Risk factors for spinal cord ischaemia after thoracic endovascular aortic repair

Hiraoka, Toshifumi; Komiya, Tatsuhiko; Tsuneyoshi, Hiroshi; Shimamoto, Takeshi

doi:10.1093/icvts/ivy037

Cited by 27 publications

(23 citation statements)

References 16 publications

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“…Other risk factors for SCI, as described in published reports, include prior aortic repair, perioperative hypotension (mean arterial pressure <70 mmHg), COPD, and single-stage procedure. 27 , 28 In our study, we consciously avoided these risk factors of SCI. As shown in Tables 1 and 2 , there were fewer patients with advanced age, previous aortic repair, COPD, and LSA coverage in the TEVAR+Cuff group ( P >0.05).…”

Section: Discussionmentioning

confidence: 99%

Aortic remodeling in Type B aortic dissection after thoracic endovascular aortic repair with an aortic extender cuff implantation

Zhang¹,

Qiao²

2018

CIA

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ObjectiveThis study investigated the safety and efficiency of thoracic endovascular aortic repair (TEVAR) plus an aortic extender cuff placement in treating Stanford Type B aortic dissections (TBADs).MethodsClinical data on 157 patients with TBADs who underwent TEVAR in two tertiary medical centers from February 2013 to March 2018 were analyzed retrospectively. An estimated mismatch rate >120% was the indication for placement of an aortic extender cuff. Results in the perioperative and follow-up periods (≥3 months) were analyzed, especially those of aortic remodeling.ResultsIn total, 106 patients (67.5%) underwent standard TEVAR, and 51 (32.5%) received TEVAR plus an aortic extender cuff placement. The primary technical success rate was 96.8% (152/157). Perioperative adverse events included endoleak (2%, 3/157), spinal cord ischemia (SCI) (1.3%, 2/157), and transient renal failure (0.6%, 1/157), with no between-group differences. The median follow-up was 15 months (range 3–71 months). Ten cases of late stent complications were observed, including three endoleak, one upper limb ischemia, one stent distortion, and five stent graft-induced distal re-dissection (SIDR). Patients with a cuff had less distal re-dissection and fewer second interventions, but the differences lacked significance. In the last follow-up, the TEVAR+Cuff group were found to have better true lumen recovery and false lumen shrinkage, and increased complete false lumen thrombosis in the thoracic and abdominal segments; however, no statistical difference was evident in comparison with the TEVAR group (P>0.05).ConclusionTEVAR plus an aortic extender cuff implantation improves remodeling of the dissected thoracic aorta, thus reducing the potential of SIDR. Furthermore, the covered stent with a length of 250 mm does not increase the rate of SCI or paraplegia. However, these results should be confirmed in a larger series of patients with longer follow-up.

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Section: Discussionmentioning

confidence: 99%

Aortic remodeling in Type B aortic dissection after thoracic endovascular aortic repair with an aortic extender cuff implantation

Zhang¹,

Qiao²

2018

CIA

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“…9 10 Other risk factors for the development of PSCI, which can represent relative indications for HGA preservation, are young age, left ventricular dysfunction, severe atherosclerotic disease of the superior mesenteric artery or the ipsilateral CFA or contralateral HGA, and presence of a large patent inferior mesenteric artery. 11 In a recent review, it was shown that higher rates of PSCI seem to be associated with extensive endovascular procedures, particularly with concomitant thoracic aneurysm repair, even when only a single collateral was occluded. 12 In that sense, preservation of HGA perfusion is important to minimize the risk of spinal cord injury because its patency significantly reduces the incidence of PSCI after extensive aortic endografting.…”

Section: Discussionmentioning

confidence: 99%

Hypogastric Artery Occlusion with Evoked Potentials Monitoring as Bailout Technique to Assess the Risk of Postoperative Spinal Cord Ischemia

D’Oria

Calvagna

Chiarandini

et al. 2019

Aorta

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A 65-year-old man, with previous open surgical repair of an infrarenal abdominal aortic, presented with acute complicated (paraplegia) Type B aortic dissection. He successfully underwent endovascular repair of the descending thoracic and abdominal aorta. Following the procedure, the neurological manifestations resolved. As he had a concomitant aneurysm of the right hypogastric artery (HGA), we executed a 10-minute balloon occlusion of this artery with evoked potential measurements to assess the risk of spinal cord ischemia after exclusion of the right HGA. The examination was interpreted as negative, and we proceeded with coil embolization of the right HGA and subsequent placement of an endograft landing distally within the external iliac artery. The postoperative course was totally uneventful, and the patient was discharged home 4 days after the operation. Computed tomography angiography follow-up at 1, 6, 12 and 24 months showed patency of all endografts without any signs of endoleak and effective remodeling of the descending thoracic aorta with volume reduction of the false lumen.

