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Ohashi Y, Washiyama N, Takahashi D, Tsuda K, Hirano M, Shiiya N. Safety and validity of selective cerebrospinal fluid drainage in open and endovascular aortic repair. Gen Thorac Cardiovasc Surg 2024:10.1007/s11748-024-02085-z. [PMID: 39325337 DOI: 10.1007/s11748-024-02085-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 09/15/2024] [Indexed: 09/27/2024]
Abstract
OBJECTIVES Although cerebrospinal fluid drainage has been shown to reduce the risk of ischemic spinal cord injury, serious complications have also been reported. We have been using it selectively in a pressure- and volume-regulated method and aimed to evaluate its safety, and its validity in elective thoracic endovascular aortic repair in a propensity-matched cohort. METHODS Among the 450 patients who underwent open surgery (n = 169) or thoracic endovascular aortic repair (n = 281) on the descending or thoracoabdominal aorta, 147 underwent cerebrospinal fluid drainage, which was prophylactic in 135 and therapeutic in 12. Prophylactic drainage was performed in elective open surgery under distal aortic perfusion (n = 67) or in selected patients undergoing thoracic endovascular aortic repair (n = 68). RESULTS Drainage-related complications were observed in 13 (9.6%), one of which was graded severe (0.74%). In patients undergoing prophylactic drainage, spinal cord injury was detected in 2/135 (1.5%). In patients without prophylactic drainage, 15/315 (4.8%) developed spinal cord injury. Therapeutic drainage was performed in 12 of these 15 patients, 10 of whom remained paralytic in varying degree. In the inverse probability weighted analysis of the patients undergoing elective thoracic endovascular aortic repair, the incidence of spinal cord injury was lower with prophylactic drainage (p = 0.028). CONCLUSIONS Pressure- and volume-regulated spinal drainage rarely causes serious complications. Its prophylactic use seems beneficial in selected patients, including those undergoing thoracic endovascular aortic repair with high risk for spinal cord injury.
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Affiliation(s)
- Yuko Ohashi
- First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-Ku, Hamamatsu, 431-3192, Japan
| | - Naoki Washiyama
- First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-Ku, Hamamatsu, 431-3192, Japan
| | - Daisuke Takahashi
- First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-Ku, Hamamatsu, 431-3192, Japan
| | - Kazumasa Tsuda
- First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-Ku, Hamamatsu, 431-3192, Japan
| | - Masahiro Hirano
- First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-Ku, Hamamatsu, 431-3192, Japan
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-Ku, Hamamatsu, 431-3192, Japan.
- Department of Cardiovascular Surgery, NHO Hakodate Medical Center, 18-16 Kawaharacho, Hakodate, 041-8512, Japan.
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Thet MS, D'Oria M, Sef D, Klokocovnik T, Oo AY, Lepidi S. Neuromonitoring during Endovascular Thoracoabdominal Aortic Aneurysm Repair: A Systematic Review. Ann Vasc Surg 2024; 109:206-215. [PMID: 39009132 DOI: 10.1016/j.avsg.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/06/2024] [Accepted: 06/10/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Spinal cord ischemia (SCI) is a potentially devastating complication of thoracic endovascular aortic repair (TEVAR) and fenestrated-branched endovascular aortic repair (F-BEVAR). The aim of this systematic review was to evaluate the efficacy of neuromonitoring modalities to mitigate the risk of SCI during TEVAR and F-BEVAR procedures. METHODS Following the PRISMA guidelines, we conducted a detailed literature search of databases including PubMed, MEDLINE via Ovid, Embase, Scopus, and Cochrane CENTRAL, from 1998 to the present. Inclusion criteria were original research articles examining neuromonitoring during TEVAR and F-BEVAR. The primary outcome was the incidence of SCI, while the secondary outcome included early mortality. The quality of studies was assessed using the Newcastle-Ottawa Scale. RESULTS From 1,450 identified articles, 11 met inclusion criteria, encompassing data from 1,069 patients. Neuromonitoring modalities included motor-evoked potentials (MEPs), somatosensory evoked potentials (SSEPs), and near-infrared spectroscopy. The combination of MEPs and SSEPs was most commonly used, with 93% sensitivity and 96% specificity for detecting SCI risks. SCI incidence ranged from 3.8 to 17.3%, with permanent deficits occurring in 2.7-5.8% of cases. In-hospital mortality ranged from 0.4 to 8%. Risk factors for SCI were identified, including operation duration and extent of aortic coverage. CONCLUSIONS Neuromonitoring with MEPs and SSEPs appears to be effective in detecting perioperative SCI risk during TEVAR and F-BEVAR. However, discrepancies between neuromonitoring changes and actual SCI outcomes suggest the need for cautious interpretation. While the incidence of SCI remains variable, identified risk factors may guide clinical decisions, particularly in high-risk procedures. Future research should focus on prospective studies and randomized controlled trials to validate these findings and improve SCI prevention strategies in TEVAR and F-BEVAR.
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Affiliation(s)
- Myat Soe Thet
- Department of Surgery and Cancer, Imperial College London, UK
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Department of Clinical Surgical and Health Sciences, University of Trieste, Italy.
| | - Davorin Sef
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton, UK
| | | | - Aung Ye Oo
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Department of Clinical Surgical and Health Sciences, University of Trieste, Italy
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3
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Spratt JR, Walker KL, Neal D, Arnaoutakis GJ, Martin TD, Back MR, Zasimovich Y, Franklin M, Shahid Z, Upchurch GR, Scali ST, Beaver TM. Rescue therapy for symptomatic spinal cord ischemia after thoracic endovascular aortic repair. J Thorac Cardiovasc Surg 2024; 168:15-25.e11. [PMID: 36509568 DOI: 10.1016/j.jtcvs.2022.10.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/11/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) can cause permanent neurologic deficits and poor long-term survival. Targeted treatment of new SCI symptoms after TEVAR (rescue therapy [RT]) might improve/resolve neurologic symptoms but few data characterize the association of specific interventions with SCI outcomes. We evaluated the effectiveness of post-TEVAR RT at our tertiary aortic center. METHODS Our institutional TEVAR database was reviewed for SCI incidence and details of RT. This included cerebrospinal fluid drainage (CSFD), medical therapy, and optimization of spinal cord oxygen delivery. SCI outcomes were categorized at discharge as paralysis/paraparesis and temporary/permanent. RESULTS Nine hundred forty-three TEVAR procedures were performed in 869 patients from 2011 to 2020. Post-TEVAR SCI occurred in 7.8% (n = 74) with permanent paraplegia in 1.5%. Older patient age, chronic obstructive pulmonary disease, and previous abdominal aortic surgery were predictive of SCI. Half (n = 37) of SCI episodes resulted in only temporary paralysis/paraparesis. Rescue postoperative cerebrospinal fluid drains were implanted in 3.7% (n = 35) of procedures and was predicted by higher American Society of Anesthesiologists class, lower serum hemoglobin level, elevated international normalized ratio, bilateral iliac artery occlusion, nonelective procedures, and penetrating atherosclerotic ulcer/intramural hematoma indication. The most commonly used RTs were emergent placement of or increased drainage from an existing cerebrospinal fluid drain (87.8%), induced/permissive hypertension (77.0%), corticosteroid bolus (36.5%), and naloxone infusion (33.8%). Neurologic improvement occurred in 68.9% (n = 51/74). New/increased drainage was associated with improved SCI outcome. CONCLUSIONS Permanent paraplegia from post-TEVAR SCI is rare (1.5%). Older patients with comorbidities carry greater post-TEVAR SCI risk. SCI symptoms improved/resolved with CSFD and multimodal RT in 68.9% of patients, but no intervention was independently associated with improvement. TEVAR centers should have robust protocols for timely and safe CSFD placement to augment RT strategies for SCI.
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Affiliation(s)
- John R Spratt
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla.
| | - Kristen L Walker
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Dan Neal
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - George J Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Tomas D Martin
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Martin R Back
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - Yury Zasimovich
- Acute and Perioperative Pain Medicine Division, Department of Anesthesia, University of Florida, Gainesville, Fla
| | - Michael Franklin
- Acute and Perioperative Pain Medicine Division, Department of Anesthesia, University of Florida, Gainesville, Fla
| | - Zain Shahid
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - Gilbert R Upchurch
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
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Afifi RO, Mussa FF. Navigating clinical appropriateness: A review of management strategies for type B aortic dissection. Semin Vasc Surg 2024; 37:240-248. [PMID: 39152002 DOI: 10.1053/j.semvascsurg.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 08/19/2024]
Abstract
Aortic dissection is a catastrophic, life-threatening event. Its management depends on the anatomic location of the intimal tear (type A v B) and the clinical presentation in type B aortic dissection. In this article, the current evidence supporting clinical practice, gaps in knowledge, and the need for more rigorous research and higher-quality studies are reviewed.
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Affiliation(s)
- Rana O Afifi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth, 6400 Fannin Street, Suite 2850, Houston, TX 77030.
| | - Firas F Mussa
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth, 6400 Fannin Street, Suite 2850, Houston, TX 77030
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Vervoort D, An KR, Deng MX, Elbatarny M, Fremes SE, Ouzounian M, Tarola C. The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch. Can J Cardiol 2024; 40:478-495. [PMID: 38052303 DOI: 10.1016/j.cjca.2023.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 12/07/2023] Open
Abstract
Aortic arch pathology is relatively rare but potentially highly fatal and associated with considerable comorbidity. Operative mortality and complication rates have improved over time but remain high. In response, aortic arch surgery is one of the most rapidly evolving areas of cardiac surgery in terms of surgical volume and improved outcomes. Moreover, there has been a surge in novel devices and techniques, many of which have been developed by or codeveloped with vascular surgeons and interventional radiologists. Nevertheless, the extent of arch surgery, the choice of nadir temperature, cannulation, and perfusion strategies, and the use of open, endovascular, or hybrid options vary according to country, centre, and surgeon. In this review article, we provide a technical overview of the surgical, total endovascular, and hybrid repair options for aortic arch pathology through historical developments and contemporary results. We highlight key information for surgeons, cardiologists, and trainees to understand the management of patients with aortic arch pathology. We conclude by discussing training paradigms, the role of aortic teams, and gaps in knowledge, arguing for the need for wire skills for the future "interventional aortic surgeon" and increased research into techniques and novel devices to continue improving outcomes for aortic arch surgery.
