Fate of patients with spinal cord ischemia complicating thoracic endovascular aortic repair

Abstract

Objective Spinal cord ischemia(SCI) is a potentially devastating complication of thoracic endovascular aortic repair(TEVAR) that can result in varying degrees of short-term and permanent disability. This study was undertaken to describe the clinical outcomes, long-term functional impact, and influence on survival of SCI after TEVAR. Methods A retrospective review of all TEVAR patients at the University of Florida from 2000–2011 was performed to identify individuals experiencing SCI as defined by any new lower extremity neurologic deficit not attributable to another cause. SCI was dichotomized into immediate or delayed onset, with immediate onset defined as SCI noted upon awakening from anesthesia, and delayed characterized as a period of normal function followed by development of neurologic injury. Ambulatory status was determined using database query, chart review and phone interviews with patients and/or family. Mortality was estimated using life-tables. Results 607 TEVARs were performed for various indications, with 57 patients(9.4%) noted to have postoperative SCI(4.3% permanent). SCI patients were more likely to be older (63.9±15.6 vs. 70.5±11.2;p=.002) and have a number of comorbidities including: COPD, hypertension, dyslipidemia and cerebrovascular disease(P<.0001). Fifty-four patients(95%) had a CSF drain placed at some point in their care, with the majority placed postoperatively(54%). In-hospital mortality was 8.8% for the entire cohort(SCI vs. No SCI;P=.45). Twelve patients developed immediate SCI, 40 had delayed onset, and 5 were indeterminate due to indiscriminate timing from postoperative sedation. Three(25%) immediate SCI patients had measurable functional improvement (FI), while 28(70%) of the delayed-onset patients experienced some degree of neurologic recovery(P=.04). Of the 34 patients with complete data available, 26(76%) reported quantifiable FI, while only 13(38%) experienced return to preoperative baseline. Estimated mean survival(±standard error) for patients with and without SCI was 37.2±4.5 and 71.6±3.9 months(P<.0006), respectively. Patients with FI had a mean survival of 53.9±5.9 months compared to 9.6±3.6 months for those without improvement(P<.0001). Survival and return of neurologic function were not significantly different when comparing patients with pre- and postoperative CSF drains. Conclusions The minority of patients experience complete return to baseline function after suffering SCI with TEVAR, and outcomes in patients without early functional recovery are particularly dismal. Patients experiencing delayed SCI are more likely to have FI and may anticipate similar life-expectancy with neurologic recovery compared to patients without SCI. Timing of drain placement does not appear to have an impact on post-discharge FI or long-term mortality.

Preoperative prediction of spinal cord ischemia after thoracic endovascular aortic repair

“…Despite the perioperative advantage of TEVAR compared to open aortic repair, SCI remains a devastating complication that has profound influence on long-term outcome. In our own experience, patients who develop permanent SCI after TEVAR have a mean postoperative survival of 37±5 compared to 72±4 months in patients without SCI (P < .0006) 7 . Therefore, identification of which patients are most vulnerable and/or prevention of this complication are crucial to achieving successful outcome after TEVAR.…”

“…SCI has been consistently 7, 12, 14, 17 defined at our institution as any new lower extremity motor and/or sensory deficit that is not explained by any intracranial process and/or peripheral nerve dysfunction (e.g. epidural hematoma, stroke, peripheral neuropathy, or neuropraxia), and may range from frank paralysis to mild paraparesis.…”

Effects of preemptive cerebrospinal fluid drainage on spinal cord protection during thoracic endovascular aortic repair

“…Patients who had any new neurological deficit at the first postoperative neurological examination were classified as having an immediate SCI. Delayed SCI was defined as a newly developed SCI after the first postoperative neurological examination (8). All CSFDs were inserted by the neurosurgery team at our hospital.…”

Cardiovascular Surgical Technique Under Cardiopulmonary Bypass and Cerebrospinal Protection

“…The independent predictors are extensive aortic lesions (extent I and II TAAA), emergency surgery, prolonged aortic cross-clamp time, bleeding, chronic renal failure, old age, severe atherosclerosis, impaired cardiac function, hypotension, history of abdominal aortic repair, and occlusion of the left subclavian artery or internal iliac arteries. Even in the recently advanced thoracic endovascular aortic repair (TEVAR), neurological sequelae develop at an incidence of approximately 5 % [52], particularly in patients requiring a longer coverage of the aortic lesions, including the closure of the arteria radicularis magna (Adamkiewicz artery, AKA) with a stent graft [53,54]. Consequently, appropriate protection of the spinal cord is still a great concern in the critical arguments regarding dTAA and TAAA repairs, including TEVARs and hybrid procedures.…”