Association between aortic coverage and spinal cord ischemia after endovascular repair of type B aortic dissection

Discussing on the Aortic Coverage in Type B Aortic Dissection Treatment: A Comprehensive Scoping Review

OBJECTIVE

The objective of this study is to investigate and address the question surrounding the determination of the optimal endograft length of coverage during TEVAR for type B aortic dissection (TBAD), with a particular emphasis on the distal landing zone (DLZ).

DATA SOURCES

MEDLINE, Scopus, and Web of Science databases were used.

METHODS

The PRISMA-ScR statement was followed.

RESULTS

Several variables can contribute to the length of coverage during TEVAR in TBAD patient. Baseline patient's characteristics, TBAD-related features, the type of endoprosthesis, and postoperative graft behaviour may contribute to the choice of coverage.

CONCLUSIONS

No robust data have been published regarding the optimal length of TEVAR. Therefore, reporting the percentage of covered aorta and improving computational studies should be valorised to improve postoperative outcomes.

Prophylactic cerebrospinal fluid drainage and spinal cord ischemia in thoracic and thoracoabdominal endovascular procedures: a systematic review and meta-analysis

Background

Spinal cord ischemia (SCI) is one of the most devastating complications of thoracic endovascular aortic repair (TEVAR). Prophylactic cerebrospinal fluid drainage (CSFD) has been shown to decrease the risk of SCI in open thoracic aortic procedures; however, its utility in TEVAR remains uncertain. This systematic review and meta-analysis aim to determine the role of prophylactic CSFD in preventing SCI in TEVAR.

Methods

A literature search of five databases was performed and all studies published before September 2022 that reported SCI rates in TEVAR patients undergoing prophylactic CSFD were included. A random effects meta-analysis of means or proportions was performed for single-arm data. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported for comparisons between groups.

Results

A total of 4,793 patients undergoing TEVAR from 40 studies were included. The mean age was 68.8 years and 70.9% of patients were male. The overall SCI rate was 3.5%, with a 1.3% rate of immediate SCI and a 1.9% rate of delayed SCI. There were no significant differences in SCI rates between prophylactic CSFD patients and non-drained patients. Routine CSFD did not have a significant impact on SCI rates compared to non-drained patients. There was an increased rate of transient SCI with selective CSFD compared to non-drained patients (OR 2.08; 95% CI: 1.06-4.08; P=0.03). The most common drain-related complication was spinal headache (4.3%). The major complication rate was 1.6%, of which epidural or spinal hematoma (0.9%) was the most common, followed by intracranial or subdural hemorrhage (0.8%) and paraparesis or paraplegia (0.8%).

Conclusions

This study found no significant difference in SCI rates between prophylactic CSFD patients and their non-drained counterparts. CSFD is associated with a small but non-negligible risk of serious complications. Multi-center randomized controlled trials (RCTs) are warranted to help stratify the risk of both SCI and CSFD-related complications in patients undergoing endovascular aortic procedures.

How much should be covered a type B aortic dissection? Just do it, but don't forget about spinal cord protection

Revascularization of the left subclavian artery (LSA) is considered a method of spinal cord protection from ischemia during thoracic endovascular aortic repair (TEVAR). Coverage of the artery of Adamkiewicz with TEVAR is usually well tolerated because of collateral pathways to this vessel, but on the other side, the LSA is crucial in this regard since it represents the primary source of collateral pathways. In our commentary, we wish to focus the discussion on the LSA revascularization and about the complexity of the anatomy of spinal cord supply in order to underline what have been already studied, analyzed, and recommended from the current guidelines.