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Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kevin R An
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mimi X Deng
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Tarola
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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6
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Seike Y, Nishii T, Yoshida K, Yokawa K, Masada K, Inoue Y, Fukuda T, Matsuda H. Covering the intercostal artery branching of the Adamkiewicz artery during endovascular aortic repair increases the risk of spinal cord ischemia. JTCVS OPEN 2024; 17:14-22. [PMID: 38420547 PMCID: PMC10897655 DOI: 10.1016/j.xjon.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/14/2023] [Accepted: 11/20/2023] [Indexed: 03/02/2024]
Abstract
Objectives This study aimed to determine the relationship between covering the intercostal artery branching of the Adamkiewicz artery (ICA-AKA) and spinal cord ischemia (SCI) during thoracic endovascular aortic repair (TEVAR). Methods Patients who underwent TEVAR from 2008 to 2022 were enrolled. Stent grafts covered the ICA-AKA in 108 patients (covered AKA group) and stent grafts didn't cover the ICA-AKA in 114 patients (uncovered AKA group). The characteristics of 58 patients from each group were matched based on propensity scores. Results No significant differences in SCI rates were detected between the covered AKA (10%; 11/108) and uncovered AKA (3.5%; 4/114) groups (P = .061). Shaggy aorta (odds ratio [OR], 5.16; 95% confidence interval [CI], 1.74-15.3, P = .003), iliac artery access (OR, 6.81; 95% CI, 2.22-20.9, P = .001), and procedural time (OR, 1.01; 95% CI, 1.00-1.02, P = .003) were risk factors for SCI in the entire cohort. Although covering the ICA-AKA (OR, 2.60; 95% CI, 0.86-7.88, P = .058) was not a significant risk factor, shaggy aorta (OR, 8.15; 95% CI, 2.07-32.1, P = .003), iliac artery access (OR, 9.09; 95% CI, 2.22-37.2, P = .002), and procedural time (OR, 1.01; 95% CI, 1.01-1.02, P = .008) were risk factors for SCI in the covered AKA group. No significant risk factors were detected in the uncovered AKA group. Conclusions Covering the ICA-AKA was not an independent risk for SCI in TEVAR. However, covering the ICA-AKA was indirectly associated with the risk of SCI in patients with shaggy aorta, iliac access, and procedural time.
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Affiliation(s)
- Yoshimasa Seike
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tatsuya Nishii
- Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazufumi Yoshida
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Koki Yokawa
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kenta Masada
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yosuke Inoue
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
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Kuru Bektaşoğlu P, Arıkök AT, Ergüder Bİ, Sargon MF, Altun SA, Ünlüler C, Börekci A, Kertmen H, Çelikoğlu E, Gürer B. Cinnamaldehyde has ameliorative effects on rabbit spinal cord ischemia and reperfusion injury. World Neurosurg X 2024; 21:100254. [PMID: 38148767 PMCID: PMC10750183 DOI: 10.1016/j.wnsx.2023.100254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 06/14/2023] [Accepted: 11/28/2023] [Indexed: 12/28/2023] Open
Affiliation(s)
- Pınar Kuru Bektaşoğlu
- Department of Neurosurgery, University of Health Sciences, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Ata Türker Arıkök
- Department of Pathology, University of Health Sciences, Dışkapı Education and Research Hospital, Ankara, Turkey
| | - Berrin İmge Ergüder
- Department of Biochemistry, Ankara University School of Medicine, Ankara, Turkey
| | - Mustafa Fevzi Sargon
- Department of Anatomy, Lokman Hekim University School of Medicine, Ankara, Turkey
| | - Seda Akyıldız Altun
- Department of Neurosurgery, University of Health Sciences, Dışkapı Education and Research Hospital, Ankara, Turkey
| | - Caner Ünlüler
- Department of Neurosurgery, University of Health Sciences, Dışkapı Education and Research Hospital, Ankara, Turkey
| | - Ali Börekci
- Istinye University Faculty of Medicine, Department of Neurosurgery, Istanbul, Turkey
| | - Hayri Kertmen
- Department of Neurosurgery, University of Health Sciences, Dışkapı Education and Research Hospital, Ankara, Turkey
| | - Erhan Çelikoğlu
- Istinye University Faculty of Medicine, Department of Neurosurgery, Istanbul, Turkey
| | - Bora Gürer
- Istinye University Faculty of Medicine, Department of Neurosurgery, Istanbul, Turkey
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8
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Lucas SJ, Johnson KB, Rykhus R, Hora K, VandenHull A, Bates K, Sengos J, Kelly PW. Single-Site Review of Spinal Cord Protection Protocols Including the Utilization of Spinal Drains versus Medical Management with Branched Endovascular Aortic Repair. Ann Vasc Surg 2023; 97:236-247. [PMID: 37659649 DOI: 10.1016/j.avsg.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/26/2023] [Accepted: 08/20/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Spinal cord ischemia (SCI) continues to be a devastating complication after repair of thoracoabdominal aortic aneurysms. The objective of this review is to present our single-center outcomes after the implementation of a standardized neuroprotective protocol following branched endovascular aortic repair. METHODS A standardized neuroprotective protocol including preoperative steroids, acetazolamide, intraoperative hemodynamic parameters, and postoperative treatment goals was initiated in November 2019. Physician-modified branched endovascular repairs were completed at a single center from 2012 to 2021 with outcomes reviewed both before (n = 107) and after (n = 67) the implementation of the neuroprotective protocol. The primary end point was the incidence of any SCI event at 30 days. Secondary end points included all-cause mortality, stroke, myocardial infarction, and renal failure at 30 days. Patients with Crawford extents I-III, renal failure, or necessitating emergent repair were deemed high risk for SCI events and underwent a subset analysis. Survivability after SCI was estimated using Kaplan-Meier tables. RESULTS Of the 174 consecutive patients treated, the 67 patients treated following implementation of the neuroprotective protocol were more likely to have experienced a prior myocardial infarction (26.9% vs. 14%; P = 0.0466) and have a history of chronic obstructive pulmonary disease (64.3% vs. 45.8%; P = 0.02). This group was more likely to be treated for paravisceral aneurysms (53.7% vs. 24.3%; P = 0.0002). Postprotocol implementation, spinal drain use was lower (6% vs. 38.3%; P = <0.0001) with 100% of these drains placed in urgent or unstaged thoracoabdominal aortic aneurysm repairs as a part of the protocol. Rates of any SCI event among all patients before and after implementation of the protocol were 9.3% (n = 10 of 107) and 6% (n = 4 of 67; P = 0.57), respectively. In comparison, the protocol significantly reduced SCI rates to 0 (0% vs. 17.1%; P = 0.0407) in high-risk patients. Frequency of renal failure was reduced (3% vs. 14%; P = 0.018) after initiation of the protocol. Patients in the postprotocol group had significantly improved 1-year mortality rate (9% vs. 27.1%; P = 0.0035) and renal failure rates (2% vs. 15%; P = 0.018). Regression models indicated that patients in the postprotocol group had lower likelihood of mortality and renal failure than patients in preprotocol group (P < 0.05) and that spinal drain reduced mortality (P < 0.1). CONCLUSIONS Implementation of a standardized neuroprotective protocol that focuses on medical management and fluid dynamics may significantly reduce risk of SCI after branched endovascular repairs, with the most significant improvement of SCI outcomes involving those at greatest risk for developing SCI. Also noteworthy, there was significant improvement to 1-year survivability after the implementation of this neuroprotective protocol.
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Affiliation(s)
- Spencer J Lucas
- University of South Dakota - Sanford School of Medicine, Sioux Falls, SD
| | | | - Ryan Rykhus
- University of South Dakota - Sanford School of Medicine, Sioux Falls, SD
| | - Kirby Hora
- University of South Dakota - Sanford School of Medicine, Sioux Falls, SD
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9
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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10
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Jónsson GG, Mani K, Mosavi F, D'Oria M, Semenas E, Wanhainen A, Lindström D. Spinal drain-related complications after complex endovascular aortic repair using a prophylactic automated volume-directed drainage protocol. J Vasc Surg 2023; 78:575-583.e2. [PMID: 37105333 DOI: 10.1016/j.jvs.2023.03.505] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/13/2023] [Accepted: 03/14/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE A common measure to lower the risk for spinal cord ischemia (SCI) during complex endovascular aortic repair (cEVAR) is prophylactic cerebrospinal fluid drainage (CSFD). This method has caused controversy because of drain-related complications. Spinal drains are usually pressure directed. The objective of this study was to evaluate the risk of CSFD-related complications and SCI within the context of an automated volume-directed drain protocol. METHODS This is a retrospective, single-center study of all cEVARs with CSFD at a tertiary vascular center between January 2014 and December 2020. Demographics, complications, and spinal drain data were recorded. All drainages were volume based using an automatic drainage system (LiquoGuard7; Möller Medical GmbH). Spinal drain complications were categorized as disabling and nondisabling according to the modified Rankin scale. The primary end point was any CSFD-related complication. RESULTS A total of 448 cEVAR patients were identified, of whom 147 (32.8%) had prophylactic CSFD. The mean age was 69 years (63% male). The most common pathology (61%) was thoracoabdominal aortic aneurysm, and the most common procedure was branched EVAR (55.1%). Eighteen (12.2%) patients developed a CSFD-related complication, whereof three (2%) were disabling. Nineteen (13%) patients developed SCI: 12 (8.4%) paraparetic, 5 (3.4%) paraplegic, and 2 (1.4%) paresthesias. Of these, 13 (68%) had full reversal of symptoms, whereas 6 patients (4%) had residual symptoms and were deemed disabling. Drain-related complications were more common in patients with SCI (31.6%) compared with those without (9.4%, P = .014). In the latter group, only two patients (1.6%) developed a disabling drain-related complication. CONCLUSIONS Selective use of prophylactic, automated volume-directed CSFD in patients at high risk for SCI was associated with a high incidence of complications and should be used with caution. Among those developing SCI, reversal was achieved frequently with increased CSFD volume, but at the price of more bleeding complications.
