, higher-stage disease at surgery became more frequent over time (15% of patients had metastatic disease in the 3rd decade of the study period vs 4% in the 1st decade). Despite the inclusion of patients with progressively higher-stage disease, median overall survival (OS) remained stable in each decade at approximately 10 years (p = 0.16). OS was significantly worse in patients with brain invasion (p = 0.006) or metastasis at the time of surgery (p = 0.014). Complications occurred after 28% of operations, but typically resulted in no long-term negative sequelae. Use of a lumbar drain was a significant predictor of complications (p = 0.02). Permanent ophthalmological disabilities were observed after 4% of surgical procedures. One patient died during the perioperative period. Finally, major complications (Clavien-Dindo grade ≥ IIIb) decreased from 27% of patients in the 1st decade to 10% in the 3rd decade (p = 0.007). The surgical management of sinonasal malignancies with anterior skull base involvement is effective and generally safe. Surgical management, however, is only one facet of the overall multimodal management paradigms created to optimize patient outcomes. Survival outcomes have remained stable despite more extensive disease at surgery in patients who have presented in recent decades. The safety of such surgery has improved over time owing to the incorporation of endoscopic surgical techniques and the avoidance of lumbar spinal drainage with open resection.

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.

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

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

Brain Fluid Channels for Metabolite Removal.

The adult human brain represents only 2% of the body's total weight, however it is one of the most metabolically active organs in the mammalian body. Its high metabolic activity necessitates an efficacious waste clearance system. Besides the blood, there are two fluids closely linked to the brain and spinal cord drainage system: interstitial fluid (ISF) and cerebrospinal fluid (CSF). The aim of this review is to summarize the latest research clarifying the channels of metabolite removal by fluids from brain tissue, subarachnoid space (SAS) and brain dura (BD). Special attention is focused on lymphatic vascular structures in the brain dura, their localizations within the meninges, morphological properties and topographic anatomy. The review ends with an account of the consequences of brain lymphatic drainage failure. Knowledge of the physiological state of the clearance system is crucial in order to understand the changes related to impaired brain drainage.

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.

Anterior spinal artery syndrome due to Clostridium septicum aortitis

Anterior spinal artery syndrome due to Clostridium septicum aortitis

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.

Prediction of Shunt Responsiveness in Suspected Patients With Normal Pressure Hydrocephalus Using the Lumbar Infusion Test: A Machine Learning Approach

Machine learning (ML) approaches can significantly improve the classical Rout-based evaluation of the lumbar infusion test (LIT) and the clinical management of the normal pressure hydrocephalus. To develop a ML model that accurately identifies patients as candidates for permanent cerebral spinal fluid shunt implantation using only intracranial pressure and electrocardiogram signals recorded throughout LIT. This was a single-center cohort study of prospectively collected data of 96 patients who underwent LIT and 5-day external lumbar cerebral spinal fluid drainage (external lumbar drainage) as a reference diagnostic method. A set of selected 48 intracranial pressure/electrocardiogram complex signal waveform features describing nonlinear behavior, wavelet transform spectral signatures, or recurrent map patterns were calculated for each patient. After applying a leave-one-out cross-validation training-testing split of the data set, we trained and evaluated the performance of various state-of-the-art ML algorithms. The highest performing ML algorithm was the eXtreme Gradient Boosting. This model showed a good calibration and discrimination on the testing data, with an area under the receiver operating characteristic curve of 0.891 (accuracy: 82.3%, sensitivity: 86.1%, and specificity: 73.9%) obtained for 8 selected features. Our ML model clearly outperforms the classical Rout-based manual classification commonly used in clinical practice with an accuracy of 62.5%. This study successfully used the ML approach to predict the outcome of a 5-day external lumbar drainage and hence which patients are likely to benefit from permanent shunt implantation. Our automated ML model thus enhances the diagnostic utility of LIT in management.

Anatomy of Spinal Venous Drainage for the Neurointerventionalist: From Puncture Site to Intervertebral Foramen.

CSF-venous fistula is a relatively novel entity that is increasingly being recognized as a cause for spontaneous intracranial hypotension. Recently, our group published the first series of transvenous embolization of CSF-venous fistulas in this journal. Having now performed the procedure in 60 patients, we have garnered increasing familiarity with the anatomy and how to navigate our way through the venous system to any intervertebral foramen in the cervical, thoracic, and lumbar spine. The first part of this review summarizes the organization of spinal venous drainage as described in classic anatomy and interventional radiology texts, the same works that we studied when attempting our first cases. In the second part, we draw mostly on our own experience to provide a practical roadmap from the puncture site to the foramen. On the basis of these 2 parts, we hope this article will serve to collate the relevant anatomic knowledge and give confidence to colleagues who wish to embark on transvenous spinal procedures.

