Spinal cord ischemia after TEVAR in patients with abdominal aortic aneurysms

Thoracic Endovascular Aortic Repair and Endovascular Aneurysm Repair Approaches for Managing Aortic Pathologies: A Retrospective Cohort Study

Background/Objectives: Since thoracic endovascular aortic repair (TEVAR) and endovascular aneurysm repair (EVAR) are increasingly utilized, examining their outcomes and safety in real-world scenarios is crucial. This study investigated the management and outcomes of TEVAR and EVAR as alternatives to traditional open surgical repair for managing aortic pathologies. Methods: This was a retrospective cohort study. We analyzed the data from 59 consecutive patients who underwent TEVAR or EVAR between 2015 and 2022 at a single tertiary care center. The primary outcome was survival, and secondary outcomes were complications assessment, including re-intervention and occurrence of endoleaks. Results: TEVAR accounted for 47.5% of cases (n = 28), while EVAR comprised 52.5% (n = 31). Patients were mostly 61-70 years old (23.7%) and male (91.5%). Surgery indications differed, with aneurysmal repair being the prevalent indication for EVAR (90.3%, n = 28) and trauma being the main indication for TEVAR (67.9%, n = 19). Regarding the primary outcome, 11 patients (18.6%) died for various reasons; of those, 2 patients (3.4%) were determined to have died from vascular-related issues. Most patients (81.4%, n = 48) did not experience intraoperative complications. The most common intraoperative complications were endoleaks and access failure, each affecting 5.1% (n = 3) of patients. Re-intervention was necessary in 16.9% (n = 10) of cases, with endoleaks being the major indication (60%). Emergency intervention was more frequent in the TEVAR group (p = 0.013), resulting in significantly longer hospitalization (p = 0.012). Conclusions: Despite limitations, our analysis indicates a good safety profile with high success rates and a low incidence of adverse health outcomes and mortality in TEVAR/EVAR procedures. Nevertheless, the results emphasize the ongoing concern of endograft leaks, necessitating re-interventions.

Systematic Review of the Effect of Cerebrospinal Fluid Drainage on Outcomes After Endovascular Descending Thoracic/Thoraco-Abdominal Aortic Aneurysm Repair

OBJECTIVE

This study aimed to investigate whether prophylactic use of cerebrospinal fluid (CSF) drainage in endovascular descending thoracic aortic aneurysm (DTAA) and thoraco-abdominal aortic aneurysm (TAAA) repair contributes to a lower rate of post-operative spinal cord ischaemia (SCI).

DATA SOURCES

MEDLINE, Embase, and CINAHL.

REVIEW METHODS

A literature review was conducted in accordance with PRISMA guidelines (PROSPERO registration no. CRD42021245893). Risk of bias was assessed through the Newcastle-Ottawa scale (NOS), and the certainty of evidence was graded using the GRADE approach. A proportion meta-analysis was conducted to calculate the pooled rate and 95% confidence interval (CI) of both early and late onset SCI. Pooled outcome estimates were calculated using the odds ratio (OR) and associated 95% CI. The primary outcome was SCI, both early and lateonset. Secondary outcomes were complications of CSF drainage, length of hospital stay, and peri-operative (30 day or in hospital) mortality rates.

RESULTS

Twenty-eight observational, retrospective studies were included, reporting 4 814 patients (2 599 patients with and 2 215 without CSF drainage). The NOS showed a moderate risk of bias. The incidence of SCI was similar in patients with CSF drainage (0.05, 95% CI 0.03 ‒ 0.08) and without CSF drainage (0.05, 95% CI 0.00 ‒ 0.14). No significant decrease in SCI was found when using CSF drainage (OR 0.67, 95% CI 0.29 ‒ 1.55, p = .35). The incidence rate of CSF drainage related complication was 0.10 (95% CI 0.04 ‒ 0.19). The 30 day and in hospital mortality rate with CSF drainage was 0.08 (95% CI 0.05 ‒ 0.12). The 30 day and in hospital mortality rate without CSF drainage and comparison with late mortality and length of hospital stay could not be determined due to lack of data. The quality of evidence was considered very low.

CONCLUSION

Pre-operative CSF drainage placement was not related to a favourable outcome regarding SCI rate in endovascular TAAA and DTAA repair. Due to the low quality of evidence, no clear recommendation on pre-operative use of CSF drainage placement can be made.

Thoracic endovascular aortic repair of metachronous thoracic aortic aneurysms following prior infrarenal abdominal aortic aneurysm repair

OBJECTIVE

Thoracic endovascular aortic repair (TEVAR) of metachronous thoracic aortic aneurysms (M-TAAs) following previous infrarenal abdominal aortic aneurysm (AAA) repair has been associated with higher spinal cord ischemia (SCI) risk compared with TEVAR of primary thoracic aortic aneurysms (TAAs). However, data on the impact of the type of prior infrarenal aortic repair on outcomes are scarce. In this study, we examined perioperative outcomes and long-term mortality following TEVAR M-TAA compared with primary TEVAR of TAA.