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Affiliation(s)
- Gísli Gunnar Jónsson
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Firas Mosavi
- Department of Surgical Sciences, Section of Radiology, Uppsala University, Uppsala, Sweden
| | - Mario D'Oria
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Egidijus Semenas
- Department of Surgical Sciences, Section of Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - David Lindström
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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11
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Ellauzi H, Arora H, Elefteriades JA, Zaffar MA, Ellauzi R, Popescu WM. Cerebrospinal Fluid Drainage for Prevention of Spinal Cord Ischemia in Thoracic Endovascular Aortic Surgery-Pros and Cons. AORTA (STAMFORD, CONN.) 2022; 10:290-297. [PMID: 36539146 PMCID: PMC9767776 DOI: 10.1055/s-0042-1757792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 04/14/2022] [Indexed: 06/17/2023]
Abstract
Thoracic endovascular aortic repair (TEVAR) carries a risk of spinal cord ischemia (SCI) which exerts a devastating impact on patient's quality of life and life expectancy. Although routine prophylactic cerebrospinal fluid (CSF) drainage is not unequivocally supported by current data, several studies have demonstrated favorable outcomes. Patients at high risk for SCI following TEVAR likely will benefit from prophylactic CSF drains. However, the intervention is not risk free, and thorough risk/benefit analysis should be individualized to each patient.
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Affiliation(s)
- Hesham Ellauzi
- Aortic Institute at Yale New-Haven, Department of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
- Department of Surgery, Istishari Hospital, Amman, Jordan
| | - Harendra Arora
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - John A Elefteriades
- Aortic Institute at Yale New-Haven, Department of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Mohammad A Zaffar
- Aortic Institute at Yale New-Haven, Department of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Rama Ellauzi
- Department of Surgery, Istishari Hospital, Amman, Jordan
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Wanda M Popescu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
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12
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Marturano F, Nisi F, Giustiniano E, Benedetto F, Piccioni F, Ripani U. Prevention of Spinal Cord Injury during Thoracoabdominal Aortic Aneurysms Repair: What the Anaesthesiologist Should Know. J Pers Med 2022; 12:1629. [PMID: 36294768 PMCID: PMC9605294 DOI: 10.3390/jpm12101629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 11/06/2022] Open
Abstract
Thoraco-abdominal aortic repair is a high-risk surgery for both mortality and morbidity. A major complication is paraplegia-paralysis due to spinal cord injury. Modern thoracic and abdominal aortic aneurysm repair techniques involve multiple strategies to reduce the risk of spinal cord ischemia during and after surgery. These include both surgical and anaesthesiologic approaches to optimize spinal cord perfusion by staging the procedure, guaranteeing perfusion of the distal aorta through various techniques (left atrium-left femoral artery by-pass) by pharmacological and monitoring interventions or by maximizing oxygen delivery and inducing spinal cord hypothermia. Lumbar CSF drainage alone or in combination with other techniques remains one of the most used and effective strategies. This narrative review overviews the current techniques to prevent or avoid spinal cord injury during thoracoabdominal aortic aneurysms repair.
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Affiliation(s)
- Federico Marturano
- Department of Anaesthesia, Analgesia and Intensive Care, Vito Fazzi Hospital, 73100 Lecce, Italy
| | - Fulvio Nisi
- Department of Anaesthesia and Intensive Care Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Enrico Giustiniano
- Department of Anaesthesia and Intensive Care Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Francesco Benedetto
- Department of Anaesthesia and Intensive Care Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
| | - Federico Piccioni
- Department of Anaesthesia and Intensive Care Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Umberto Ripani
- Division of Clinic Anaesthesia, Department of Emergency Hospital Riuniti, Conca Street 71, 60126 Ancona, Italy
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13
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Dias-Neto M, Tenorio ER, Baumgardt Barbosa Lima G, Baghbani-Oskouei A, Oderich GS. Postoperative management in patients with complex aortic aneurysms. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:587-596. [PMID: 35687066 DOI: 10.23736/s0021-9509.22.12359-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Patients with complex aortic aneurysms (CAA) are often high risk due to advanced age and widespread atherosclerosis affecting numerous vascular territories. Therefore, a thorough perioperative evaluation is needed prior to performing in any type of aortic repair, regardless of whether an endovascular or open surgical approach is selected. Because these operations are technically demanding and often result in end organ ischemia, it is not surprising that complex aortic repair carries significant risk of morbidity and mortality. Disabling complications such as dialysis, major stroke and paraplegia constitute the main limitation of complex aortic repair. The aim of this article was to review postoperative management to mitigate complications after CAA repair.
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Affiliation(s)
- Marina Dias-Neto
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Emanuel R Tenorio
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Guilherme Baumgardt Barbosa Lima
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Aidin Baghbani-Oskouei
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Gustavo S Oderich
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA -
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14
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Klijn AJ, Heida J, Burger DH, Heyligers JM, Pouwels S. Brown–Séquard Syndrome after Thoracic Endovascular Aortic Repair for a Stanford Type B Aortic Dissection. Vasc Specialist Int 2022; 38:12. [PMID: 35686522 PMCID: PMC9188867 DOI: 10.5758/vsi.220008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We present a case of Brown–Séquard syndrome (BSS) after thoracic endovascular aortic repair (TEVAR) to treat Stanford type B aortic dissection. A 49-year-old male presented to the emergency department with acute tearing pain between the scapulae, connected to respiratory movements. Computed tomography showed Stanford type B aortic dissection from the left subclavian artery to the level of the 11th thoracic vertebra. Conservative treatment was initiated with intravenous antihypertensives. However, due to persistent pain and an increase in the aortic diameter with an intramural hematoma, TEVAR was performed. The patient developed symptoms suspicious of spinal cord ischemia postoperatively. A lesion limited to the left-sided spinal cord was observed on magnetic resonance imaging at the level of the 4th to 5th thoracic vertebra. BSS after TEVAR is a rare phenomenon with a fairly good prognosis, depending on the initial injury severity.
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Affiliation(s)
- Adine J. Klijn
- Departments of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Jennie Heida
- Departments of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Desiree H.C. Burger
- Departments of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
- Departments of Vascular Surgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Jan M.M. Heyligers
- Departments of Vascular Surgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Sjaak Pouwels
- Departments of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
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15
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Hypothermia as a potential remedy for canine and feline acute spinal cord injury: a review. ACTA VET BRNO 2022. [DOI: 10.2754/avb202291020189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Severe spinal cord injury (SCI) resulting in permanent sensory-motor and autonomic dysfunction caudal to a damaged spinal cord (SC) segment is a catastrophic event in human as well as in veterinary medicine. The situation of paraplegic/tetraplegic people or animals is further impaired by serious complications and often displays an image of permanent suffering. Therapeutic hypothermia (TH) has shown neuroprotective capacity in numerous experimental and several clinical studies or case reports. Hence, the method draws increasing attention of neuroscientists as well as health care workers. While systemic TH is a too complex procedure for veterinary practice, local application of TH with a reduced risk of the whole body temperature fluctuations and minimal side effects can become one of the therapeutic tools considered in the treatment of acute traumatic SCIs in bigger animals, especially when surgical decompression of spinal medulla and vertebral column reconstruction is indicated. Still, additional large prospective randomized studies are essential for the standardization of therapeutic protocols and the introduction of the method into therapeutic armamentarium in canine and feline spinal traumatology. The research strategy involved a PubMed, MEDLINE (Ovid), EMBASE (Ovid), and ISI Web of Science search from January 2000 to July 2021 using the terms “canine and feline spinal cord injuryˮ, “hypothermiaˮ, and “targeted temperature managementˮ in the English language literature; also references from selected studies were scanned and relevant articles included.
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16
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Steffner KR, Cheung AT. Preservation of Spinal Cord Function. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00023-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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17
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Role of historical and procedural staging during elective fenestrated and branched endovascular treatment of extensive thoracoabdominal aortic aneurysms. J Vasc Surg 2021; 75:1501-1511. [PMID: 34861361 DOI: 10.1016/j.jvs.2021.11.056] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 11/08/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Procedural staging is often performed to reduce the incidence of spinal cord ischemia (SCI) during endovascular treatment of extensive thoracoabdominal aortic aneurysms (TAAAs). However, its role in the case of previous thoracic or infrarenal aortic repair (historical staging) has been controversial. In the present study, we evaluated the SCI rates when procedural staging was routinely used and studied its potential benefits when previous aortic repairs had already been performed. METHODS The data from patients treated electively with fenestrated/branched endovascular aortic repair for extent I, II, III, and V TAAAs were retrieved from a multicenter registry (four high-volume national teaching hospitals) and analyzed. The primary endpoint was the rate of SCI and its association with preoperative and postoperative variables, including historical staging, procedural staging, and an impaired collateral network (subclavian or hypogastric stenosis >75% per occlusion). Variables were defined in accordance with the Society for Vascular Surgery reporting standards. A logistic regression model with stepwise selection was used to identify the predictors of SCI. RESULTS A total of 240 patients (76% male; median age, 73 years) were analyzed. Of the 240 patients, 43 (18%) had presented with an impaired collateral network, 136 (57%) had had historical staging, and 157 (65%) had received procedural staging. Preoperative spinal fluid cerebrospinal drainage was performed in 130 patients (54%). Permanent grade 3 SCI was observed in 13 patients (5%) and was negatively affected by both an impaired collateral network (odds ratio [OR], 17.3; 95% confidence interval [CI], 1.7-176; P = .016) and the presence of bilateral iliac occlusive disease (OR, 10.1; 95% CI, 1.1-98.3; P = .046). Both historical (OR, 0.02; 95% CI, 0.001-0.46; P = .014) and procedural (OR, 0.01; 95% CI, 0.02-0.7; P = .019) staging mitigated the permanent SCI rates. The need for postoperative transfusions (OR, 1.4; 95% CI, 1.1-1.8; P = .014) and the occurrence of postoperative renal complications (OR, 6.5; 95% CI, 1.2-35.0; P < .001) were associated with the development of SCI. Among the patients with historical staging, no further benefit from procedural staging was observed (SCI with procedural staging, 1%; vs no staging, 2%; P = NS). CONCLUSIONS For patients with extensive TAAAs treated with fenestrated/branched endovascular aortic repair, both historical and planned procedural staging were associated with reduced permanent SCI rates. However, no additional benefit was observed when procedural staging was performed in patients with historical staging and an intact collateral network. The protective role of preoperative cerebrospinal fluid drainage placement requires further investigation.
