Editor's Choice – Spinal Cord Ischaemia in Endovascular Thoracic and Thoraco-abdominal Aortic Repair: Review of Preventive Strategies

Neuromonitoring during Endovascular Thoracoabdominal Aortic Aneurysm Repair: A Systematic Review

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.

Trends in hospitalization of patients undergoing endovascular treatment of thoracoabdominal aortic aneurysms based on cerebrospinal fluid drainage strategy

OBJECTIVE

The aim of this study was to identify trends in hospital length of stay (HLOS) and intensive care unit length of stay (ICULOS), and the relationship with cerebrospinal fluid drainage (CSFD) protocols in patients undergoing fenestrated-branched endovascular aortic repair (FB-EVAR) of thoracoabdominal aortic aneurysms (TAAAs).

METHODS

A retrospective review of patients who underwent elective FB-EVAR for extent I to IV TAAAs between 2008 and 2023 at a single aortic center of excellence was conducted. Patient demographics, cardiovascular comorbidities, surgical risk, technical details, CSFD strategy (prophylactic or therapeutic), procedural success, and perioperative outcomes were collected. Patients were divided into two groups based on CSFD protocol. Group 1 included patients treated before 2020 when prophylactic CSFD was performed widely, and Group 2 consisted of patients treated since 2020 with therapeutic CSFD. Primary end points were HLOS, ICULOS, major adverse events, and perioperative mortality.

RESULTS

FB-EVAR was performed in 702 patients; 412 underwent elective TAAA repair and were included in the analysis. Mean age was 73 ± 8 years and 68% were male. Patient-specific manufactured devices were used in 252 patients (61%), physician-modified endografts in 110 (27%), and 50 patients (12%) were treated with off-the-shelf devices. Demographics, aneurysm extent, major adverse events (including spinal cord ischemia [SCI]), and mortality were similar in both groups. A significant reduction in mean HLOS between the groups (9 ± 9 vs 6 ± 5 days; P = .02) coincided with decreased use of prophylactic CSFD (70% vs 1.2%; P < .001), with similar rates of SCI (7.6% vs 4.9%; P = .627) and ICULOS (3 ± 3 vs 2.5 ± 3; P = .19). Patients in the therapeutic drainage cohort (group 2) had a higher incidence of congestive heart failure (24% vs 11%; P = .003), hypercholesterolemia (91% vs 80%; P = .015), chronic obstructive pulmonary disease (55% vs 37%; P = .004), and peripheral artery disease (39% vs 19%; P < .001) compared with group 1, suggesting treatment of a more complex patient cohort. On adjusted multivariable analysis accounting for American Society of Anesthesiologists score, comorbidities, and device type, the difference in HLOS remained statistically significant (P = .01).

CONCLUSIONS

HLOS decreased over time in patients undergoing FB-EVAR for TAAA after transition from a prophylactic to a therapeutic CSFD protocol. This transition was the only modifiable, independent risk factor for a shorter HLOS, without an increase in SCI, albeit with similar ICULOS.

Risk Factors for Spinal Cord Injury during Endovascular Repair of Thoracoabdominal Aneurysm: Review of the Literature and Proposal of a Prognostic Score

Despite recent improvements, spinal cord ischemia remains the most feared and dramatic complication following extensive aortic repair. Although endovascular procedures are associated with a lower risk compared with open procedures, this risk is still significant and must be considered. A combined medical and surgical approach may help to optimize the tolerance of the spinal cord to ischemia. The aim of this review is to describe the underlying mechanism involved in spinal cord injury during extensive endovascular aortic repair, to describe the different techniques used to improve spinal cord tolerance to ischemia-including the prophylactic or curative use of spinal drainage-and to propose our algorithm for spinal cord protection and the rational use of spinal drainage.

Retrospective investigation of >400 patients undergoing thoracic endovascular aortic repair with or without cerebrospinal fluid drainage

OBJECTIVES

The aim of this study was to analyse the risks and benefits of cerebrospinal fluid drainage (CSFD) placement in patients undergoing thoracic endovascular aortic repair.

METHODS

Between 2009 and 2020, 411 patients underwent thoracic endovascular aortic repair in 1 institution where 236 patients (57%) received a preoperative CSFD. Patient and outcome characteristics were retrospectively analysed and compared between patients with and without preoperative CSFD placement.

RESULTS

Preoperative CSFD was performed significantly more frequently in elective patients, especially those undergoing distal stent graft extension following frozen elephant trunk-stent placement (P < 0.001). Significantly fewer CSFD was placed in patients with acute aortic injury (P < 0.001). The incidence of permanent spinal cord ischaemia (SCI) was higher in patients without preoperative CSFD [10 patients (2%) vs 1 patient (0.2%), P = 0.001]. Postoperative CSFD was placed in 3 patients (0.7%). Severe CSFD-associated complications affected 2 patients (0.5%) namely, a subdural spinal haematoma causing permanent paraplegia in one of those 2 patients.

CONCLUSIONS

CSFS placement is associated with low procedural risk and can potentially help to prevent SCI. However, the SCI incidence is most likely also associated with other preoperative factors including the patient's haemodynamics. Hence, a general recommendation for placing a preoperative CSFD cannot be made when relying on the present evidence.

Spinal cord protection in open and endovascular approaches to thoracoabdominal aortic aneurysms

Despite advancements in surgical and postoperative management, spinal cord injury has been a persistent complication of both open and endovascular repair of thoracoabdominal and descending thoracic aortic aneurysm. Spinal cord injury can be explained with an ischemia-infarction model which results in local edema of the spinal cord, damaging its structure and leading to reversible or irreversible loss of its function. Perfusion of the spinal cord during aortic procedures can be enhanced by several adjuncts which have been described with a broad variety of evidence in their support. These adjuncts include systemic hypothermia, cerebrospinal fluid drainage, extracorporeal circulation and distal aortic perfusion, segmental arteries reimplantation, left subclavian artery revascularization, and staged aortic repair. The Authors here reviewed and discussed the role of such adjuncts in preventing spinal cord injury from occurring, pinpointing current evidence and outlining future perspectives.

Cervical Debranching: Regional versus General Anesthesia for Carotid-Subclavian Bypass. A Single Center Experience

BACKGROUND

We report here the first cohort study comparing regional and general anaesthesia for left subclavian artery (LSA) revascularization.

METHODS

A single-centre retrospective cohort study was performed, including all consecutive patients who underwent cervical debranching with carotid-subclavian bypass before aortic repair from February 2018 to May 2022. Patients were divided into 2 groups according to the type of anesthesia: Regional anesthesia (RA) versus general anesthesia (GA). Primary endpoints included the following: 1) technical success of RA and 2) neurological complications (NCs) (stroke and peripheral neurological lesions). Secondary endpoints included postoperative bleeding, wound complications, 30-day reintervention rate, and midterm events.