METHODS

We identified all Vascular Quality Initiative (VQI) patients who underwent TEVAR of TAA in the descending thoracic aorta from 2013 to 2022. Only patients undergoing primary TEVAR or TEVAR following infrarenal open (OAR) or endovascular (EVAR) repair were included. We performed univariate analyses to identify differences in baseline and procedural characteristics, and multivariable analyses for perioperative outcomes and 5-year mortality using logistic and Cox regression, respectively.

RESULTS

We included 1493 patients who underwent primary TEVAR (81%) or TEVAR following prior OAR (9.0%) or prior EVAR (9.7%). Compared with primary TEVAR, patients undergoing TEVAR M-TAA were older, more commonly male, white, and had higher rates of hypertension, smoking, and renal dysfunction. Patients with M-TAA were more likely to be asymptomatic and have larger diameters at presentation but were exposed to greater contrast volume and procedural times relative to primary TEVAR patients. Following risk-adjustment, compared with primary TEVAR, TEVAR after prior EVAR was associated with higher perioperative mortality (9.7% vs 3.9%; odds ratio [OR], 5.3; 95% confidence interval [CI], 2.3-12; P < .001) and 5-year mortality (40% vs 24%; hazard ratio [HR], 2.1; 95% CI, 1.4-3.1; P = .001). Specifically, among octogenarians (n = 375; 25%), the perioperative and 5-year mortality differences were even more pronounced (perioperative mortality: 17% vs 8.4%; OR, 6.7; 95% CI, 2.2-21; P = .001; 5-year mortality: 50% vs 27%; HR, 3.0; 95% CI, 1.5-5.7; P = .010). However, in-hospital complications, including SCI (2.6% vs 2.8%; OR, 1.2; 95% CI, 0.33-3.3; P = .77), were not notably different. In contrast, TEVAR after previous OAR was associated with comparable perioperative mortality (4.4% vs 3.9%; OR, 1.2; 95% CI, 0.32-3.8; P = .73), 5-year mortality (28% vs 24%; HR, 1.3; 95% CI, 0.80-2.1; P = .54), and in-hospital complications, including SCI (2.6% vs 0.7%; OR, 0.21; 95% CI, 0.01-1.1; P = .16).

CONCLUSIONS

Patients undergoing TEVAR of M-TAAs after prior EVAR, particularly octogenarians, have higher perioperative and 5-year mortality and therefore, represent a high-risk group. Future efforts should strive to discern the underlying factors leading to these poorer outcomes; meanwhile, these findings emphasize the need for careful patient selection and appropriate preoperative counseling in these high-risk individuals.

Unusual presentation of acute ruptured penetrating aortic ulcer of descending thoracic aorta with right hemothorax

Right-sided hemothorax is a rare presentation of ruptured penetrating aortic ulcers. A 72-year-old female presented to the hospital with a penetrating aortic ulcer of the mid-thoracic aorta and a right-sided hemothorax. The patient was taken for thoracic endovascular aortic repair and right-sided tube thoracostomy. The diagnosis was complicated by the patient's history of pacemaker placement causing prominent venous collaterals in the mediastinum. The postoperative course was complicated by lower extremity weakness, requiring lumbar cerebrospinal fluid drain placement. The patient regained full function of her lower extremities. This case illustrates that patients with ruptured acute aortic syndromes may present with right hemothorax, so index of suspicion should remain high in this population.

Postoperative management in patients with complex aortic aneurysms

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.

Simultaneous Endovascular Repair Is Not Associated With Increased Risk for Thoracic and Abdominal Aortic Pathologies: Early and Midterm Outcomes

Coexisting multilevel aortic pathologies were caused by atherosclerosis and hypertension and presented in a small subgroup of patients. Endovascular repair is a safe and effective treatment for a variety of aortic pathologies. However, fewer small series and cases were reported using simultaneous thoracic endovascular repair (TEVAR) and endovascular aneurysm repair (EVAR) for both aortic segments. To determine the outcomes of simultaneous and separately TEVAR and EVAR treating for multilevel aortic pathologies. Between 2010 and 2020, 31 patients and 22 patients were treated by one-staged and two-staged repair, respectively at a single center. All patients had the concomitant thoracic and abdominal aortic disease (aortic dissection, aneurysms, and penetrating aortic ulcers). Compared with the patients with two-staged aortic repair, the one-staged repair patients were older (mean age, 68 vs. 57 years; P < 0.001) and had a larger preoperative maximal aortic diameter (67.03 ± 10.65 vs. 57.45 ± 10.36 mm; p = 0.002). The intraoperative and postoperative outcomes show that the procedure times and length of hospital stay (LOS) were longer in the two-staged group. There is no significant difference in postoperative complications between the two groups. In the follow up, the freedom from re–intervention and the mean survival rate for the one-staged group were 100 vs. 100%, 92.4 vs. 95%, and 88 vs. 88% at one, two, and 5 years, respectively, whereas the mean survival rate for the two-staged group was 86.4 vs. 90.5%, 87 vs. 90.5%, and 76 vs. 84% at one, two, and 5 years, respectively, all with no statistical difference. Combined TEVAR and EVAR can be performed successfully with minimal morbidity and mortality. The one-staged repair was not associated with the increased risk for multilevel aortic pathologies treatment.