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18
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Marcellino C, Zalewski NL, Rabinstein AA. Treatment of Vascular Myelopathies. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00689-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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19
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Jónsson GG, Marklund N, Blennow K, Zetterberg H, Wanhainen A, Lindström D, Eriksson J, Mani K. Dynamics of Selected Biomarkers in Cerebrospinal Fluid During Complex Endovascular Aortic Repair - A Pilot Study. Ann Vasc Surg 2021; 78:141-151. [PMID: 34175417 DOI: 10.1016/j.avsg.2021.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Ischemic spinal cord injury (SCI) is a serious complication of complex aortic repair. Prophylactic cerebrospinal fluid (CSF) drainage, used to decrease lumbar cerebrospinal fluid (CSF) pressure, enables monitoring of CSF biomarkers that may aid in detecting impending SCI. We hypothesized that biomarkers, previously evaluated in traumatic SCI and brain injury, would be altered in CSF over time following complex endovascular aortic repair (cEVAR). OBJECTIVES To examine if a chosen cohort of CSF biomarker correlates to SCI and warrants further research. METHODS A prospective observational study on patients undergoing cEVAR with extensive aortic coverage. Vital parameters and CSF samples were collected on ten occasions during 72 hours post-surgery. A panel of ten biomarkers were analyzed (Neurofilament Light Polypeptide (NFL), Tau, Glial Fibrillary Acidic Protein (GFAP), Soluble Amyloid Precursos Protein (APP) α and β, Amyloid β 38, 40 and 42 (Aβ38, 40 and 42), Chitinase-3-like protein 1 (CHI3LI or YKL-40), Heart-type fatty acid binding protein (H-FABP).). RESULTS Nine patients (mean age 69, 7 males) were included. Median total aortic coverage was 68% [33, 98]. One patient died during the 30-day post-operative period. After an initial stable phase for the first few postoperative hours, most biomarkers showed an upward trend compared with baseline in all patients with >50% increase in value for NFL in 5/9 patients, in 7/9 patients for Tau and in 5/9 patients for GFAP. One patient developed spinal cord and supratentorial brain ischemia, confirmed with MRI. In this case, NF-L, GFAP and tau were markedly elevated compared with non-SCI patients (maximum increase compared with baseline in the SCI patient versus mean value of the maximal increase for all other patients: NF-L 367% vs 79%%, GFAP 95608% versus 3433%, tau 1020% vs 192%). CONCLUSION This study suggests an increase in all ten studied CSF biomarkers after coverage of spinal arteries during endovascular aortic repair. However, the pilot study was not able to establish a specific correlation between spinal fluid biomarker elevation and clinical symptoms of SCI due to small sample size and event rate.
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Affiliation(s)
- Gísli Gunnar Jónsson
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.
| | - Niklas Marklund
- Department of Neuroscience, Section of Neurosurgery, Uppsala University and Uppsala University Hospital; Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Neurosurgery, Lund, Sweden
| | - Kaj Blennow
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK; UK Dementia Research Institute at UCL, London, UK
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Surgical and Perioperative Sciences, Umeå University, Sweden
| | - David Lindström
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Jacob Eriksson
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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20
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Steenberge SP, Clair DG, Eagleton MJ, Caputo FJ, Smolock CJ, Lyden SP. Visceral segment aortic thrombus is associated with proximal aortic degeneration after infrarenal abdominal aortic aneurysm repair. Vascular 2021; 30:607-615. [PMID: 34165017 DOI: 10.1177/17085381211021282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To identify predictors of aortic aneurysm formation at or above an infrarenal abdominal aortic aneurysm repair. METHODS A total of 881 infrarenal abdominal aortic aneurysm repairs were identified at a single institution from 2004 to 2008; 187 of the repairs were identified that had pre-operative and post-operative computed tomography imaging at least one year or greater to evaluate for aortic degeneration following repair. Aortic diameters at the celiac, superior mesenteric, and renal arteries were measured on all available computed tomographic scans. Aortic thrombus and calcification volumes in the visceral and infrarenal abdominal aortic segments were calculated. Multivariable modeling was used with log transformed variables to determine potential predictors of future aortic aneurysm development after infrarenal abdominal aortic aneurysm repair. RESULTS Of the 187 patients in the cohort, 100 had an open abdominal aortic aneurysm repair while 87 were treated with endovascular repair. Proximal aortic aneurysms developed in 26% (n = 49) of the cohort during an average of 72 ± 34.2 months of follow-up. After multivariable modeling, visceral segment aortic thrombus on pre-operative computed tomography imaging increased the risk of aortic aneurysm development above the infrarenal abdominal aortic aneurysm repair within both the open abdominal aortic aneurysm (hazard ratio 2.04, p = 0.033) and endovascular repair (hazard ratio 3.31, p = 0.004) cohorts. Endovascular repair was independently associated with a higher risk of future aortic aneurysm development after infrarenal abdominal aortic aneurysm repair when compared to open abdominal aortic aneurysm (hazard ratio 2.19, p = 0.025). CONCLUSIONS Visceral aortic thrombus present prior to abdominal aortic aneurysm repair and endovascular repair are both associated with an increased risk of future proximal aortic degeneration after infrarenal abdominal aortic aneurysm repair. These factors may predict patients at higher risk of developing proximal aortic aneurysms that may require complex aortic repairs.
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Affiliation(s)
- Sean P Steenberge
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel G Clair
- Department of Surgery, Palmetto Health USC, Columbia, SC, USA
| | - Matthew J Eagleton
- Department of Vascular Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Francis J Caputo
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Christopher J Smolock
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sean P Lyden
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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21
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Abstract
Vascular disorders of the spinal cord are uncommon yet under-recognized causes of myelopathy. Etiologies can be predominantly categorized into clinical and radiographic presentations of arterial ischemia, venous congestion/ischemia, hematomyelia, and extraparenchymal hemorrhage. While vascular myelopathies often produce significant morbidity, recent advances in the understanding and recognition of these disorders should continue to expedite diagnosis and proper management, and ideally improve patient outcomes. This article comprehensively reviews relevant spinal cord vascular anatomy, clinical features, radiographic findings, treatment, and prognosis of vascular disorders of the spinal cord.
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22
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Antegrade Hybrid Chimney TEVAR Endograft in a Patient with Blunt Aortic Injury: A Challenging Case with Technical Success but Unfavorable Result. Case Rep Vasc Med 2021; 2021:6380428. [PMID: 33954006 PMCID: PMC8057905 DOI: 10.1155/2021/6380428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 11/03/2020] [Accepted: 03/31/2021] [Indexed: 11/22/2022] Open
Abstract
Thoracic Endovascular Aortic Repair (TEVAR) has modified aortic medicine, particularly in patients with traumatic aortic injury (TAI). Conventional repair of TAI in the aortic arch is technically demanding as it requires cardiopulmonary bypass and deep hypothermic arrest with still a significant number of complications. Despite recent improvements in endovascular techniques, many patients have been excluded from endovascular repair due to unfavorable anatomy. To increase the feasibility of endovascular repair, adjunctive open extra-anatomical bypasses may be required to provide an adequate proximal landing zone. Several methods, for instance, chimney technique, hybrid technique, and fenestrated or branched stent-grafts, have been proposed as options to preserve the supra-aortic branches, each with its own advantages and disadvantages. We herein present a patient with complex anatomical features and blunt aortic injury, who underwent antegrade chimney stent-graft deployment through the ascending aorta, not otherwise amenable to standard retrograde delivery because of severe peripheral artery disease. The remarkable aspect, in this case, is that both stents were placed antegrade, through the ascending aorta.
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Kahveci R, Kahveci FO, Gokce EC, Gokce A, Kısa Ü, Sargon MF, Fesli R, Gürer B. Effects of Ganoderma lucidum Polysaccharides on Different Pathways Involved in the Development of Spinal Cord Ischemia Reperfusion Injury: Biochemical, Histopathologic, and Ultrastructural Analysis in a Rat Model. World Neurosurg 2021; 150:e287-e297. [PMID: 33689849 DOI: 10.1016/j.wneu.2021.02.129] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 02/28/2021] [Accepted: 02/28/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Inflammation and oxidative stress are 2 important factors in the emergence of paraplegia associated with spinal cord ischemia-reperfusion injury (SCIRI) after thoracoabdominal aortic surgery. Here it is aimed to investigate the effects of Ganoderma lucidum polysaccharide (GLPS) on SCIRI. METHODS Rats were randomly selected into 4 groups of 8 animals each: sham, ischemia, methylprednisolone, and GLPS. To research the impacts of various pathways that are efficacious in formation of SCIRI, tumor necrosis factor α, interleukin 1β, nitric oxide, superoxide dismutase levels, and catalase, glutathione peroxidase activities, malondialdehyde levels, and caspase-3 activity were measured in tissues taken from the spinal cord of rats in all groups killed 24 hours after ischemia reperfusion injury. The Basso, Beattie, and Bresnahan locomotor scale and inclined plane test were used for neurologic assessment before and after SCIRI. In addition, histologic and ultrastructural analyses of tissue samples in all groups were performed. RESULTS SCIRI also caused marked increase in tissue tumor necrosis factor α, interleukin 1β, nitric oxide, malondialdehyde levels, and caspase-3 activity, because of inflammation, increased free radical generation, lipid peroxidation, and apoptosis, respectively. On the other hand, SCIRI caused significant reduction in tissue superoxide dismutase, glutathione peroxidase, and catalase activities. Pretreatment with GLPS likewise diminished the level of the spinal cord edema, inflammation, and tissue injury shown by pathologic and ultrastructural examination. Pretreatment with GLPS reversed all these biochemical changes and improved the altered neurologic status. CONCLUSIONS These outcomes propose that pretreatment with GLPS prevents progression of SCIRI by alleviating inflammation, oxidation, and apoptosis.
