Safety of perioperative cerebrospinal fluid drain as a protective strategy during descending and thoracoabdominal open aortic repair

Abstract

Objective: We present our experience with routine application of the cerebrospinal fluid (CSF) drain (CSFD) during open aortic repair.Methods: We retrospectively reviewed 100 patients with descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) or who underwent CSFD insertion before open repair between 2006 and 2017. All CSFDs were inserted by the cardiovascular anesthesia team. The goal was to keep intracranial pressure<10 mm Hg during the surgical procedure by draining CSF at a rate of 20 to 30 mL/h. Postoperatively, CSFD was set to maintain the lumbar pressure <10 mm Hg to reduce the risk of postoperative paraplegia. CSFD was part of our standard cord protection regimen.Results: The mean patient age was 65.4 AE 11.7 years, and 60 (60%) were male. A CSFD was successfully inserted in all patients. The mean hospital length of stay was 11.9 AE 11.8 days, and hospital mortality was 6%. Postoperative transient paresis was observed in 4 patients (4%), and permanent paraplegia was seen in 2 (2%). CSFDrelated complications were reported in 14 patients (14%). Complications included persistent CSF leakage and blood-tinged CSF with and without intracranial hemorrhage and spinal cutaneous fistula in 7 (7%), 9 (9%), and 1 (1%), respectively. Longterm survival was excellent (68.4% at 10 years).Conclusions: CSFD is a safe practice when applied routinely as an adjunct strategy to prevent paraplegia in surgical management of DTAA and TAAA. We feel that this contributed to good early and late clinical results. (JTCVS Techniques 2021;6:1-8)Three-dimensional reconstruction of the anterior spinal artery (T12) using the dual-intensity Yale technique.

Safety of cerebrospinal fluid drainage for spinal cord ischemia prevention in thoracic endovascular aortic repair

“…A pressure of ≤10 mm Hg was maintained during this period at surgeon discretion to alleviate symptoms. 24 Details of the evolution of our institutional SCI prevention protocol to its current form, including prescribed CSFD rates, are shown in Table E1 . 25 Anticoagulant medications were held for drain placement/removal according to a standardized protocol concordant with the American Society of Regional Anesthesia guidelines ( Online Data Supplement ).…”

Cerebrospinal Fluid Drainage for Prevention of Spinal Cord Ischemia in Thoracic Endovascular Aortic Surgery—Pros and Cons

“… 39 Another very recent study that assessed the safety of perioperative CSFD placement came to similar conclusions. 40 A large meta-analysis performed to define a more accurate risk-benefit ratio analyzed 34 studies from 1990 to 2017 and included 4,714 patients who had CSFD placed for open or endovascular repairs of thoracic or thoracoabdominal aortic aneurysms. The study identified the overall CSFD-related complication rate at 6.5%, with severe complications occurring in 2.5% of the cases and a pooled CSFD-related mortality rate of 0.9%.…”

Safety of cerebrospinal fluid drainage in descending and thoracoabdominal aortic replacement surgery

“…Prevention of SCI requires appropriate pre-operative risk assessment for the patients, as well as employing a combination of protective strategies peri-and postoperatively to ensure adequate perfusion of the spinal cord. These treatment adjuncts may include cerebrospinal fluid drainage Safety of cerebrospinal fluid drainage in descending and thoracoabdominal aortic replacement surgery (CSFD), motor evoked potential monitoring, left heart bypass, epidural cooling, and preoperative imaging to identify and preserve the artery of Adamkiewicz (7)(8)(9)(10)(11). The American College of Cardiology and American Heart Association designates a class IA level recommendation (12) for the use of CSFD for decreasing the incidence of temporary, as well as permanent SCI, in patients undergoing open thoracoabdominal aortic repair.…”