Mechanisms of Symptomatic Spinal Cord Ischemia After TEVAR: Insights From the European Registry of Endovascular Aortic Repair Complications (EuREC)

Abstract

Extensive coverage of intercostal arteries alone by a thoracic stent-graft is not associated with symptomatic SCI; however, simultaneous closure of at least 2 vascular territories supplying the spinal cord is highly relevant, especially in combination with prolonged intraoperative hypotension. As such, these results further emphasize the need to preserve the left subclavian artery during TEVAR.

Anatomia da circulação medular

“…The mathematical algorithm employed identified intraoperative hypotension and simultaneous exclusion of at least two spinal supply territories as relevant to the genesis of ischemia, and it was concluded that extensive exclusion of the intercostal arteries alone was not associated with symptomatic spinal ischemia. 30 Notwithstanding, retrospective assessment of 457 patients and their intrahospital complications demonstrated that paraplegia and paraparesis had a significant relationship with endovascular exclusion of more than 20 cm of the aorta, 32 which corroborates the importance of the segmental arteries to spinal blood supply. Yingbin et al 33 demonstrated the importance of identifying the AKA to selection of long endoprostheses for aortic dissection.…”

“…There is an axial network of small arteries in the spinal canal, in paravertebral tissues and in paraspinal muscles that anastomose with each other and with the arteries supplying the spinal marrow; the entry to this network includes segmental vessels (intercostal and lumbar arteries), subclavian arteries, hypogastric arteries and their branches (Figure 4). 30,31 In addition to these multiple entry routes, there is also an extensive network of epidural arterial and small vessels that supply the paraspinal musculature. All of these vessels are interconnected and anastomose with the subclavian arteries cranially and the hypogastric arteries caudally.…”

Surgical repair of descending thoracic and thoracoabdominal aortic aneurysm involving the distal arch: Open proximal anastomosis under deep hypothermia versus arch clamping technique

“…The results of our study support the collateral network concept described by Griepp and colleagues 13 ; occlusion of the collateral flow from the LSCA or hypogastric artery may influence spinal cord ischemia, 11 and mild or moderate hypothermia alone may not afford sufficient spinal cord protection during the clamping period. This hypothesis is also supported by data from the European Registry on Endovascular Aortic Repair Complications, 23 which showed that extensive coverage of intercostal arteries alone was not associated with spinal cord injury, but simultaneous closure of the collateral vascular territories was highly related to the development of spinal cord injury. DHCA might be more advantageous in extensive procedures where the risk of spinal cord ischemia can be significant.…”

Early period results for repair of complex thoracic aortic diseases with E-vita open stent graft

“…23,24 In this study, there are restrictions due to the limited number of patient groups and the lacking of a long follow-up period. However, even with these data sufficient evidences showing treatment principles were presented and results reflecting literature were obtained.…”