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Affiliation(s)
- Ramazan Kahveci
- Department of Neurosurgery, Balıkesir University, Faculty of Medicine, Balıkesir, Turkey
| | - Fatih Ozan Kahveci
- Department of Emergency Medicine, Balıkesir Atatürk City Hospital, Balıkesir, Turkey
| | - Emre Cemal Gokce
- Department of Neurosurgery, Abdurrahman Yurtaslan Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Aysun Gokce
- Department of Pathology, Ministry of Health, Diskapi Yildirim Beyazit Education and Research Hospital, Ankara, Turkey
| | - Üçler Kısa
- Department of Biochemistry, Kirikkale University, Faculty of Medicine, Kirikkale, Turkey
| | - Mustafa Fevzi Sargon
- Department of Anatomy, Lokman Hekim University, Faculty of Medicine, Ankara, Turkey
| | - Ramazan Fesli
- Department of Neurosurgery, Tarsus Medical Park Hospital, Mersin, Turkey
| | - Bora Gürer
- Department of Neurosurgery, University of Health Sciences, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey.
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Takebayashi K, Shiwa T, Ishikawa T, Taira T, Kawamata T. Spinal cord infarction six months after thoracic endovascular aortic repair- A case report. Heliyon 2020; 6:e04869. [PMID: 32964161 PMCID: PMC7490530 DOI: 10.1016/j.heliyon.2020.e04869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/02/2020] [Accepted: 09/04/2020] [Indexed: 11/24/2022] Open
Abstract
Spinal cord infarction is reported to account for less than 1% of all strokes and is a relatively rare disease. In recent years, thoracic endovascular aortic repair (TEVAR) has become a common treatment for aortic aneurysms, and spinal cord ischemia is one of its complications. Most cases occur in the perioperative period; however, a few cases have been reported in the chronic stage. Here, we report a case of spinal cord infarction, 6 months after TEVAR. A 77-year-old man experienced sudden onset paraparesis following dumbbell exercises and defecation. He had a history of an infectious thoracoabdominal aortic aneurysm treated by TEVAR 6 months prior. Paralysis and disturbance of the thermal pain and tactile sensations of the lower limbs were observed, but proprioception and deep sensation were preserved. Computed tomography (CT) showed no evidence of intraspinal hemorrhage, new aortic dissection, or endoleak around the aortic stent placed from Th11 to L3. Magnetic resonance imaging (MRI) showed intramedullary hyperintensity from Th11 to the conus 2 days after onset. Anticoagulant therapy and rehabilitation were performed, and the lower-limb muscle strength gradually improved. After aortic stenting, particularly including the level of the Adamkiewicz artery, the risk of spinal cord ischemia must be monitored, because spinal circulation depends on collateral circulation.
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Aucoin VJ, Eagleton MJ, Farber MA, Oderich GS, Schanzer A, Timaran CH, Schneider DB, Sweet MP, Beck AW. Spinal cord protection practices used during endovascular repair of complex aortic aneurysms by the U.S. Aortic Research Consortium. J Vasc Surg 2020; 73:323-330. [PMID: 32882346 DOI: 10.1016/j.jvs.2020.07.107] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/29/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Spinal cord ischemia/infarction (SCI) is a devastating complication of thoracoabdominal aortic aneurysm repair that can result in permanent paresis or paralysis. The reported incidence of SCI after aortic interventions has ranged from 2% to 10%. Methods to prevent SCI are a topic of ongoing research, and many current practices have been based on expert opinion. METHODS In an effort to better delineate the best practice models for SCI prevention during endovascular thoracoabdominal aortic aneurysm repair, a 65-question survey was completed by the eight principal investigators of the U.S. Aortic Research Consortium to capture data related to current practices and management strategies related to the prevention and treatment of SCI. Specific categories of interest included considerations for the "high-risk" classification of SCI, current perioperative prevention practices, indications for and management of spinal drains, and SCI rescue maneuvers. RESULTS The most common practices routinely included blood pressure elevation (7 of 8; 87.5%), with most having a mean arterial pressure goal of not less than 90 mm Hg in the perioperative period (5 of 7; 71%), a hemoglobin goal intra- and postoperatively of not less than 10 mg/dL (6 of 8; 75%), and the use of prophylactic spinal drains in high-risk patients (6 of 8; 75%). Significant variation was found among the group for the timing of the resumption of antihypertensive medications, duration of hemoglobin goals after the procedure, and management of spinal drains. Many methods described in reported studies were not routinely used by most of the group, including a perioperative steroid bolus (1 of 8; 12.5%), mannitol (2 of 8; 25%), and naloxone infusion (1 of 8; 12.5%). Rescue maneuvers included placement of a cerebrospinal fluid (CSF) drain if not already present (8 of 8; 100%), decreasing the target CSF drain pop-off pressure (6 of 8; 75%), increasing the CSF drainage volume (5 of 8; 62.5%), increasing the mean arterial pressure goal (8 of 8; 100%), increasing the hemoglobin goal (8 of 8; 100%), and imaging the spine using computed tomography or magnetic resonance imaging (7 of 8; 87.5). CONCLUSIONS In general, consistent broad practices were used by most of the consortium; however, the details of specific parameters (ie, spinal drain management, therapy duration, and timing of resumption of antihypertensive medication) varied among the group. The U.S. Aortic Research Consortium group used the results of the survey for discussion and agreed on standardized SCI prevention recommendations in accordance with the group's collective expert opinion and experience. Variations in current practice were also identified to act as a foundation for future study, the most notable of which was the comparative effectiveness of therapeutic vs prophylactic use of CSF drains in the prevention of SCI.
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Affiliation(s)
- Victoria J Aucoin
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Center, Massachusetts General Hospital, Boston, Mass
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Gustavo S Oderich
- Division of Vascular Surgery at McGovern Medical School at UTHealth, Houston, Tex
| | - Andres Schanzer
- Division of Vascular Surgery, University of Massachusetts, Worcester, Mass
| | - Carlos H Timaran
- Division of Vascular Surgery, University of Texas - Southwestern, Dallas, Tex
| | - Darren B Schneider
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Matthew P Sweet
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, Wash
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala.
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Aortic angioscopy assisted thoracic endovascular repair for chronic type B aortic dissection. J Cardiol 2020; 76:60-65. [DOI: 10.1016/j.jjcc.2020.02.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 12/15/2019] [Accepted: 02/03/2020] [Indexed: 02/03/2023]
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Hickerson LC, Madden AM, Keeyapaj W, Cheung AT. Sphenopalatine Ganglion Blockade for the Management of Postdural Puncture Headache After Lumbar Drain Placement in Patients Undergoing Thoracoabdominal Aortic Aneurysm Repair. J Cardiothorac Vasc Anesth 2020; 34:2736-2739. [PMID: 32553645 DOI: 10.1053/j.jvca.2020.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/07/2020] [Accepted: 03/09/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Leigh C Hickerson
- Division of Cardiothoracic Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Anne-Marie Madden
- Division of Cardiothoracic Anesthesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Worasak Keeyapaj
- Division of Cardiothoracic Anesthesiology, Stanford Health Care, Palo Alto, CA
| | - Albert T Cheung
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Stanford Health Care, Palo Alto, CA
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Lou X, Duwayri YM, Jordan WD, Chen EP, Veeraswamy RK, Leshnower BG. The Safety and Efficacy of Extended TEVAR in Acute Type B Aortic Dissection. Ann Thorac Surg 2020; 110:799-806. [PMID: 32006479 DOI: 10.1016/j.athoracsur.2019.12.036] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 11/25/2019] [Accepted: 12/16/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) with endograft coverage from the left subclavian artery to the celiac artery has been hypothesized to increase spinal cord ischemia. This study analyzes the impact of extended coverage on adverse outcomes and aortic remodeling in patients with complicated acute type B aortic dissection (aTBAD). METHODS From January 2012 to October 2018, 91 patients underwent TEVAR for aTBAD. Median follow-up was 3.1 (interquartile range, 1.2-4.9) years and was complete in 94% of patients. The extent of aortic endograft coverage was categorized as standard (n = 39) or extended (n = 52). Contrast-enhanced imaging scans were analyzed to determine length of coverage, maximum aortic diameters, and false lumen (FL) status. RESULTS The mean age was 52.6 ± 13.9 years, and 66% were men. The most common indications for intervention were malperfusion (42%) and refractory pain (34%). Thirteen (14%) patients required a lumbar drain (preoperative: n = 3; postoperative: n = 10). Mean duration between scans was 2.0 ± 1.9 years. Length of aortic coverage was significantly longer in the extended group (241.7 ± 29.2 mm vs 180.8 ± 22.3 mm in the standard group; P < .001). In-hospital and overall mortality were 6% and 11%, respectively. There were no cases of paraplegia, and the incidence of spinal cord ischemia was 3%. After TEVAR, there was a higher incidence of FL obliteration or thrombosis at the distal descending thoracic aorta in the extended group (53% vs 16% in the standard group; P = .004). CONCLUSIONS Extended TEVAR carries a low risk of spinal cord ischemia and improves FL remodeling of the descending thoracic aorta in patients with aTBAD. This strategy may decrease the need for reinterventions on the thoracic aorta in the chronic phase of TBAD.
