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

Kasprzak, Piotr; Gallis, Konstantinos; Cucuruz, Beatrix; Pfister, Karin; Janotta, M.; Kopp, Reinhard

doi:10.1016/j.ejvs.2014.05.020

Cited by 114 publications

(77 citation statements)

References 23 publications

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“…An additional benefit may come from temporary aneurysm sac perfusion associated with type 1b endoleaks partially perfusing the spinal cord until the open surgery. 28 While the reduction seen with staged hybrid repair is confounded by a higher rate of lumbar drain use, this likely does not account for the 50% reduction in MAE.…”

Section: Discussionmentioning

confidence: 99%

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Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair

Hawkins

Mehaffey

Narahari

et al. 2017

Journal of Vascular Surgery

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Objective Complex Crawford extent II thoracoabdominal aortic aneurysms (TAAA) can be treated in a hybrid manner with proximal thoracic endovascular aneurysm repair, followed by staged distal open thoracoabdominal repair. The purpose of this study was to evaluate the outcomes and healthcare associated value of this new method compared to traditional open repair over 10 years. Methods A prospectively collected database was used to identify all patients with extent II TAAA undergoing repair at a single institution between 2005 and 2015. Patient characteristics, post-operative outcomes, and incidence of major adverse events (MAE = renal failure, spinal cord ischemia, death) were compared. After adjusting for time since surgery, value was analyzed looking at quality (1/MAE) divided by cost (total health system cost). This is multiplied by a constant to set the value of open TAAA repair to 100. Results A total of 113 consecutive patients underwent extent II TAAA repairs, of which 25 (22.1%) had a staged hybrid approach with a median of 129 days between procedures. No baseline differences in demographic or comorbidity variables existed between groups (p>0.05). The hybrid group had shorter operative time (255 vs 306 minutes; p=0.01), shorter postoperative length of stay (LOS) (10.1 vs 13.3 days; p=0.02), as well as reduced blood loss (1300 vs 2600 mL; p=0.01) at the time of open operation. Despite higher rates of acute kidney injury in the hybrid group (76.0%vs 51.1%, p=0.03) there was no difference in renal failure (8.0% vs 4.5%, p=0.84) The incidence of MAE was lower in the staged hybrid group (20.0% vs 48.9%; p=0.01), without a difference in hospital mortality (4.0 vs 3.4%, p=0.89). Median total cost was higher in the hybrid group ($112,920 vs $72,037, p=0.003). Value was improved in the hybrid group by 56% using mean cost and 178% by median cost. Conclusions The 20% major adverse event rate associated with staged hybrid repair of extent II TAAA was significantly decreased compared to open repair, with a relative reduction of over 50%. Despite higher total hospital costs, staged hybrid repair had 56% to 178% higher healthcare related value compared to standard open repair. In an era of increasing focus on costs and quality, staged hybrid repair of extensive TAAAs is associated with fewer complications than open TAAA repair resulting in a good value investment from a resource utilization perspective.

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Section: Discussionmentioning

confidence: 99%

“…Current spinal cord ischemia rates are high, but as the technology advances and adjuncts such as temporary aneurysm sac perfusion help decrease this rate, its value should be assessed. 28 …”

Section: Discussionmentioning

confidence: 99%

Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair

Hawkins

Mehaffey

Narahari

et al. 2017

Journal of Vascular Surgery

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“…This is followed by second procedure to complete the exclusion of endobranch (with a stent that bridges the TEVAR stent to the intended visceral vessel) feeding the aneurysm sac after a 1–3 month time interval. 103, 106 Use of this technique showed reduction in the rate of permanent paralysis. Kasprzak et al 103 tested the feasibility of this technique in a prospective study on 83 TEVAR patients (40 patients with TASP vs 43 patients without TASP).…”

Section: Newer Surgical Techniques For Prevention Of Scimentioning

confidence: 93%

“…103, 106 Use of this technique showed reduction in the rate of permanent paralysis. Kasprzak et al 103 tested the feasibility of this technique in a prospective study on 83 TEVAR patients (40 patients with TASP vs 43 patients without TASP). The incidence of SCI was significantly reduced in the TASP group (5% vs 21%, P = 0.03).…”

Section: Newer Surgical Techniques For Prevention Of Scimentioning

confidence: 93%

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Spinal cord injury after thoracic endovascular aortic aneurysm repair

Awad

Ramadan

Sayed

et al. 2017

Can J Anesth/J Can Anesth

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Purpose Thoracic endovascular aortic aneurysm repair (TEVAR) has become a mainstay of therapy for aneurysmal and other disorders of the thoracic aorta. The purpose of this narrative review article is to summarize the current literature on the risk factors, pathophysiology of spinal cord injury (SCI) following TEVAR, and to discuss various intraoperative monitoring and treatment strategies. Source Articles considered in this review were identified through PubMed using the following search terms: thoracic aortic aneurysm, TEVAR, paralysis+TEVAR, risk factors+TEVAR, spinal cord ischemia+TEVAR, neuromonitoring+thoracic aortic aneurysm, spinal drain, cerebrospinal fluid drainage, treatment of spinal cord ischemia. Principal findings Spinal cord injury continues to be a challenging complication after TEVAR. Its incidence after TEVAR is not significantly reduced compared to open TAAA repair. However, compared to open procedures, delayed paralysis/paresis is the predominant presentation of SCI after TEVAR. The pathophysiology of SCI is complex and remains not fully understood though the evolving concept of the importance of the spinal cord’s collateral blood supply network and its imbalance after TEVAR is emerging as a leading factor in the development of SCI. Cerebrospinal fluid drainage, optimal blood pressure management, and newer surgical techniques are important components of the most current spinal cord protection strategies. Conclusion Further experimental and clinical research is needed to aid in the discovery of novel neuroprotective strategies for protection and treatment of SCI following TEVAR.

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