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“…4,5 Indications for CSF drain placement included: all patients being treated with TEVAR (n ¼ 1), all patients being treated with TEVAR without specific contraindications (n ¼ 1), and patients determined by the authors to be high risk for SCI (n ¼ 6). 3,[11][12][13][14][15][16][17] Methods of risk stratification varied between studies but generally were based on the size of the aneurysm and/or involvement of branching or segmental arteries.…”

Section: Protocol and Indication For Csfdmentioning

confidence: 99%

“…Seven of 8 protocols for CSF drainage involved drainage of CSF to a target pressure, between 7 and 12 mm Hg. 3,11,[13][14][15][16][17] Three had limits of CSF volume drained, of 10 to 20 mL/h. 11,12,16 Three studies lowered the target CSF pressure if symptoms of SCI became evident.…”

Section: Protocol and Indication For Csfdmentioning

confidence: 99%

“…Since 2016, several studies have been published on the use of CSFD in TEVAR procedures. 2,3,[12][13][14][15][16][17] The aim of this systematic literature review is to provide an updated summary of the current literature regarding CSFD in endovascular aortic aneurysm repair. The primary objective of the review is to examine the utility of CSFD in adult patients who underwent endovascular aortic aneurysm repair in decreasing rates of SCI, and the secondary objective is to catalog the variations in CSFD protocols used within these studies.…”

Section: Introductionmentioning

confidence: 99%

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Cerebrospinal Fluid Drainage During Endovascular Aortic Aneurysm Repair: A Systematic Review of the Literature and Treatment Recommendations

Malloy

Raghavan

Elder

et al. 2019

Vasc Endovascular Surg

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Introduction: Spinal cord injury (SCI) is a known complication of aortic aneurysm repair. Previous reports indicate that cerebrospinal fluid drainage (CSFD) may reduce incidence of SCI during open aortic aneurysm repair but its utility in endovascular repair remains poorly understood. We performed a systematic review of the literature to examine the protocols and outcomes of CSFD in patients undergoing endovascular aortic aneurysm repair. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were utilized to conduct a systematic literature review. PubMed, Scopus, Ovid, Cochrane, and EMBASE were queried for articles published since 2016 using search terms “(cerebrospinal fluid diversion OR CSF diversion OR lumbar drain OR subarachnoid drain OR spinal) AND (aortic aneurysm AND thoracic AND endovascular OR TEVAR).” Ninety-two articles were identified and screened by 2 independent reviewers, and 23 studies met criteria for full-text review after initial screening. Results: A total of 8 studies met full inclusion criteria for final analysis. Six studies reported incidence of SCI in patients with CSFD and 2 compared SCI incidence between patients with and without CSFD. Protocols for drainage most commonly included draining to a target pressure intra- and postoperatively, between 8 and 12 mm Hg. Incidence of SCI ranged from 0% to 17% in patients with CSFD, and from 0% to 50% in those without CSFD. Rates of CSFD-related complications ranged from <1% to 28%. Conclusion: There may be a protective benefit of CSFD in preventing SCI, but there remains significant variation in drain placement protocols. Significant potential bias exists in the reviewed data. Higher quality studies on the role of CSFD in endovascular aortic aneurysm repair are needed.

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Risk factors for spinal cord ischaemia after thoracic endovascular aortic repair

Abstract: Sufficient perioperative care should be given to high-risk patients who have endografts that cover more than 9 segments and endografts that cover segments from Th8 to Th12. Adequate haemoglobin levels and mean arterial pressure are needed to provide sufficient spinal cord perfusion.

Cited by 27 publications

References 16 publications

Aortic remodeling in Type B aortic dissection after thoracic endovascular aortic repair with an aortic extender cuff implantation

Aortic remodeling in Type B aortic dissection after thoracic endovascular aortic repair with an aortic extender cuff implantation

Hypogastric Artery Occlusion with Evoked Potentials Monitoring as Bailout Technique to Assess the Risk of Postoperative Spinal Cord Ischemia

Cerebrospinal Fluid Drainage During Endovascular Aortic Aneurysm Repair: A Systematic Review of the Literature and Treatment Recommendations

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