RESULTS

Eighty-three patients were included in the study. The mean age was 64 years (interquartile range [IQR]:13.5) and 69% were male. Thirty-seven patients (44.5%) were performed under RA. Technical success of RA was 89.2%. Two minor strokes (2.4%) were observed in the GA group (P = 0.199). Peripheral neurological disorders occurred in 4 patients (4.8%) (RA group n = 1 (2.7%), GA group n = 3 (6.5%), P = 0.491). 30-day complication rate was 27.7% (n = 23, GA: n = 15 (32.6%), RA: n = 8 (21.6%), P = 0.266). 30-day reintervention rate was 14.5% (n = 12) ten bleeding complications (12%) (RA group n = 3 (8.1%), GA group n = 7 (15.2%), P = 0.323), and 2 seroma evacuations (2.4%) in the RA group. The incidence of superficial wound infections was n = 6 (7.2%) (RA group n = 2 (5.4%), GA group n = 4 (8.7%), P = 0.565). Median follow-up time was 22 months (IQR 22 min/max 1-44).

CONCLUSIONS

In our cohort, RA for carotid subclavian bypass surgery proved to be a feasible and effective anesthetic procedure compared with GA.

Spinal drain-related complications after complex endovascular aortic repair using a prophylactic automated volume-directed drainage protocol

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.

Increased Aortic Exclusion in Endovascular Treatment of Complex Aortic Aneurysms

PURPOSE

Perioperative risk assessments for complex aneurysms are based on the anatomical extent of the aneurysm and do not take the length of the aortic exclusion into account, as it was developed for open repair. Nevertheless, in the endovascular repair (ER) of complex aortic aneurysms, additional segments of healthy aorta are excluded compared with open repair (OR). The aim of this study was to assess differences in aortic exclusion between the ER and OR of complex aortic aneurysms, to subsequently assess the current classification for complex aneurysm repair.

METHODS

This retrospective observational study included patients that underwent complex endovascular aortic aneurysm repair by means of fenestrated endovascular aneurysm repair (FEVAR), fenestrated and branched EVAR (FBEVAR), or branched EVAR (BEVAR). The length of aortic exclusion and the number of patent segmental arteries were determined and compared per case in ER and hypothetical OR, using a Wilcoxon signed-rank test.

RESULTS

A total of 71 patients were included, who were treated with FEVAR (n = 44), FBEVAR (n = 8), or BEVAR (n = 19) for Crawford types I (n = 5), II (n = 7), III (n = 6), IV (n = 7), and V (n = 2) thoracoabdominal or juxtarenal (n = 44) aneurysms. There was a significant increase in the median exclusion of types I, II, III, IV, and juxtarenal aneurysms (p < 0.05) in ER, compared with hypothetical OR. The number of patent segmental arteries in the ER of type I-IV and juxtarenal aneurysms was significantly lower than in hypothetical OR (p < 0.05).

CONCLUSION

There are significant differences in the length of aortic exclusion between ER and hypothetical OR, with the increased exclusion in ER resulting in a lower number of patent segmental arteries. The ER and OR of complex aortic aneurysms should be regarded as distinct modalities, and as each approach deserves a particular risk assessment, future efforts should focus on reporting on the extent of exclusion per treatment modality, to allow for appropriate comparison.

Biomarkers of Spinal Cord Injury in Patients Undergoing Complex Endovascular Aortic Repair Procedures-A Narrative Review of Current Literature

Complex endovascular aortic repair (coEVAR) of thoracoabdominal aortic aneurysms (TAAA) has greatly evolved in the past decades. Despite substantial improvements of postoperative care, spinal cord injury (SCI) remains the most devastating complication of coEVAR being associated with impaired patient outcome and having an impact on long-term survival. The rising number of challenges of coEVAR, essentially associated with an extensive coverage of critical blood vessels supplying the spinal cord, resulted in the implementation of dedicated SCI prevention protocols. In addition to maintenance of adequate spinal cord perfusion pressure (SCPP), early detection of SCI plays an integral role in intra- and postoperative patient care. However, this is challenging due to difficulties with clinical neurological examinations during patient sedation in the postoperative setting. There is a rising amount of evidence, suggesting that subclinical forms of SCI might be accompanied by an elevation of biochemical markers, specific to neuronal tissue damage. Addressing this hypothesis, several studies have attempted to assess the potential of selected biomarkers with regard to early SCI diagnosis. In this review, we discuss biomarkers measured in patients undergoing coEVAR. Once validated in future prospective clinical studies, biomarkers of neuronal tissue damage may potentially add to the armamentarium of modalities for early SCI diagnosis and risk stratification.

Outcomes of Secondary Endovascular Aortic Repair After Frozen Elephant Trunk

OBJECTIVE

The aim of this study was to evaluate the midterm outcomes of secondary extension of frozen elephant trunk (FET) by means of thoracic endovascular aortic repair (TEVAR).

METHODS

This single-center prospective study was conducted in a tertiary aortic center on consecutive patients having undergone TEVAR with an endograft covering most of the 10 cm FET module with 2 to 4 mm oversizing. All patients were monitored by computerized tomography angiography (CTA) at sixth month and yearly thereafter.

RESULTS

From January 2015 to July 2022, among 159 patients who received FET, 30 patients (18.8%) underwent a TEVAR procedure (13 for a thoracoabdominal aneurysm, 11 for a chronic aortic dissection and 6 for an emergency procedure). All connections were successfully achieved with 2 postoperative deaths (6.6%) and 1 paraplegia (3.3%). At a median follow-up of 21 months (interquartile range [IQR], 4.2-34.7), 5 patients (25%) required a fenestrated-branched endovascular aortic repair (F-BEVAR) extension followed by 4 patients with 5 reinterventions, 3 for a Type 3 endoleak due to disconnection between FET and TEVAR endograft, and 2 unrelated to the FET for a secondary Type 1C endoleak. All reinterventions were successful, without mortality or morbidity.

CONCLUSIONS

In this series, FET connection with a TEVAR endograft was effective with low postoperative morbidity but with a risk of aortic reintervention related to disconnection between the FET and TEVAR endograft. These results suggest the need for annual CTA monitoring with no time limit in patients following connection of the FET with a TEVAR endograft.

CLINICAL IMPACT

In this series of 30 patients, midterm outcomes of secondary extension of frozen elephant trunk (FET) by thoracic endovascular repair (TEVAR) showed 3 disconnections (10%) with a Type 3 endoleak between FET and TEVAR. These findings suggest the need for annual CTA monitoring with no time limit. But so far, only a few studies provide some information after one year while the risk of disconnection increases over time and becomes a concern after 3 years. This is the new message brought by our study.

Effect of cerebrospinal fluid drainage pressure in descending and thoracoabdominal aortic repair: a prospective multicenter observational study

PURPOSE

Cerebrospinal fluid drainage (CSFD) is recommended during open or endovascular thoracic aortic repair. However, the incidence of CSFD complications is still high. Recently, CSF pressure has been kept high to avoid complications, but the efficacy of CSFD at higher pressures has not been confirmed. We hypothesize that CSFD at higher pressures is effective for preventing motor deficits.