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Affiliation(s)
- Xiaoying Lou
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Yazan M Duwayri
- Division of Vascular and Endovascular Therapy, Emory University School of Medicine, Atlanta, Georgia
| | - William D Jordan
- Division of Vascular and Endovascular Therapy, Emory University School of Medicine, Atlanta, Georgia
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Ravi K Veeraswamy
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
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Yang GK, Misskey J, Arsenault K, Gagnon J, Janusz M, Faulds J. Outcomes of a Spinal Drain and Intraoperative Neurophysiologic Monitoring Protocol in Thoracic Endovascular Aortic Repair. Ann Vasc Surg 2019; 61:124-133. [PMID: 31344465 DOI: 10.1016/j.avsg.2019.04.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 04/09/2019] [Accepted: 04/10/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Adjuncts for early detection and treatment of spinal cord ischemia (SCI) in thoracic aortic surgery are supported by robust clinical experience in open repair. The utility of cerebrospinal fluid (CSF) drainage and neurophysiologic monitoring (NPM) in thoracic endovascular aortic repair (TEVAR) is less clear. The purpose of this investigation is to determine the influence of a selective institutional spinal cord protection protocol using prophylactic NPM and CSF on outcomes for standard TEVAR. METHODS Patients undergoing standard TEVAR entered into a prospectively maintained database from a single institution from 2007 to 2016 were retrospectively reviewed. Preoperative characteristics, aneurysm extent, and etiology were reviewed. Utilization of CSF drains including volume of fluid removed, duration of drainage, and catheter-related complications were collected. NPM data were reviewed to determine the influence on intraoperative management. Exact logistic regression was used to identify independent predictors of SCI. RESULTS Of 223 patients undergoing TEVAR, 130 met inclusion criteria for the study. CSF drains were used in 71 patients (54.6%), and 56 of 130 (43%) had NPM. SCI occurred in 7 patients (5.4%), of whom 5 had partial or complete recovery. Median time to symptoms of SCI was delayed in all cases (median 52 hr, range 8-312), and none of the 4 of 7 patients with adjunct NPM demonstrated intraoperative changes. Intraoperative changes in NPM occurred in 26 (46%), and represented unilateral leg ischemia in all but 2 cases. In both patients, changes consistent with SCI were associated with intraoperative hypotension and resolved with blood pressure augmentation. Neither patient developed postoperative SCI. Median length of stay (22 vs. 9 days, P = 0.012), operative room time (262 vs. 209, P = 0.040), and perioperative mortality (28.6% vs. 4.1%, P = 0.046) were significantly higher for patients with SCI versus those without. Length of aortic coverage was found to be the sole independent predictor of SCI (odds ratio 8.2, P = 0.026). Complications related to CSF drainage occurred in 4 patients (5.6%) with major complications occurring in 2 patients (2.8%), including 1 with an intrathecal hematoma and permanent bilateral paraparesis. CONCLUSIONS Selective use of prophylactic CSF drainage in TEVAR was associated with moderate risk and questionable benefit. The use of neurophysiological monitoring allowed for early detection and treatment of spinal ischemia, but its utility is limited by logistical factors and to the minority of patients with intraoperative spinal ischemic events.
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Affiliation(s)
- Gary K Yang
- Division of Vascular Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Jonathan Misskey
- Division of Vascular Surgery, University of British Columbia, Vancouver, BC, Canada.
| | - Kyle Arsenault
- Division of Vascular Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Joel Gagnon
- Division of Vascular Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Michael Janusz
- Division of Cardiac Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Jason Faulds
- Division of Vascular Surgery, University of British Columbia, Vancouver, BC, Canada
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Bignami E, Di Lecce M, Baciarello M, Bellini V, Fanelli M, D'Ospina RM, Perini P, Freyrie A. Direct Intraoperative Neurologic Assessment to Monitor Spinal Cord Ischemia During Thoracoabdominal Aneurysm Endovascular Repair. J Cardiothorac Vasc Anesth 2019; 33:2775-2780. [PMID: 30898423 DOI: 10.1053/j.jvca.2019.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/04/2019] [Accepted: 02/07/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Marco Di Lecce
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Marco Baciarello
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Valentina Bellini
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Mara Fanelli
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Maggiore Hospital, Parma, Italy
| | - Rita Maria D'Ospina
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Maggiore Hospital, Parma, Italy
| | - Paolo Perini
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Maggiore Hospital, Parma, Italy
| | - Antonio Freyrie
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Maggiore Hospital, Parma, Italy
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Parotto M, Ouzounian M, Djaiani G. Spinal Cord Protection in Elective Thoracoabdominal Aortic Procedures. J Cardiothorac Vasc Anesth 2019; 33:200-208. [DOI: 10.1053/j.jvca.2018.05.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Indexed: 11/11/2022]
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Xue L, Luo S, Ding H, Zhu Y, Liu Y, Huang W, Li J, Xie N, He P, Fan X, Fan R, Nie Z, Luo J. Risk of spinal cord ischemia after thoracic endovascular aortic repair. J Thorac Dis 2018; 10:6088-6096. [PMID: 30622780 DOI: 10.21037/jtd.2018.10.99] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Spinal cord ischemia (SCI) is a recognized grave complication after thoracic endovascular aortic repair (TEVAR). The present study aimed to evaluate the incidence and investigate risk of SCI after TEVAR based on current prophylactic strategies designed against established risk factors. Methods The study retrospectively reviewed a prospectively maintained database to investigate patients who underwent TEVAR successfully between January 2009 and December 2012 in a single cardiovascular center. Detailed assessment of SCI risk was routinely performed for all patients before TEVAR was carried out. Prophylactic measures, including left subclavian artery (LSA) revascularization, blood pressure augmentation and cerebrospinal fluid (CSF) pressure control after TEVAR, were employed in high-risk patients and physical neurological examinations were regularly done to evaluate SCI after TEVAR. Patients were further divided into SCI group and non-SCI group. Results A total of 650 patients were enrolled in the study. Eleven patients (1.69%) developed SCI after TEVAR. Baseline level of hemoglobin was significantly lower in the SCI group (113.00 vs. 128.50, P=0.023). More patients in the SCI patients in the SCI group underwent TEVAR under general anesthesia (45.5% vs. 17.7%, P=0.033). A significantly higher incidence of post TEVAR hypotension was found in the SCI group (2.7% vs. 27.3%, P=0.004). Logistic regression analysis revealed that post-TEVAR hypotension (OR, 8.379; 95% CI, 1.833-38.304; P=0.006) was strongly associated with development of SCI and high normal baseline hemoglobin was a protective factor (OR, 0.969; CI, 0.942-0.998; P=0.037). The mortality in hospital and mortality at 1 year were not significant different between the SCI and the non-SCI group (0% vs. 1.6% P=1.000; 9.1% vs. 3.0%, P=0.294, respectively). While length of post-TEVAR stay (13.00 vs. 7.00 days, P=0.000) and length of hospital stay (20.00 vs. 13.00 days, P=0.001) were significantly greater in the SCI group. Conclusions Our study revealed that, based on current prophylactic measures to curtail SCI, including LSA revascularization, blood pressure augmentation and CSF pressure control after TEVAR, post-TEVAR hypotension remains a major and independent risk factor for SCI and high normal baseline hemoglobin level is protective. SCI results in longer post-TEVAR stay and hospital stay, but not associated with increased mortality. Robust precautions should be taken against underlying causes for post-TEVAR hypotension and low level of hemoglobin should be avoided.
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Affiliation(s)
- Ling Xue
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Songyuan Luo
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Huanyu Ding
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Yi Zhu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Yuan Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Wenhui Huang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Jie Li
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Nianjin Xie
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Pengcheng He
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xiaoping Fan
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Ruixin Fan
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Zhiqiang Nie
- Department of Epidemiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Jianfang Luo
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
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The impact of prior aortic surgery on outcomes after multibranched endovascular aortic aneurysm repair. J Vasc Surg 2018. [DOI: 10.1016/j.jvs.2017.11.075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Rong L, Kamel M, Rahouma M, White R, Lichtman A, Pryor K, Girardi L, Gaudino M. Cerebrospinal-fluid drain-related complications in patients undergoing open and endovascular repairs of thoracic and thoraco-abdominal aortic pathologies: a systematic review and meta-analysis. Br J Anaesth 2018; 120:904-913. [DOI: 10.1016/j.bja.2017.12.045] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 12/06/2017] [Accepted: 01/29/2018] [Indexed: 01/16/2023] Open
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Arora H, Kumar PA. Prophylactic Cerebrospinal Fluid Drainage for High-Risk Thoracic Endovascular Aortic Repair: Safe and Effective? J Cardiothorac Vasc Anesth 2018; 32:890-892. [DOI: 10.1053/j.jvca.2018.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Qiu J, Cai W, Shu C, Li M, Xiong Q, Li Q, Li X. Application of thoracic endovascular aortic repair (TEVAR) in treating dwarfism with Stanford B aortic dissection: A case report. Medicine (Baltimore) 2018; 97:e0542. [PMID: 29703033 PMCID: PMC5944474 DOI: 10.1097/md.0000000000010542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE To apply thoracic endovascular aortic repair (TEVAR) to treat dwarfism complicated with Stanford B aortic dissection. PATIENT CONCERNS In this report, we presented a 63-year-old male patient of dwarfism complicated with Stanford B aortic dissection successfully treated with TEVAR. DIAGNOSES He was diagnosed with dwarfism complicated with Stanford B aortic dissection. INTERVENTIONS After conservative treatment, the male patient underwent TEVAR at 1 week after hospitalization. After operation, he presented with numbness and weakness of his bilateral lower extremities, and these symptoms were significantly mitigated after effective treatment. At 1- and 3-week after TEVAR, the aorta status was maintained stable and restored. OUTCOMES The patient obtained favorable clinical prognosis and was smoothly discharged. During subsequent follow-up, he remained physically stable. LESSONS TEVAR is probably an option for treating dwarfism complicated with Stanford B aortic dissection, which remains to be validated by subsequent studies with larger sample size.