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

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

Multicentre Outcomes of Redo Fenestrated/Branched Endovascular Aneurysm Repair to Rescue Failed Fenestrated Endografts

To report the outcomes of redo fenestrated and/or branched endovascular aortic repair (F/BEVAR in FEVAR) to rescue previous failed FEVAR. Retrospective review of all consecutive patients undergoing F/BEVAR in FEVAR at eight aortic centres including pre-, intra-, and post-operative data according to a pre-established protocol. Follow up consisted of at least yearly computed tomography angiography. Values are presented as median and interquartile range, and survival as estimate ± standard error in percentage. 18 male patients (76 years old; range 69 – 78 years) receiving FEVAR involving two (two or three) target vessels between 2006 and 2016 underwent F/BEVAR in FEVAR between 2012 and 2019 (aneurysm diameter of 63 mm; range 56 – 69 mm). Median interval between the procedures was 53 (29 – 103) months. The indication for F/BEVAR in FEVAR was type Ia endoleak in 16 cases (eight isolated and eight combined with graft migration), one graft migration without endoleak and one migration with significant proximal aortic expansion. F/BEVAR in FEVAR involved all patent renovisceral arteries and had an operating time of 260 (204 – 344) minutes. Technical success was achieved in 15 (83%) cases. There was a failure to bridge one renal artery, one renal capsular bleed with the subsequent need for renal artery embolisation within 24 hours and one persistent type Ib endoleak despite iliac extension. There was no peri- or in hospital death. Two patients developed spinal cord ischaemia, one transient paraparesis and one permanent paraplegia. The latter occurred in a non-staged procedure where spinal drainage was used. During a follow up of 27 (7 – 39) months, three (17%) patients underwent late re-interventions. Overall survival at 24 months was 70 ± 11% with no aneurysm related death and a secondary clinical success at 24 months of 84 ± 11%. F/BEVAR in FEVAR is a technically challenging but feasible solution to rescue failed FEVAR. The outcomes are promising in many aortic centres but need to be confirmed by further studies with longer follow up.

Stroke, spinal cord ischemia and upper limb ischemia in patients undergoing TEVAR with coverage of the left subclavian artery: a case series study

BackgroundWe performed routine spinal fluid drainage for patients who underwent TEVAR for thoracic aortic pathology together with left subclavian artery coverage, which was needed for achievement of a safe proximal sealing zone. We assessed the occurrence of spinal cord ischemia as well the rate of occurrence of other complications such as stroke, and upper limb ischemia.ResultsThis was a case series study done between July 2014 and April 2020, in them all the left subclavian artery was covered to ensure a proximal safe seal zone. Routine spinal fluid drainage was done, keeping the spinal fluid pressure < 10–15 mmHg with catheter in place for 48 h. Data was obtained from twenty-three patients who underwent TEVAR for thoracic aortic dissection (73.91%), thoracic aortic aneurysm (21.74%), or ulcer (4.35%). Planning was based upon multi-slice computed tomographic angiography and covering the left subclavian was mandatory to achieve a proximal sealing zone. Technical success was achieved in 100% of cases. 4.35% of patients had three endograft, 56.52% had two endografts, 39.13% had one endograft. All patients lost their radial pulsations immediately after implantation, 8.70% developed post implantation syndrome(fever) that was managed conservatively, 4.35% developed stroke related to the anterior circulation, 4.35% developed signs of spinal cord ischemia. During the follow up, one patient died within 6 h after the procedure due to extensive myocardial infarction (patient was scheduled for CABG after our procedure). 17.40% developed upper limb symptoms that were tolerable and were managed conservatively.ConclusionBy adopting routine spinal cord drainage and pressure monitoring, we can consider not to revascularize the left subclavian artery prior to TEVAR if it will be covered.

Successful surgical management of a tentorial dural arteriovenous fistula causing spinal cord myelopathy

Intracranial dural arteriovenous fistulas account for 10 to 15% of all intracranial arteriovenous malformations. Tentorial dural arteriovenous fistulas with spinal medullary venous drainage causing spinal cord myelopathy have been rarely reported in the literature. We describe a case using a temporo-pterional approach for the surgical treatment of a tentorial artery dural arteriovenous fistula causing spinal cord myelopathy.

Neurological Outcomes in Open Thoracoabdominal Aortic Aneurysm Repair Performed Under Deep Hypothermic Circulatory Arrest With and Without Spinal Drainage

Spinal drainage is a well-accepted adjunct used to reduce the incidence of spinal cord morbidity after open thoracoabdominal aortic aneurysm (TAAA) repair. However, the occurrence of major complications associated with spinal drains such as epidural hematoma can be devastating. Our practice has evolved to routinely performing extensive TAAA repair with the patient under cardiopulmonary bypass and deep hypothermic circulatory arrest (DHCA), because the intraoperative hypothermia provides spinal cord and other organ protection.

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.

VESS Paper SessionAortic Coverage Above the Celiac Artery and Risk Factors for Spinal Cord Ischemia After Fenestrated and Branched Endovascular Aneurysm Aortic Repair (F-BEVAR)

Spinal cord ischemia (SCI) remains a devastating complication after fenestrated or branched endovascular aortic repair (F-BEVAR). A coverage above the celiac artery (CA) greater than 5 cm has traditionally been considered a risk factor for SCI and indication for prophylactic spinal drainage (PSD). The aim of this study was to assess risk factors, particularly aortic coverage above the CA, for SCI in patients treated with F-BEVAR.

Reintervention and Spinal Cord Ischemia After Thoracic Endovascular Aortic Repair for Acute Type B Aortic Dissection With a Zone 3 Entry Tear

Treatment of acute type B aortic dissections (TBADs) using thoracic endovascular aortic repair (TEVAR) is influenced by the location and extent of the pathology, the presence of high-risk features, and complication status. The technical aspects of TEVAR for TBAD (specifically the location of the proximal seal zone [PSZ], the need to cover the left subclavian artery [LSA], distal seal zone [DSZ; length of aortic coverage]), the benefits of LSA revascularization, and prophylactic lumbar spinal drainage are still debated.