METHODS

This prospective observational study included 14 hospitals that are members of the Japanese Society of Cardiovascular Anesthesiologists. Patients who underwent thoracic and thoracoabdominal aortic repair were divided into four groups: Group 1, CSF pressure around 10 mmHg; Group 2, CSF pressure around 15 mmHg; Group 3, CSFD initiated when motor evoked potential amplitudes decreased; and Group 4, no CSFD. We assessed the association between the CSFD group and motor deficits using mixed-effects logistic regression with a random intercept for the institution.

RESULTS

Of 1072 patients in the study, 84 patients (open surgery, 51; thoracic endovascular aortic repair, 33) had motor deficits at discharge. Groups 1 and 2 were not associated with motor deficits (Group 1, odds ratio (OR): 1.53, 95% confidence interval (95% CI): 0.71-3.29, p = 0.276; Group 2, OR: 1.73, 95% CI: 0.62-4.82) when compared with Group 4. Group 3 was significantly more prone to motor deficits than Group 4 (OR: 2.56, 95% CI: 1.27-5.17, p = 0.009).

CONCLUSION

CSFD is not associated with motor deficits in thoracic and thoracoabdominal aortic repair with CSF pressure around 10 or 15 mmHg.

Preoperative Spinal Drain Placement is Associated with Reduced Risk of Spinal Cord Ischemia in Patients Undergoing Thoracic Endovascular Aortic Repair for Aortic Dissection

BACKGROUND

Spinal cord ischemia (SCI) is a rare but serious complication of Thoracic Endovascular Aortic Repair (TEVAR). Several measures including spinal drain (SD) placement have been proposed to reduce the risk of SCI in TEVARs performed for aneurysms. However, there are no specific large-scale data on potential benefits of SD placement in Stanford Type B aortic dissection (TBAD). We aimed to assess the impact of preoperative SD placement on preventing SCI during TEVARs performed for TBAD.

METHODS

We included all TEVAR cases performed for TBAD in Vascular Quality Initiative (VQI) from 2012 to 2021. Patients with connective tissue disease, open conversion, rupture, proximal disease > zone 5, proximal landing zone <2 or SCI on presentation were excluded. One-to-one propensity score matching was used to balance patients on 34 dimensions by the nearest neighbor principle to compare patients based on preoperative SD placement. The primary outcome was SCI. Secondary outcomes included 30-day and 90-day mortality, perioperative complications, and 90-day2intervention.

RESULTS

A total of 2,683 TEVARs were performed for TBAD with 1,227 (45.7%) undergoing preoperative SD placement. Propensity matching produced 672 well-matched pairs. In the matched cohort, SD placement was not associated with significant reduction in temporary SCI (3.0% vs. 3.7%, P = 0.45). However, SD placement was associated with significant reduction of the risk of permanent SCI at discharge (1.3% vs. 3.4%, P = 0.012). SD was also associated with lower risk of 30-day mortality (3.7% vs 6.4%, P = 0.025) and shorter length of stay but not 90-day mortality or 90-day reintervention.

CONCLUSIONS

Our study suggests that preoperative SD placement in patients undergoing TEVAR for TBAD is beneficial in reducing the risk of permanent SCI without increasing risks of perioperative complications. Further prospective studies are necessary to confirm these findings.

Patient Blood Management in Vascular Surgery

Patient blood management (PBM) is an evidence-based, multidisciplinary approach aimed at appropriately allocating blood products to patients requiring transfusion while simultaneously minimizing inappropriate transfusions. The 3 pillars of patient blood management are optimizing erythropoiesis, minimizing blood loss, and optimizing physiological reserve of anemia. Benefits seen from PBM include limiting hospital costs and mitigating harm from numerous risks of transfusion.

Postoperative Intensive Care Management of Aortic Repair

Vascular surgery patients have multiple comorbidities and are at high risk for perioperative complications. Aortic repair surgery has greatly evolved in recent years, with an increasing predominance of endovascular techniques (EVAR). The incidence of cardiac complications is significantly reduced with endovascular repair, but high-risk patients require postoperative ST-segment monitoring. Open aortic repair may portend a prohibitive risk of respiratory complications that could be a contraindication for surgery. This risk is greatly reduced in the case of an endovascular approach, and general anesthesia should be avoided whenever possible in the case of endovascular repair. Preoperative renal function and postoperative kidney injury are powerful determinants of short- and long-term outcome, so that preoperative risk stratification and secondary prevention are critical tasks. Intraoperative renal protection with selective renal and distal aortic perfusion is essential during open repair. EVAR has lower rates of postoperative renal failure compared to open repair, with approximately half the risk for acute kidney injury (AKI) and one-third of the risk of hemodialysis requirement. Spinal cord ischemia used to be the most distinctive and feared complication of aortic repair. The risk has significantly decreased since the beginning of aortic surgery, with advances in surgical technique and spinal protection protocols, and is lower with endovascular repair. Endovascular repair avoids extensive aortic dissection and aortic cross-clamping and is generally associated with reduced blood loss and less coagulopathy. The intensive care physician must be aware that aortic repair surgery has an impact on every organ system, and the importance of early recognition of organ failure cannot be overemphasized.

Safety of Cerebrospinal Fluid Drainage for Spinal Cord Ischemia Prevention in Thoracic Endovascular Aortic Repair

Objective

Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) is associated with permanent neurologic deficit and decreased survival. Prophylactic cerebrospinal fluid (CSF) drainage (CSFD) in TEVAR is controversial. We evaluated the usage of CSFD in TEVAR at our tertiary aortic center.

Methods

Our institutional TEVAR database was reviewed to determine the frequency of CSFD usage/complications. Complications were categorized as mild (headache/CSF leak not requiring intervention, urinary retention), moderate (headache/CSF leak requiring intervention, drain malfunction requiring replacement), or severe (intrathecal hemorrhage, CSFD-attributable neurologic deficit). The relationships between CSFD complications and patient/procedural characteristics, CSFD placement timing, and survival were analyzed.

Results

Nine hundred thirty-six TEVAR procedures were performed in 869 patients from 2011 to 2020. Three hundred ninety CSFD drains were placed in 373 (41.7%) TEVAR patients. Most CSFD drains (89.5%) were pre-TEVAR. Most post-TEVAR drains were placed for new SCI symptoms (n = 21). Twenty-five patients (6.4%) suffered 32 CSFD complications. Most (n = 17) were mild in severity. Severe CSFD complications occurred in 5/432 (1.1% CSF drains) patients. No patient/procedural characteristics were predictive of CSFD complications. Post implant CSFD placement for new SCI symptoms conferred an increased risk of CSFD complication (odds ratio, 6.9; 95% CI, 2.42-19.6; P < .01). The long-term survival of the CSFD complication cohort did not differ from the overall population.

