Paraplegia Following Elective Endovascular Repair of Abdominal Aortic Aneurysm: Reversal with Cerebrospinal Fluid Drainage

Abstract

Paraplegia secondary to spinal cord ischaemia is a rare but devastating complication of abdominal aortic aneurysm repair. We report a case of paraplegia following elective endovascular repair of an infrarenal aortic aneurysm. A cerebrospinal fluid (CSF) drain was immediately inserted and resulted in full neurological recovery. This case highlights the fact that endovascular techniques are prone to similar complications as open surgery, and the importance of prompt cerebrospinal fluid drainage in cases of spinal cord ischaemia.

Spinal Cord Ischemia after Endovascular Repair of Infrarenal Abdominal Aortic Aneurysm: A Rare Complication

“…In this report the second case was actually an attempted endovascular repair, since difficulties with the device's deployment led to standard open repair, thus raising the possibility that the neurologic event may have occurred at the time of the open repair. Bajwa et al reported bilateral lower extremity sensory and motor loss with no bladder dysfunction after the deployment of an AUI device, while Lioupis et al reported paraplegia in a patient with complex iliac anatomy, necessitating covering of one and reconstruction of the other hypogastric artery during a five-hour procedure [3, 4]. …”

“…Factors that may contribute to spinal cord ischemia after open AAA repair include prolonged aortic occlusion, intraoperative hypotension, atheromatous embolization, interruption of the great radicular artery (artery of Adamkiewicz), or collateral circulation (internal iliac arteries-lumbar arteries) [1–3]. Given that EVAR consists a minimally invasive method of treatment of AAA, the last two of the above-mentioned factors seem to be mostly suited with the etiology of a neurogical complication.…”

Delayed permanent paraplegia after endovascular repair of abdominal aortic aneurysm

“…Cerebrospinal fluid drainage and raising spinal cord perfusion pressure have successfully treated these mechanisms of ischemia. 10 EVAR involves routine coverage of the inferior mesenteric artery (IMA) and lumbar arteries, and instrumentation of the aneurysmal vasculature with stiff wires and devices, yet SCI after infrarenal EVAR remains exceptionally uncommon. This is presumably due to the placement of endografts at a safe distance from the artery of Adamkiewicz (originating between T8 and T12 in over 80% of patients) and the preservation of the hypogastric circulation in most patients.…”

Clinical Practice Guidelines for Endovascular Abdominal Aortic Aneurysm Repair: Written by the Standards of Practice Committee for the Society of Interventional Radiology and Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Interventional Radiology Association

“…Although the ischemic mechanism is unproven, it is likely related to embolization combined with interruption of collateral vessels from the lumbar and iliac circulation. The treatment is the same as for open repair and consists of drainage of cerebrospinal fluid and, in some cases, reestablishment of collateral flow (193)(194)(195)(196)(197).…”