Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery†

Abstract

Ischaemic spinal cord injury (SCI) remains the Achilles heel of open and endovascular descending thoracic and thoracoabdominal repair. Neurological outcomes have improved coincidentially with the introduction of neuroprotective measures. However, SCI (paraplegia and paraparesis) remains the most devastating complication. The aim of this position paper is to provide physicians with broad information regarding spinal cord blood supply, to share strategies for shortening intraprocedural spinal cord ischaemia and to increase spinal cord tolerance to transitory ischaemia through detection of ischaemia and augmentation of spinal cord blood perfusion. This study is meant to support physicians caring for patients in need of any kind of thoracic or thoracoabdominal aortic repair in decision-making algorithms in order to understand, prevent or reverse ischaemic SCI. Information has been extracted from focused publications available in the PubMed database, which are cohort studies, experimental research reports, case reports, reviews, short series and meta-analyses. Individual chapters of this position paper were assigned and after delivery harmonized by Christian D. Etz, Ernst Weigang and Martin Czerny. Consequently, further writing assignments were distributed within the group and delivered in August 2014. The final version was submitted to the EJCTS for review in September 2014.

Malperfusion syndromes in aortic dissections

“…In fact, it is one of the most devastating complications of successful endovascular thoracic aortic aneurysm repair. Risk factors for spinal cord ischemia following TEVAR include the extent of segmental artery compromise or sacrifice during the repair, involvement of the lumbar region of the aorta, peri-operative and post-operative hypotension and coverage of the LSA during stent deployment (50). …”

Spinal cord injury after thoracic endovascular aortic aneurysm repair

“…7 In 2015, the European Association for Cardiothoracic Surgery similarly recommended CSF drainage for TAAA repair for patients at high risk for SCI. 8 Although randomized controlled studies showed benefit for CSF drainage in open TAAA repair, 9 its routine use in TEVAR procedures remains uncertain and a topic of considerable debate . 8, 10, 11 …”

Endovascular repair of residual intimal tear or distal new entry after frozen elephant trunk for type A aortic dissection

“…Spinal cord injury is a devastating complication following endovascular interventions on the thoracoabdominal aorta (29). In this series, no patient sustained spinal cord ischemia early or late after TEVAR, which may be ascribed to two reasons.…”