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Epstein NE. Cerebrospinal fluid drains reduce risk of spinal cord injury for thoracic/thoracoabdominal aneurysm surgery: A review. Surg Neurol Int 2018. [PMID: 29541489 PMCID: PMC5843969 DOI: 10.4103/sni.sni_433_17] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background The risk of spinal cord injury (SCI) due to decreased cord perfusion following thoracic/thoracoabdominal aneurysm surgery (T/TL-AAA) and thoracic endovascular aneurysm repair (TEVAR) ranges up to 20%. For decades, therefore, many vascular surgeons have utilized cerebrospinal fluid drainage (CSFD) to decrease intraspinal pressure and increase blood flow to the spinal cord, thus reducing the risk of SCI/ischemia. Methods Multiple studies previously recommend utilizing CSFD following T/TL-AAA/TEVAR surgery to treat SCI by increasing spinal cord blood flow. Now, however, CSFD (keeping lumbar pressures at 5-12 mmHg) is largely utilized prophylactically/preoperatively to avert SCI along with other modalities; avoiding hypotension (mean arterial pressures >80-90 mmHG), inducing hypothermia, utilizing left heart bypass, and employing intraoperative neural monitoring [somatosensory (SEP) or motor evoked (MEP) potentials]. In addition, preoperative magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) scans identify the artery of Adamkiewicz to determine its location, and when/whether reimplantation/reattachment of this critical artery and or other major segmental/lumbar arterial feeders are warranted. Results Utilizing CSFD for 15-72 postoperative hours in T/TL-AAA/TEVAR surgery has reduced the risks of SCI from a maximum of 20% to a minimum of 2.3%. The major complications of CSFD include; spinal and cranial epidural/subdural hematomas, VI nerve palsies, retained catheters, meningitis/infection, and spinal headaches. Conclusions By increasing blood flow to the spinal cord during/after T/TL-AAA/TEVAR surgery, CSFD reduces the incidence of permanent SCI from, up to 10-20% down to down to 2.3-10%. Nevertheless, major complications, including spinal/cranial subdural hematomas, still occur.
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Affiliation(s)
- Nancy E Epstein
- Professor of Clinical Neurosurgery, School of Medicine, State University of New York at Stony Brook, Mineola, New York, USA.,Chief of Neurosurgical Spine and Education, Winthrop NeuroScience, NYU Winthrop Hospital, Mineola, New York, USA
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Sattah AP, Secrist MH, Sarin S. Complications and Perioperative Management of Patients Undergoing Thoracic Endovascular Aortic Repair. J Intensive Care Med 2017; 33:394-406. [PMID: 28946776 DOI: 10.1177/0885066617730571] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Endovascular treatments have become increasingly common for patients with a variety of thoracic aortic pathologies. Although considered less invasive than traditional open surgical approaches, they are nonetheless complex procedures. Patients undergo manipulation of an often calcified aorta near the origin of the carotid and subclavian vessels and have stents placed in a curved vessel adjacent to a perpetually beating heart. These stents can obstruct blood flow to the spinal cord, induce an inflammatory response, and in rare cases erode into the adjacent trachea or esophagus. Renal complications range from contrast-induced nephropathy to hypotension and ischemia to dissection. Emboli can lead to strokes and mesenteric ischemia. These patients have complex medical histories, and skilled perioperative management is critical to achieving the best clinical outcomes. Here, we review the medical management of the most common complications in these patients including stroke, spinal cord ischemia, renal injury, retrograde dissections, aortoesophageal and aortobronchial fistulas, postimplantation syndrome, mesenteric ischemia, and endograft failure.
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Affiliation(s)
- Anna P Sattah
- 1 School of Arts and Sciences, Duke University, Durham, NC, USA.,2 School of Medicine and Department of Surgery, University of Virginia, Charlottesville, VA, USA.,3 Department of Anesthesia and Critical Care, George Washington University Medical Center, Washington, DC, USA.,4 Holy Cross Hospital, Silver Spring, MD, USA
| | - Michael H Secrist
- 5 College of Humanities, Brigham Young University, Provo, UT, USA.,6 Doctor of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.,7 Department of Interventional Radiology, University of California, Irvine, CA, USA.,8 Department of Radiology, George Washington University Medical Center, Washington, DC, USA
| | - Shawn Sarin
- 2 School of Medicine and Department of Surgery, University of Virginia, Charlottesville, VA, USA.,9 Kasturba Medical College, Karnataka, India.,10 Northeast Ohio Medical Universities, Rootstown, OH, USA.,11 Department of Interventional Radiology, National Institutes of Health, Stapleton, New York City, NY, USA.,12 Department of Interventional Radiology, George Washington University Medical Center, Washington, DC, USA
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Ribeiro M, Oderich GS, Macedo T, Vrtiska TJ, Hofer J, Chini J, Mendes B, Cha S. Assessment of aortic wall thrombus predicts outcomes of endovascular repair of complex aortic aneurysms using fenestrated and branched endografts. J Vasc Surg 2017; 66:1321-1333. [PMID: 28596039 DOI: 10.1016/j.jvs.2017.03.428] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 03/21/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The goal of this study was to investigate the correlation between atherothrombotic aortic wall thrombus (AWT) and clinical outcomes in patients treated by fenestrated-branched endovascular aortic repair (F-BEVAR) and present a new classification system for assessment of AWT burden. METHODS The clinical data of 301 patients treated for pararenal and thoracoabdominal aortic aneurysms (TAAAs) by F-BEVAR was reviewed. The study excluded 89 patients with extent I to III TAAA because of extensive laminated thrombus within the aneurysm sac. Computed tomography angiograms were analyzed in all patients to determine the location, extent, and severity of atherothrombotic AWT. The aorta was divided into three segments: ascending and arch (A), thoracic (B) and renal-mesenteric (C). Volumetric measurements (cm3) of AWT were performed using TeraRecon software (TeraRecon Inc, Foster City, Calif). These volumes were used to create an AWT index by dividing the AWT volume from the total aortic volume. A classification system was proposed using objective assessment of the number of affected segments, thrombus type, thickness, area, and circumference. Clinical outcomes included 30-day mortality, neurologic and gastrointestinal complications, renal events (Risk, Injury, Failure, Loss of kidney function, End-stage renal disease [RIFLE]), and solid organ infarction. RESULTS The study included 212 patients, 169 men (80%) and 43 women (20%), with a mean age of 76 ± 7 years. A total of 700 renal-mesenteric arteries were incorporated (3.1 ± 1 vessels/patient). AWT was classified as mild in 98 patients (46%) and was considered moderate or severe in 114 (54%). There was one death (0.5%) at 30 days. Solid organ infarction was present in 50 patients (24%), and acute kidney injury occurred in 45 patients (21%) by RIFLE criteria. An association with higher AWT indices was found for time to resume enteral diet (P = .0004) and decline in renal function (P = .0003). Patients with acute kidney injury 2 by RIFLE criterion had significantly higher (P = .002) AWT index scores in segment B. Spinal cord injury occurred in three patients (1.4%) and stroke in four (1.9%), but were not associated with the AWT index. Severity of AWT using the new proposed classification system correlated with the AWT index in all three segments (P < .001). Any of the end points occurred in 35% of the patients with mild and in 53% of those with moderate or severe AWT (P = .016). CONCLUSIONS AWT predicts solid organ infarction, renal function deterioration, and longer time to resume enteral diet after F-BEVAR of pararenal and type IV TAAAs. Evaluation of AWT should be part of preoperative planning and decision making for selection of the ideal method of treatment in these patients.
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Affiliation(s)
- Mauricio Ribeiro
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn; Division of Vascular and Endovascular Surgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Gustavo S Oderich
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
| | | | | | - Jan Hofer
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Julia Chini
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Bernardo Mendes
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Stephen Cha
- Department of Epidemiology and Biostatistics, Mayo Clinic, Rochester, Minn
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Gallis K, Kasprzak PM, Cucuruz B, Kopp R. Evaluation of visible spinal arteries on computed tomography angiography before and after branched stent graft repair for thoracoabdominal aortic aneurysm. J Vasc Surg 2017; 65:1577-1583. [DOI: 10.1016/j.jvs.2016.10.118] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 10/27/2016] [Indexed: 11/29/2022]
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Wortmann M, Böckler D, Geisbüsch P. Perioperative cerebrospinal fluid drainage for the prevention of spinal ischemia after endovascular aortic repair. GEFASSCHIRURGIE 2017; 22:35-40. [PMID: 28944782 PMCID: PMC5573755 DOI: 10.1007/s00772-017-0261-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Endovascular treatment of thoracic and thoracoabdominal aortic diseases is accompanied by a risk of spinal ischemia in 1-19% of patients, depending on the entity and extent of the disease. The use of perioperative drainage of cerebrospinal fluid is one of the invasive measures to reduce the occurrence of this severe complication. This article reviews the incidence of spinal ischemia, its risk factors, the evidence for carrying out cerebrospinal fluid drainage and its modern use by means of an automated, pressure controlled system (LiquoGuard®7).