Conclusions

Post-TEVAR CSFD placement for new SCI symptoms was associated with substantially greater risk of CSFD complications. Avoidance of post-implant therapeutic drain placement might be the key to prevention of CSFD complications, favoring a strategy of selective pre-implant drain placement in patients at higher risk for SCI.

Stroke, spinal cord ischemia and upper limb ischemia in patients undergoing TEVAR with coverage of the left subclavian artery: a case series study

Background

We performed routine spinal fluid drainage for patients who underwent TEVAR for thoracic aortic pathology together with left subclavian artery coverage, which was needed for achievement of a safe proximal sealing zone. We assessed the occurrence of spinal cord ischemia as well the rate of occurrence of other complications such as stroke, and upper limb ischemia.

Results

This was a case series study done between July 2014 and April 2020, in them all the left subclavian artery was covered to ensure a proximal safe seal zone. Routine spinal fluid drainage was done, keeping the spinal fluid pressure < 10–15 mmHg with catheter in place for 48 h. Data was obtained from twenty-three patients who underwent TEVAR for thoracic aortic dissection (73.91%), thoracic aortic aneurysm (21.74%), or ulcer (4.35%). Planning was based upon multi-slice computed tomographic angiography and covering the left subclavian was mandatory to achieve a proximal sealing zone. Technical success was achieved in 100% of cases. 4.35% of patients had three endograft, 56.52% had two endografts, 39.13% had one endograft. All patients lost their radial pulsations immediately after implantation, 8.70% developed post implantation syndrome(fever) that was managed conservatively, 4.35% developed stroke related to the anterior circulation, 4.35% developed signs of spinal cord ischemia. During the follow up, one patient died within 6 h after the procedure due to extensive myocardial infarction (patient was scheduled for CABG after our procedure). 17.40% developed upper limb symptoms that were tolerable and were managed conservatively.

Conclusion

By adopting routine spinal cord drainage and pressure monitoring, we can consider not to revascularize the left subclavian artery prior to TEVAR if it will be covered.

A systematic review and meta-analysis of the occurrence of spinal cord ischemia following endovascular repair of thoraco-abdominal aortic aneurysms

OBJECTIVE

The rates of endovascular repair of thoracoabdominal aortic aneurysms (TAAA-ER) have increased considerably in the last years. While mortality and morbidity rates have improved, spinal cord ischemia (SCI) rates have not declined significantly. The aim of this systematic review and meta-analysis was to examine SCI rates with respect to the efficacy of the different approaches.

METHODS

Cohort studies and case series (>20 patients) reporting SCI rates after TAAA-ER were eligible for inclusion. The primary outcome was the evaluation of SCI. Moderators considered were primarily the staged/non-staged approach, the use of cerebrospinal fluid drainage (CSFD) and TAAA extension. Permanent SCI and mortality rates were extracted.

RESULTS

Twenty-seven studies (n=2333 patients) were included in the meta-analysis. The pooled estimate for SCI was 11% (95% confidence interval [CI]: 8%-15%; I²:80%). For extent I,II,III and V TAAA, the pooled SCI rate was 13% (95% CI: 10%-17%; I²=71%), while for extent IV TAAA it was 6% (95% CI: 3%-10%; I²=62%). A staged TAAA-ER approach was used in 18 studies and a non-staged approach in 6 (one study included both). A lower pooled SCI rate was identified following staged compared with non-staged TAAA-ER (9% vs. 18%, respectively; P=.02). Staging was accomplished in >1 month in 9 studies and ≤1 month in 2, leading to similar SCI rates (7% vs. 11%, respectively; P=.29). The method of staging (thoracic-endoprosthesis or temporary aortic sac perfusion) did not affect SCI rates. Symptomatic CSFD was associated with a similar pooled rate of SCI compared with prophylactic CSFD (10% vs. 10%, respectively; P=.95). Pooled permanent SCI was 5% (6% following extent I,II,III and V TAAA; 3% following extent IV TAAA). Prophylactic or symptomatic CSFD have a similar rate of SCI (10% vs. 10%, respectively; P=.89). The pooled rate of 30-day mortality was 7%, with a similar incidence for the staged and non-staged approaches (6% vs. 9%, respectively). The inter-stage mortality was reported in 10 studies, with a pooled estimate rate of 1.6%.

CONCLUSIONS

SCI occurs in 11% of TAAA-ER and half of these cases are permanent. A staged approach can reduce SCI rates independently from the timing and the method adopted. The overall mortality rate for staged TAAA-ER is 6%, with one fourth of deaths (1.6%) occurring between stages.

Conventional open versus hybrid aortic arch repair: a meta-analysis of propensity-matched studies

Background

Comparison of conventional (open) surgical versus hybrid aortic arch repair remains debatable. While the majority of previous comparative studies including meta-analyses contained primarily risk-unadjusted cohorts, those focusing on propensity-matched comparisons were limited by their small sample size. We aimed to compare outcomes of these two approaches through an up-to-date search and meta-analysis of the best evidence currently available in the literature.

Methods

The PubMed/MEDLINE, EMBASE, and Cochrane library from inception to September 2019 were searched to identify articles reporting propensity-score matching data on open versus hybrid aortic arch repair. Patients’ baseline characteristics and clinical outcomes were extracted from the articles and pooled for analysis. Heterogeneity and biases were assessed among the included studies.

Results

Five studies, including a total of 378 patients (189 pairs), were included in the study. The two groups were similar in patients’ baseline characteristics. Stroke rate favoured the open group [2.1% versus 14.3%, OR 0.18 (0.07, 0.46), P=0.0004, I²=0%]. There was no significant difference between the two groups with regard to paraplegia. The hybrid group had numerically higher short-term mortality, but lower rate of acute renal failure requiring dialysis. There was a statistically significant difference between the mid-term survivals of the open and hybrid groups, with lower pooled mortality seen for the open group at 1-year and 2-years (P=0.02).

Conclusions

Open and hybrid repairs do not offer equivalent outcomes. Compared with hybrid aortic arch repair, conventional surgical aortic repair could be associated with favourable outcomes including postoperative stroke. Hybrid repair does not appear to provide better survival. Operative approaches should be carefully selected in treating aortic arch pathology.

Cerebrospinal Fluid Drainage in Thoracic and Thoracoabdominal Endovascular Aortic Repair: A Survey of Current Clinical Practice in European Medical Centers

OBJECTIVES

The aim of this survey was to evaluate the daily clinical practice in European hospitals regarding the modalities to prevent spinal cord ischemia, with an emphasis on cerebrospinal fluid drainage (CSFD), in patients undergoing thoracic and thoracoabdominal endovascular repair.

DESIGN

A 21-item online survey on current practice of spinal cord protection with an emphasis on CSFD.

SETTING

Online service using Castor EDC software.

