Intracranial Hemorrhage After Endovascular Repair of Thoracoabdominal Aortic Aneurysm

Abstract

Background Intracranial hemorrhage (ICH) is a rare but devastating complication of thoracoabdominal aortic aneurysm (TAAA) repair with fenestrated/branched endograft (f/bEVAR). The cerebrospinal fluid drainage (CSFD) is considered one of the leading causes; however, other possible concomitant factors have not been individualized yet. The aim of the present work was to evaluate the pattern of ICH events after f/bEVAR for TAAA and to identify possible associated factors. Materials and Methods All f/bEVAR procedures for TAAA performed in a single academic center from 2012 to 2020 were evaluated. ICH was assessed by cerebral computed tomography if neurological symptoms arose. Pre-, intra-, and postoperative characteristics were analyzed in order to identify possible factors associated. Results A total of 135 f/bEVAR were performed for 72 (53%) type I, II, III and 63 (47%) type IV TAAA; 74 (55%) were staged procedures, 101 (73%) required CSFD, and 24 (18%) were performed urgently. The overall 30-day mortality was 8% (5% in elective cases); spinal-cord ischemia occurred in 11(8%) and ICH in 8 (6%) patients. All ICH occurred in patients with CSFD. ICH occurred intraoperatively in 1 case, inter-stage in 4 and after F/BEVAR completion in 3, after a median of 6 days the completion stage. Three (38%) of 8 patients with ICH died at 30 days and ICH was associated with 30-day mortality: odds ratio (OR) 13.2, 95% confidence interval (CI): 2.3–76, p=0.01. The analysis of the perioperative characteristics identified platelet reduction >60% (OR 11, 95% CI 1.6–77, p=0.03), chronic kidney disease (16% vs 0%, p=0.002), and total volume of liquor drained >50 mL (OR 8.1, 95% CI 1.1–69, p=0.03) as associated with ICH. Conclusions Current findings may suggest that ICH is a potential lethal complication of the endovascular treatment for TAAAs and it mainly occurs in patients with CSFD. High-volume liquor drainage, platelet reduction, and chronic kidney disease seems increase significantly the risk of ICH and should be considered during the perioperative period and for further studies.

Results of a multidisciplinary spinal cord ischemia prevention protocol in elective repair of Crawford's extent I-III thoracoabdominal aneurysm by fenestrated and branched endografts

“…Recently, the US Aortic Research Consortium (US-ARC) [26] published the results of a 65-question survey on the methods and protocols to prevent SCI in high-risk patients. These high-risk patients were identified in the presence of Crawford's extent I-III, a shaggy aorta, a previous EVAR or open infra-renal aortic repair, or an abnormal pelvic or vertebral perfusion.…”

“…On this point, Aucoin et al reported worse neurologic outcomes and lower survival with the therapeutic CSFD for SCI symptoms onset compared with prophylactic CSFD [26] . These findings again highlight the necessity of randomized controlled trials to compare prophylactic and therapeutic CSFD.…”

Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes

“…Owing to the extensive aortic coverage and involvement of critical renal-mesenteric vessels in the repair, management of antithrombotic therapy in F-BEVAR can be complex. Antithrombotic therapy requires a careful balance between the benefits of obtaining the optimal inhibition of the coagulation cascade to ensure TV patency versus the risks of serious bleeding events (including potential lethal complications, such as intracranial hemorrhage) [ 34 ]. Significant blood loss and blood product transfusion requirements have been shown to be associated with poorer clinical outcomes [ 35 ].…”