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Affiliation(s)
- M Wortmann
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - D Böckler
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - P Geisbüsch
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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Flanagan EP, Pittock SJ. Diagnosis and management of spinal cord emergencies. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:319-335. [PMID: 28187806 DOI: 10.1016/b978-0-444-63600-3.00017-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Most spinal cord injury is seen with trauma. Nontraumatic spinal cord emergencies are discussed in this chapter. These myelopathies are rare but potentially devastating neurologic disorders. In some situations prior comorbidity (e.g., advanced cancer) provides a clue, but in others (e.g., autoimmune myelopathies) it may come with little warning. Neurologic examination helps distinguish spinal cord emergencies from peripheral nervous system emergencies (e.g., Guillain-Barré), although some features overlap. Neurologic deficits are often severe and may quickly become irreversible, highlighting the importance of early diagnosis and treatment. Emergent magnetic resonance imaging (MRI) of the entire spine is the imaging modality of choice for nontraumatic spinal cord emergencies and helps differentiate extramedullary compressive causes (e.g., epidural abscess, metastatic compression, epidural hematoma) from intramedullary etiologies (e.g., transverse myelitis, infectious myelitis, or spinal cord infarct). The MRI characteristics may give a clue to the diagnosis (e.g., flow voids dorsal to the cord in dural arteriovenous fistula). However, additional investigations (e.g., aquaporin-4-IgG) are often necessary to diagnose intramedullary etiologies and guide treatment. Emergency decompressive surgery is necessary for many extramedullary compressive causes, either alone or in combination with other treatments (e.g., radiation) and preoperative neurologic deficit is the best predictor of outcome.
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Affiliation(s)
- E P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - S J Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
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Rössel T, Paul R, Richter T, Ludwig S, Hofmockel T, Heller AR, Koch T. [Management of anesthesia in endovascular interventions]. Anaesthesist 2016; 65:891-910. [PMID: 27900415 DOI: 10.1007/s00101-016-0241-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Cardiovascular diseases are one of the leading causes of morbidity and mortality in Germany. In these patients, the high-risk profile necessitates an interdisciplinary and multimodal approach to treatment. Endovascular interventions and vascular surgery have become established as an important element of this strategy in the past; however, the different anatomical localizations of pathological vascular alterations make it necessary to use a wide spectrum of procedural options and methods; therefore, the requirements for management of anesthesia are variable and necessitate a differentiated approach. Endovascular procedures can be carried out with the patient under general or regional anesthesia (RA); however, in the currently available literature there is no evidence for an advantage of RA over general anesthesia regarding morbidity and mortality, although a reduction in pulmonary complications could be found for some endovascular interventions. Epidural and spinal RA procedures should be carefully considered with respect to the risk-benefit ratio and consideration of the recent guidelines on anesthesia against the background of the current study situation and the regular use of therapy with anticoagulants. The following article elucidates the specific characteristics of anesthesia management as exemplified by some selected endovascular interventions.
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Affiliation(s)
- T Rössel
- Klinik für Anästhesiologie und Intensivmedizin, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - R Paul
- Klinik für Anästhesiologie und Intensivmedizin, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - T Richter
- Klinik für Anästhesiologie und Intensivmedizin, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - S Ludwig
- Klinik für Viszeral-, Thorax- und Gefäßchirurgie, TU Dresden, Dresden, Deutschland
| | - T Hofmockel
- Institut und Poliklinik für Radiologische Diagnostik, TU Dresden, Dresden, Deutschland
| | - A R Heller
- Klinik für Anästhesiologie und Intensivmedizin, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - T Koch
- Klinik für Anästhesiologie und Intensivmedizin, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
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Endovascular treatment of synchronous and metachronous aneurysms of the thoracic aorta. Is there an increase in the procedural risk? ANGIOLOGIA E CIRURGIA VASCULAR 2016. [DOI: 10.1016/j.ancv.2016.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Kothandan H, Haw Chieh GL, Khan SA, Karthekeyan RB, Sharad SS. Anesthetic considerations for endovascular abdominal aortic aneurysm repair. Ann Card Anaesth 2016; 19:132-41. [PMID: 26750684 PMCID: PMC4900395 DOI: 10.4103/0971-9784.173029] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Aneurysm is defined as a localized and permanent dilatation with an increase in normal diameter by more than 50%. It is more common in males and can affect up to 8% of elderly men. Smoking is the greatest risk factor for abdominal aortic aneurysm (AAA) and other risk factors include hypertension, hyperlipidemia, family history of aneurysms, inflammatory vasculitis, and trauma. Endovascular Aneurysm Repair [EVAR] is a common procedure performed for AAA, because of its minimal invasiveness as compared with open surgical repair. Patients undergoing EVAR have a greater incidence of major co-morbidities and should undergo comprehensive preoperative assessment and optimization within the multidisciplinary settings. In majority of cases, EVAR is extremely well-tolerated. The aim of this article is to outline the Anesthetic considerations related to EVAR.
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Affiliation(s)
- Harikrishnan Kothandan
- Department of Anaesthesiology, National Heart Centre, Singapore General Hospital, Singapore
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Keenan JE, Benrashid E, Kale E, Nicoara A, Husain AM, Hughes GC. Neurophysiological Intraoperative Monitoring During Aortic Arch Surgery. Semin Cardiothorac Vasc Anesth 2016; 20:273-282. [PMID: 27708177 DOI: 10.1177/1089253216672441] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Circulatory management during replacement of the aortic arch is complex and involves a period of circulatory arrest to provide a bloodless field during arch vessel anastomosis. To guard against ischemic brain injury, tissue metabolic demand is reduced by systemically cooling the patient prior to circulatory arrest. Neurophysiological intraoperative monitoring (NIOM) is often used during the course of these procedures to provide contemporaneous assessment of brain status to help direct circulatory management decisions and detect brain ischemia. In this review, we discuss the characteristics of electrocerebral activity through the process of cooling, circulatory arrest, and rewarming as depicted through commonly used NIOM modalities, including electroencephalography and peripheral nerve somatosensory-evoked potentials. Attention is directed toward the role NIOM has traditionally played during deep hypothermic circulatory arrest, where it is used to define the point of electrocerebral inactivity or maximal cerebral metabolic suppression prior to initiating circulatory arrest while also discussing the evolving utility of NIOM when systemic circulatory arrest is initiated at more moderate degrees of hypothermia in conjunction with regional brain perfusion. The use of cerebral tissue oximetry by near-infrared spectroscopy as an alternative NIOM modality during surgery of the aortic arch is addressed as well. Finally, special considerations for NIOM and the detection of spinal cord ischemia during hybrid aortic arch repair and emerging operative techniques are also discussed.
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Affiliation(s)
- Jeffrey E Keenan
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Ehsan Benrashid
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Emily Kale
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Aatif M Husain
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Dias-Neto M, Reis PV, Rolim D, Ramos JF, Teixeira JF, Sampaio S. Strategies to prevent TEVAR-related spinal cord ischemia. Vascular 2016; 25:307-315. [DOI: 10.1177/1708538116671235] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Spinal cord ischemia remains the Achilles’ heel of thoracic and thoracoabdominal diseases management. Great improvements in morbidity and mortality have been obtained with the endovascular approach TEVAR (Thoracic Endovascular Aortic Repair) but this devastating complication continues to severely affect the quality of life, even if the primary success of the procedure – dissection/aneurysm exclusion – has been achieved. Several strategies to deal with this complication have been published in the literature over the time. Knowledge and technology have been evolving from identification of the risk factors associated with spinal cord ischemia, including lessons learned from open surgery, and from developments in the collateral network concept for spinal cord perfusion. In this comprehensive review, the authors cover several topics from the traditional measures comprising haemodynamic control, cerebrospinal drainage and neuroprotective drugs, to the staged-procedures approach, the emerging MISACE (minimally invasive selective segmental artery coil-embolization) and innovative neurologic monitoring such as NIRS (near-infrared spectroscopy) of the collateral network.
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Affiliation(s)
- Marina Dias-Neto
- Department of Angiology and Vascular Surgery, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal
- Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Alameda Professor Hernani Monteiro, Portugal
| | - Pedro Videira Reis
- Department of Anaesthesiology, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal
| | - Dalila Rolim
- Department of Angiology and Vascular Surgery, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal
| | - José Fernando Ramos
- Department of Angiology and Vascular Surgery, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal
| | - José Fernando Teixeira
- Department of Angiology and Vascular Surgery, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal
| | - Sérgio Sampaio
- Department of Angiology and Vascular Surgery, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal
- Faculty of Medicine, Department of Information and Decision Sciences in Health (CIDES), Research Center in Health Technologies and Information systems (CINTESIS), University of Porto, Alameda Professor Hernani Monteiro, Portugal
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Cole SP. Intensive Care Management of Thoracic Aortic Surgical Patients, Including Thoracic and Infradiaphragmatic Endovascular Repair (EVAR/TEVAR). Semin Cardiothorac Vasc Anesth 2016; 19:331-41. [PMID: 26660057 DOI: 10.1177/1089253215613791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The patient with thoracic aortic disease can present for open or endovascular repair. Thoracic endovascular aortic repair (TEVAR) has emerged as a minimally invasive option for a multitude of aortic pathology, including dissections, aneurysms, traumatic injuries, and ulcers. Postoperative management of these patients depends on the extent of procedure, whether it was open or endovascular, and, finally, on the preoperative comorbidities present. While procedural success has catapulted TEVAR to popularity, midterm results have been mixed. Additionally, periprocedural complications such as paraplegia and renal failure remain a significant morbidity in these patients.
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Jones DD, Watson RE, Heaton HA. Presentation and Medical Management of Fibrocartilaginous Embolism in the Emergency Department. J Emerg Med 2016; 51:315-8. [DOI: 10.1016/j.jemermed.2016.05.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 04/13/2016] [Accepted: 05/26/2016] [Indexed: 11/25/2022]
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Lindsay H, Srinivas C, Djaiani G. Neuroprotection during aortic surgery. Best Pract Res Clin Anaesthesiol 2016; 30:283-303. [DOI: 10.1016/j.bpa.2016.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 04/21/2016] [Accepted: 05/09/2016] [Indexed: 01/16/2023]
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