PARTICIPANTS

Members of the European Association of Cardiothoracic Anaesthesiology and Intensive Care and European Society of Vascular Surgeons.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One hundred eighty invitations were sent and 104 were used for analysis. A majority of respondents used a written protocol for spinal cord protection during endovascular thoracic and thoracoabdominal repair (81/104 = 78%). The most common protective measures used were CSFD (79/81 = 98%), controlled hypertension (59/81 = 73%), drugs (11/81 = 14%), and hypothermia (6/81 = 7%). The two most common indications for placement of a spinal catheter were the length of the stent (83/104 = 80%) and location of aneurysm (71/104 = 68%). Preventive placement of the spinal drain (96/104) is the most common approach. In the subgroup of high-volume centers, 86% (12/14) of the respondents used a written protocol and all protocols include CSFD. Ninety-two percent (11/12) had included controlled arterial hypertension in the protocol compared with 70% (48/69) of the non-high-volume centers respondents.

CONCLUSIONS

The majority of European centers use a written protocol that includes CSFD. This survey showed the similarities and differences in the management of CSFD in patients undergoing endovascular thoracic and thoracoabdominal repair.

Spinal Cord Protection for Thoracoabdominal Aortic Surgery

Open and endovascular repairs of the descending thoracic and thoracoabdominal aorta are associated with a substantial risk of spinal cord injury, namely paraplegia. Endovascular repairs seem to have a lower incidence of spinal cord injury, but there have been no randomized trials comparing outcomes of open and endovascular repairs. Paraplegia occurs when collateral blood supply to the anterior spinal artery is impaired. The risk of spinal cord injury can be mitigated with perioperative protocols that include drainage of cerebrospinal fluid, avoidance of hypotension and anemia, intraoperative neurophysiologic monitoring, and advanced surgical techniques. Drainage of cerebrospinal fluid using a spinal drain decreases the risk of spinal cord ischemia by improving spinal cord perfusion pressure. However, cerebrospinal fluid drainage has risks including neuraxial and intracranial bleeding, and these risks need to be carefully weighed against its potential benefit. This review discusses current surgical management of descending thoracic and thoracoabdominal aortic disease, incidence of and risk factors for spinal cord injury, and elements of spinal cord protection protocols that pertain to anesthesiologists, with a focus on cerebrospinal fluid drainage.

Selective Versus Routine Spinal Drain Use for Fenestrated/Branched Endovascular Aortic Repair (F-BEVAR)

BACKGROUND

Spinal drains are used to ameliorate spinal cord ischemia (SCI), but their use may result in inherent morbidity and mortality. Although prophylactic spinal drain has proven of benefit in open repairs, that is not the case for endovascular repairs. The aim of this study was to assess the outcomes of spinal cord protection with and without the routine use of spinal drains during fenestrated-branched endovascular repair (F-BEVAR).

METHODS

A retrospective single center study was performed using a prospectively maintained dataset of all patients undergoing F-BEVAR over a 4-year period. The primary endpoint of the study was the frequency of SCI. Prophylactic spinal drain was placed pre-operatively in 33 patients (23%) with a median time for removal of 3 days (IQR, 2-3 days). Routine intraoperative neuromonitoring was used. Spinal cord protection relied primarily on maintaining a perioperative systolic blood pressure between 140 and 160 mm Hg or a mean arterial pressure >90 mm Hg, avoiding hypotension, preservation of as many collateral beds as possible, staged repairs and early lower extremity reperfusion based on neuromonitoring.

RESULTS

A total of 145 patients, 104 men (71%) and 41 women (28%) with a median age of 70 years (interquartile range [IQR], 53-62) underwent F-BEVAR. Branched custom-made devices (CMDs) (11%), fenestrated CMDs (70%) and off-the-shelf T-Branch device (17%) were used with a median number of branches/fenestrations of 4 (IQR, 3-4). SVS classification of implantation zones were determined as follows: 9 (6%) zone 2, 21 (20%) zone 3, 26 (18%) zone 4 and 89 (61%) zone 5. SCI was present in 8 patients (5.5%) and classified according to the SVS SCI grading system as follows: 1 grade 1, 5 grade 2 and 2 grade 3a. When evaluating implantation zone independently of coverage length and patency of collateral beds, a high implantation zone (1-4) was not associated with SCI (P = 0.9). Similarly, prophylactic spinal drain did not demonstrate association with the occurrence of SCI (3[9%] vs. 5[4%], with and without spinal drain, respectively) (P = 0.3). For patients with high implantation zones, staged repair was performed in 38 patients (26%) at a median time of 2 months (IQR, 2-6 months). Among these patients, the frequency of SCI was 13%. Staged repair was associated with an 80% reduction in the frequency of SCI (OR, 0.19 [95% CI, 0.04-0.084]) (P = 0.02).

CONCLUSION

F-BEVAR can be performed with a minimal risk of SCI without the need for routine prophylactic spinal drains. High implantation zones did not predict SCI after F-BEVAR; however, staged repair significantly decreased the risk of SCI after F-BEVAR.

Thoracic Trauma: Aortic Injuries

Thoracic aortic injuries caused by high impact trauma are life-threatening and require emergent diagnosis and management. With improvement in the acute care services, an increasing number of such injuries are being managed such that patients survive to undergo definitive therapies. A high index of clinical suspicion is required to order appropriate imaging. Computed tomography angiography is used to classify the injuries and guide treatment strategy. While low-grade injuries might be managed conservatively, high-grade injuries require urgent surgical or endovascular intervention. Over the past decade, endovascular repair of the thoracic aorta with or without a surgical bypass has become the preferred treatment with reduced mortality and morbidity. Rapid advancements in the stent graft technology have reduced the anatomic barriers to endovascular therapy and increased the confidence of the operators. Detailed planning prior to the procedure, understanding of the anatomy, correct choice of hardware, and adherence to technical protocol are essential for a successful endovascular procedure. These patients are often young and the limited data on the long-term outcome of aortic stent grafts make a case for a robust follow-up protocol.

Clinical trial outcomes and thoracic aortic morphometry after one year with the Valiant Navion stent graft system

AUTHORS' NOTE

On February 17, 2021, Medtronic Incorporated issued a global voluntary recall of the Valiant Navion Thoracic Stent Graft System (the device under study in the Valiant Evo Global Clinical Program that is the subject of this publication), and instructed physicians to immediately cease use of the Valiant Navion system and return any unused product. Medtronic initiated the recall in response to three clinical trial subjects recently observed with stent fractures, two of whom have confirmed type IIIb endoleaks. The data collection, analysis, and manuscript submission occurred before the notice of this recall, and, specifically, the 100 procedures reviewed for this series were free of events at 1 year related to the reason for this device recall. The authors of this article and the manufacturer were unaware of the recently detected adverse events at the time of the preparation of the manuscript, and the 1-year trial results, and imaging-based analyses described are unchanged. Management of thoracic aortic aneurysms continues to be a challenging problem and outcomes are dependent on patient anatomy. The present publication focuses on the importance of achieving proximal and distal seals and the consideration of the temporal changes of the aortic morphology as a part of the TEVAR planning process. The authors believe there is still scientific merit in disclosing this information, despite the current nonavailability of the Valiant Navion system.

OBJECTIVE

The Valiant Navion stent graft system (Medtronic Inc, Santa Rosa, Calif) is a third-generation device with improved conformability. We have reported the 1-year clinical trial outcomes, with a focus on an imaging-based analysis of the aortic morphology. We assessed the effects of graft implantation on the native anatomy and the effects of the 1-year changes in thoracic aorta morphology on the original seal zones of the stent graft.

METHODS

A total of 100 subjects were enrolled in a prospective single-arm clinical trial investigating the Valiant Navion stent graft system. An independent core laboratory (Syntactx, New York, NY) assessed the anatomic characteristics and performance outcomes.

RESULTS

Through 1 year of follow-up, the freedom from all-cause mortality, aneurysm-related mortality, and secondary procedures was 89.8%, 97.0%, and 94.8% respectively. Of the 100 patients, 5 had undergone a total of six secondary procedures, and 9 patients had developed an endoleak (type Ia and Ib in 1, type Ia in 1, type Ib in 3, and type II in 4 patients) within the first year. After 1 year, 2 of 76 patients (2.6%) had had an increase in their maximum aneurysm diameter of ≥5 mm, 62 (81.6%) had had stable sacs, and 12 (15.8%) had experienced sac shrinkage. Although no deployment failures had occurred, 36 of the 100 proximal (36%) and 31 of the 100 distal (31%) attachment zones were considered short according to our definitions. The stent graft had conformed to the native anatomy at implantation, because the preprocedural thoracic aorta tortuosity (1.45 ± 0.02) had not significantly changed at 1 month after implantation (1.46 ± 0.02). Despite a natural increase in thoracic tortuosity after 1 year (1.49 ± 0.02), wall apposition had been maintained over time, as evidenced by the low endoleak rates. Aortic elongation and dilation had occurred at the proximal end of the graft by an average of 1.2 mm and 1.6 mm, respectively. Aortic remodeling was more pronounced at the distal end, with an average increase of 4.2 mm in length and 2.8 mm in diameter.

CONCLUSIONS

The included patients had had positive 1-year outcomes with high freedom from mortality, endoleak development, and secondary procedures. Aortic elongation and dilation were more prevalent at the distal end, emphasizing the importance of distal attachment zone consideration as part of preoperative planning. Because aortic remodeling can be expected to continue over time, additional follow-up and imaging analysis in the trial will be necessary to assess the aortic morphology and its effects on stent graft performance.

Preliminary results from a multicenter Italian registry on the use of a new branched device for the treatment of thoracoabdominal aortic aneurysms

OBJECTIVE

The study purpose was to present early outcomes of patients treated for thoracoabdominal aortic aneurysms or complex abdominal aortic diseases using endovascular repair with a new branched endograft.

METHODS

This multicenter, retrospective, observational cohort study included all patients treated with a new branched endograft. All elective patients were treated with a staged operative strategy and spinal drainage Primary outcomes of interest were technical success, early (≤30 days) mortality, and late (≥30 days) survival, and freedom from adverse aortic events.

RESULTS

A total of 16 consecutive patients were treated for Crawford's extent type I (n = 1), type II (n = 7), type III (n = 1), and type IV (n = 5) endoleaks, with an additional two complex pararenal abdominal aortic lesions (enlarging type Ia endoleak, n = 1; anastomotic pseudoaneurysm, n = 1). There were 13 male (81%) and 3 female (19%) patients with a median age of 72.5 years (interquartile range [IQR], 69-78 years). The median diameter of the aortic aneurysm was 65 mm (IQR, 58-81 mm) and the median EuroSCORE prediction for mortality was 18% (IQR, 12%-36%). Thoracoabdominal aortic aneurysm was secondary to a previous dissection in four patients. A total of 62 of the 64 visceral vessels (96.9%) were stented. Technical success was achieved in 14 (87.5 %) and the cumulative aorta-related mortality rate was 19%. Spinal cord ischemia did not occur. The mean follow-up was 8 ± 4 months (range, 2-15 months). No type I or type III endoleaks were detected. Primary bridging stent patency was 98% (one asymptomatic thrombotic occlusion of a celiac trunk branch). No aortic reintervention was required.

CONCLUSIONS

Endovascular repair of complex aortic aneurysms with this new branched endograft can be performed with high technical success and acceptable morbidity. A 19% mortality is quite high; however, it is tolerable in such a high-risk cohort. The survival rate was acceptable, and graft-related outcomes at early follow-up included an absence of threatening endoleaks and a high target visceral vessel patency.

Short-term and Mid-term Outcomes after Use of the Native Infrarenal Aorta as Distal Landing Zone for Fenestrated-Branched Endovascular Aortic Repair

BACKGROUND

This study aimed to examine outcomes after use of the native infrarenal aorta as distal landing zone for fenestrated-branched endovascular aortic repair (F-BEVAR) of pararenal-thoracoabdominal aortic aneurysms (PRAA-TAAA).

METHODS

All F-BEVAR procedures for treatment of PRAA-TAAA (2011-2019) at 2 aortic centers were examined. The outcomes of interest were as follows: i) technical success, ii) perioperative morbidity, iii) preservation of lumbar arteries and the inferior mesenteric artery, iv) type IB endoleaks, v) reinterventions, vi) survival, vii) aneurysm sac behavior, and viii) infrarenal aortic changes.

RESULTS

Twenty consecutive patients with distal landing in the native infrarenal aorta were included (median age 71 years; 25% men). The median number of visible lumbar arteries at baseline was 7, and a patent inferior mesenteric artery (IMA) before the operation was present in 19 (95%) of the cases. There were no deaths within 30 days. One patient (5%), operated on with a 4-BEVAR for a type 2 TAAA, experienced spinal cord ischemia (permanent paraplegia). The median decrease in the number of visible lumbar arteries at the first postoperative scan was 3 from the baseline value, whereas a patent IMA was preserved in 12 out of 19 patients. Only in one case (5%), a type IB endoleak was noted for an overall technical success rate of 95%, which required a standard EVAR 20 months after the initial operation. The median follow-up duration for the study cohort was 491 days; all patients were alive at the longest available individual follow-up, and no instances of new-onset type IB endoleaks were observed. Another 3 late reinterventions (in addition to the one mentioned previously) were performed during midterm follow-up, all because of target vessel instability. In patients with ≥12 months of follow-up after the index procedure (n = 12, 60% of the entire cohort), no instances of aneurysm sac increase >5 mm were noted; the median largest aortic diameter was 51 mm with a median difference from baseline of -6 mm. The median distal landing zone diameter increase was 4 mm from baseline but never beyond the nominal stent-graft diameter, whereas the median aortic bifurcation diameter differed 1 mm from baseline.

CONCLUSIONS

This preliminary experience shows that the use of the native infrarenal aorta as a distal landing zone for F-BEVAR is safe in the short term and midterm in patients with suitable anatomy, allowing the sparing of collateral vessels. Longer follow-up is warranted to assess durability.

Permissive Hypertension and Collateral Revascularization May Allow Avoidance of Cerebrospinal Fluid Drainage in Thoracic Endovascular Aortic Repair

BACKGROUND

The utility of cerebrospinal fluid drainage (CSFD) for prevention of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) remains unclear. We previously published our institutional algorithm restricting preoperative CSFD to patients deemed high risk for SCI. Since that publication, our algorithm has evolved with preoperative CSFD avoided in all patients undergoing isolated descending TEVAR with or without arch involvement (+/- arch TEVAR). This study evaluated the updated algorithm in a contemporary cohort.

METHODS

Patients who underwent TEVAR for descending aortic +/-arch pathology between February 2012 and September 2018 at a single center were identified from an institutional aortic surgery database. The algorithm includes left subclavian artery (LSA) revascularization in cases of coverage with no preservation of antegrade flow, permissive hypertension, and use of evoked potential monitoring. The primary end points were SCI or postoperative CSFD.

RESULTS

During the study interval, 225 patients underwent descending +/- arch TEVAR. CSFD was used before TEVAR in 2 patients (0.9%) in violation of the algorithm, and they were excluded from the study cohort. Endograft coverage below T6 occurred in 81%. The LSA was fully covered in 100 patients (47%), all of whom underwent LSA revascularization. Following the updated algorithm, the incidence of temporary or permanent SCI was 0%. No patient required postoperative CSFD.

CONCLUSIONS

A restrictive lumbar CSFD algorithm, including permissive hypertension and LSA revascularization in the setting of descending +/- arch TEVAR, appears safe, with a 0% incidence of SCI in 223 consecutive patients treated during a 6.5-year interval. We recommend consideration of further prospective study to evaluate this algorithm.

Spinal cord injury after open and endovascular repair of descending thoracic and thoracoabdominal aortic aneurysms: A meta-analysis

OBJECTIVE

An inclusive contemporary analysis of spinal cord injury (SCI) rates in patients undergoing aneurysm repair and the factors associated with complications has not been performed.

METHODS

Following a systematic literature search, studies from 2008 to 2018 on repair of descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) were pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was permanent SCI. Secondary outcomes were temporary SCI, operative mortality, long-term mortality, postoperative stroke, and cerebrospinal fluid (CSF) drain-related complications.

RESULTS

One-hundred sixty-nine studies (22,634 patients) were included. The pooled rate of permanent SCI was 4.5% (95% confidence interval [CI], 3.8-5.4); 3.5% (95% CI, 1.8-6.7) for DTA and 7.6% (96% CI, 6.2-9.3) for TAAA repair (P for subgroups = .02), 5.7% (95% CI, 4.3-7.5) for open repair and 3.9% (95% CI, 3.1-4.8) for endovascular repair (P for subgroups = .03). Rates for Crawford extents I, II, III, IV, and V aneurysms were 4.0% (95% CI, 3.0-5.0), 15.0% (95% CI, 10.0-22.0), 7.0% (95% CI, 6.0-9.0), 2.0% (95% CI, 2.0-4.0), and 7.0% (95% CI, 2.0-23.0) respectively (P for subgroups <.001). The pooled rates for operative mortality, late mortality at a mean follow-up of 5.0 years, stroke, and temporary SCI were 7.4% (95% CI, 6.1-9.4), 1.0% (95% CI, 0.0-1.0), 4.2% (95% CI, 3.6-4.8), and 3.7% (95% CI, 3.0-4.6), respectively. The pooled rates for severe, moderate, and minor CSF-drain related complications were 5.1% (95% CI, 2.23-11.1), 4.1% (95% CI, 0.6-22.0), and 3.6% (95% CI, 1.2-8.0) respectively.

CONCLUSIONS

Despite improvement, both open and endovascular aneurysm repair remain associated with a substantial risk of permanent SCI. The risk is greater for TAAA repair, especially extent II, III, and V.

Results of frozen elephant trunk from the international E-vita Open registry

Background

Over the years, frozen elephant trunk (FET) has become the treatment of choice for multisegmental thoracic aortic disease. This multicenter study presents the evolution of FET results using the E-vita Open hybrid graft with respect to institutional experience and time.

Methods

The data of International E-vita Open registry were studied according to the institutional experience of the participating centers (high- versus low-volume centers) and according to the evolution of FET treatment during time (1^st period, 2005-2011 versus 2^nd period, 2012-2018). Overall, 1,165 patients were enrolled in the study with a wide variety of multisegmental thoracic aortic pathologies and aortic emergencies. Participating centers determined their own surgical protocol.

Results

The overall 30-day mortality was 12%. Short- and long-term survival were higher in high- versus low-volume centers (P=0.048 and P=0.013, respectively). In the 2^nd time period, cerebral complications were reduced significantly (P=0.015). Incidence of permanent spinal cord-related symptoms was reduced to 3% in the 2^nd time period, but did not reach statistical significance. Hypothermic circulatory arrest time (P<0.001) and incidence of postoperative temporary renal replacement therapy (P=0.008) were significantly reduced in the 2^nd time period. Ten-year survival and freedom from aortic-related death rates were 46.6% and 85.7%, respectively, for the entire group. The freedom from distal aortic re-interventions for a new or progressive residual aortic disease was 76.0%.

Conclusions

Evolution of FET arch repair techniques with the E-vita Open graft and increasing institutional experience were associated with improved results. Progression of residual aortic disease makes close follow-up with aortic imaging mandatory in such patients.

Incidence, predictors, and outcomes of spinal cord ischemia in elective complex endovascular aortic repair: An analysis of health insurance claims

OBJECTIVE

This study aimed to determine predictors and outcomes associated with spinal cord ischemia (SCI) after elective fenestrated or branched endovascular aneurysm repair (F/BEVAR) of thoracoabdominal aortic aneurysm (TAAA), abdominal aortic aneurysm (AAA), or aortic dissection.

METHODS

Health insurance claims data of Germany's third largest insurance provider, DAK-Gesundheit, were used to investigate SCI in elective F/BEVAR performed between 2008 and 2017. The International Classification of Diseases and German Operation and Procedure Classification System were used. We stratified the results into F/BEVAR with one or two (AAA) vs three or more (TAAA) fenestrations or branches.

RESULTS

A total of 877 patients (18.9% female; 5.8% with SCI) matching the inclusion criteria were identified during the study period. SCI occurred more often after F/BEVAR of TAAA vs AAA (10.7% vs 3.0%; P < .001). SCI was associated with female sex in the AAA group (odds ratio, 3.87; 95% confidence interval [CI], 1.25-11.15; P = .014) and with cardiac arrhythmias in the TAAA group (odds ratio, 2.98; 95% CI, 1.24-7.06; P = .013). Compared with patients without SCI, SCI patients were more likely to suffer from drug use disorders (eg, opioids, cannabinoids, sedatives) in the TAAA group (17.6% vs 2.1%; P < .05). After F/BEVAR of TAAA, the occurrence of SCI was associated with higher 90-day mortality (14.7% vs 1.1%; P < .05), longer postoperative hospital stay (22 vs 9 days; P < .05), and severe adverse events, such as acute respiratory insufficiency (44.1% vs 12.7%), acute renal failure (35.3% vs 11.3%), and pneumonia (29.4% vs 4.9%; all P < .05). In adjusted analyses, SCI was associated with worse long-term survival after F/BEVAR for TAAA (hazard ratio, 2.54; 95% CI, 1.37-4.73; P < .003).

CONCLUSIONS

Female AAA patients and TAAA patients with cardiac arrhythmias are at highest risk for development of SCI after F/BEVAR. The occurrence of this event was strongly associated with higher major complication rates and worse short-term and long-term survival. This emphasizes a need to further illuminate the value of spinal cord protection protocols in F/BEVAR.

Endovascular Treatment for Thoracoabdominal Aortic Aneurysm and Complex Abdominal Aortic Aneurysm Using Fenestrated and Branched Grafts

Fenestrated and branched endovascular aneurysm repair (F/B-EVAR) is a less invasive treatment for thoracoabdominal aortic aneurysm (TAAA) and complex abdominal aortic aneurysm. Fenestrated and branched (cuff) grafts facilitate safe and durable repair, and bail-out maneuvers for target vessel cannulation and stenting have been established; however, the available bridging stent grafts have differences. The present article discusses the optimal selection of fenestrated or branched grafts, the cannulation of target vessels that have difficult anatomies, and the advantages and disadvantages of various bridging stents. We review the causes and risk factors of spinal cord injury (SCI), the protocol for prevention of SCI, and the outcomes of target vessel stent grafting, including patency and endoleak.

Although conventional open surgery is the gold standard for the repair of thoracoabdominal aortic aneurysm (TAAA), it is highly invasive. To reduce invasiveness, hybrid surgery that combines open surgery and endovascular therapy has been developed [1, 2], and fenestrated and branched endovascular aneurysm repair (F/B-EVAR) is frequently performed at centers in the USA, Europe, and Japan [3-5]. Additionally, a hostile neck may be an independent factor for sac enlargement after EVAR for abdominal aortic aneurysm (AAA) [6], but a previous study reported that 41% of AAA cases presented with neck lengths outside the range prescribed by the traditional instruction for use [7]. Stark et al. showed that extending the graft above the highest renal artery would create an augmented neck length in 90% of patients with AAA [7]. F/B-EVAR is based on this principle. However, there are some technical tips for, and limitations of, fenestrated and/or branched graft. F/B-EVAR for TAAA and complex AAA will be reviewed in the present article.

New Technique for Preconditioning of the Spinal Cord Before Endovascular Repair of Descending Thoracic and Thoracoabdominal Aortic Aneurysms

Purpose: To propose a new simplified technique to occlude multiple segmental arteries for staging and preconditioning of the spinal cord to decrease the potential for spinal cord ischemia after thoracic and thoracoabdominal aortic aneurysm repair. Technique: A thoracic stent-graft that flares out to a maximum of 51 mm is deployed in a standard fashion covering all segmental arteries where graft-wall apposition occurs in the first ~20 cm of the aneurysm. The segmental arteries are always closed at their ostia in contrast to selective coil embolization, where there is a risk of more peripheral closure. Follow-up imaging shows thrombus lining the stent-graft-covered portion of the aneurysm and secondary proximal segmental artery occlusion. Conclusion: A new and fast way of staging and preconditioning the spinal cord using a modified stent-graft prior to definitive repair might be an alternative to segmental artery embolization.

Outcomes of a Spinal Drain and Intraoperative Neurophysiologic Monitoring Protocol in Thoracic Endovascular Aortic Repair

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.

Outcomes and complications after fenestrated-branched endovascular aortic repair

OBJECTIVE

To report the outcomes of patients enrolled in a physician-sponsored investigational device exemption trial for endovascular treatment of complex thoracoabdominal aortic aneurysms with fenestrated and/or branched devices.

METHODS

This study represents a retrospective analysis of a prospectively maintained database of patients enrolled in a physician-sponsored investigational device exemption trial for endovascular treatment of complex thoracoabdominal aneurysms between July 2012 and July 2017. Subjects included high-risk patients for open repair and patients with unsuitable anatomy for either standard endovascular aneurysm repair or Zenith (Cook Medical, Bloomington, Ind) fenestrated device. Aneurysm classification was based upon Crawford classification. We included the pararenal and paravisceral aneurysms in the type IV aneurysm group, because the repair of these aneurysms usually involved treatment of all four visceral branches. The endografts implanted were custom manufactured devices or off-the-shelf devices based on the Cook Zenith platform. Variables analyzed included preoperative demographics and comorbidities, anatomic aneurysmal characteristics, procedural details, and perioperative complications.

RESULTS

One -hundred fifty patients with a mean age of 71 ± 7.9 years were treated; 69% were male. Tobacco use (93%) and hypertension (91%) were the most common risk factors. Fifty-seven patients (38%) had a history of previous aortic repair. The mean aneurysm diameter was 62 ± 12 mm and 14 (9%) aneurysms were associated with chronic dissection. A total of 573 visceral vessels were incorporated (celiac artery/superior mesenteric artery [287 vessels], renal arteries [275 vessels], and 11 additional vessels) and 539 were stented. The celiac artery/superior mesenteric artery received a fenestrated design in 76.1% of cases. Branch designs were used in the renal artery in 13.2%, with the remainder treated with fenestrations. Spinal cord drainage was used in 51% of patients (76/150). The mean operative time, fluoroscopy time, and estimated blood loss were 283 ± 89 minutes, 83 ± 38 minutes, and 417 ± 404 mL, respectively. There were five patients (3.3%) with intraoperative complications, resulting in one intraoperative death. The early mortality was 2.7% (4/150). Major complications included respiratory failure in 7% (10/150), stroke and myocardial infarction in 0.7% each (1/150), and paraplegia in 2.7% (4/150). Acute kidney injury occurred in 4.7% of patients (7/150), two of whom required temporary dialysis. Thirty-nine percent of patients experienced at least one complication. Early branch vessel patency was 99.8% (525/526). Survival, primary, and primary-assisted branch patency at 2 years of follow-up were 79%, 97%, and 99%, respectively.

CONCLUSIONS

Endovascular repair of complex aneurysms is safe and effective when performed in a high-volume center experienced in aortic disease management. Branch vessels patency and the low incidence of paraplegia and mortality support expanded use to treat most complex thoracoabdominal aortic aneurysms.