Staging Endovascular Thoracic and Thoracoabdominal Aortic Aneurysm Repairs and the Risk of Post-operative Spinal Cord Ischemia

OBJECTIVE

Staged aortic aneurysm repair is one method used to decrease the risk of spinal cord ischemia (SCI) following endovascular aortic intervention. Sequential sacrifice of arteries perfusing the spine may allow for improved spinal perfusion through the development of collateral networks over time. To evaluate the impact of staging endovascular aortic aneurysm repairs on SCI, we conducted a conservative analysis of Vascular Quality Initiative (VQI) data.

METHODS

De-identified VQI data were queried for cases of endovascular thoracic and thoracoabdominal aneurysm repairs from year 2014 to 2019. Cases were selected based on inclusion criteria: aneurysmal disease, no ruptures, no prior aortic surgeries, no retreatments, and only cases with complete data on aortic zones and SCI. Chi-square, Student's t-tests, and Mann-Whitney U tests were used for univariable analyses, as appropriate. Logistic regression analyses were used to identify independent predictors of outcome.

RESULTS

There were 116 staged aortic repairs (SARs) (8.2%) performed out of a total of 1421 endovascular aortic repairs that fit study criteria. The overall rate of SCI within the study cohort was 3.4% (n = 48). The distribution of SARs and SCI events according to aortic zone coverage are displayed in Table 1. Patients who underwent staged endovascular aortic repairs had higher rates of SCI, pre-op spinal drain placement, non-African-American race, COPD, smoking history, positive stress tests, aspirin and statin use, increased estimated blood loss, physician-modified endografts, number of aortic zones covered, lower pre-op hemoglobin levels, larger aneurysm sac size, fusiform aneurysms, and longer total procedure times, Table 2. After adjusting for factors associated with SCI, a priori, and factors with a P < 0.1 univariable analysis, SAR was not associated with SCI (odds ratio [OR] = 1.86, 95% confidence interval [CI] = 0.77-4.50, P = 0.17). Of the six factors associated with SCI on univariable analysis, only procedure time ≥6 hours (OR = 2.49, 95% CI = 1.09-5.70, P = 0.031) and the number of aortic zones covered (OR = 1.15, 95% CI = 1.00-1.32, P = 0.047) were predictive of SCI. Staged repairs had a lower proportion of permanent SCI (38%, 3 of 8 cases) compared with repairs that were not staged (68%, 27 of 40 cases), with a relative risk reduction of 44% for those who developed SCI, P = 0.21.

CONCLUSIONS

In a large national data set, SARs were performed for patients with more extensive aortic disease. SARs were only performed in about 8% of cases and the rate of SCI remained low. After adjusting for baseline comorbidities, extent of aortic disease, and other factors that may potentiate SCI, staged aortic aneurysm repair had a similar risk of SCI compared with non-staged repairs. However, there was a trend toward decreased permanent SCI risk in the SAR group.

Prior Infrarenal Aortic Surgery is Not Associated with Increased Risk of Spinal Cord Ischemia Following Thoracic Endovascular Aortic Repair and Complex Endovascular Aortic Repair

OBJECTIVES

Patients with prior infrarenal aortic intervention represent an increasing demographic of patients undergoing thoracic endovascular aortic repair (TEVAR) and/or complex EVAR. Studies have suggested that prior abdominal aortic surgery is a risk factor for spinal cord ischemia (SCI). However, these results are largely based on single-center experiences with limited multi-institutional and national data assessing clinical outcomes in these patients. The objective of this study was to evaluate the effect of prior infrarenal aortic surgery on SCI.

METHODS

The Society for Vascular Surgery Vascular Quality Initiative database was retrospectively reviewed to identify all patients ≥18 years old undergoing TEVAR/complex EVAR from January 2012 to June 2020. Patients with previous thoracic or suprarenal aortic repairs were excluded. Baseline and procedural characteristics and postoperative outcomes were compared by group: TEVAR/complex EVAR with or without previous infrarenal aortic repair. The primary outcome was postoperative SCI. Secondary outcomes included postoperative hospital length of stay (LOS), bowel ischemia, renal ischemia, and 30-day mortality. Multivariate regression was used to determine independent predictors of postoperative SCI. Additional analysis was performed for patients undergoing isolated TEVAR.

RESULTS

A total of 9506 patients met the inclusion criteria: 8691 (91.4%) had no history of infrarenal aortic repair and 815 (8.6%) had previous infrarenal aortic repair. Patients with previous infrarenal repair were older with an increased prevalence of chronic kidney disease (p=0.001) and cardiovascular risk factors including hypertension, chronic obstructive pulmonary disease, and smoking history (p<0.001). These patients presented with larger maximal aortic diameters (6.06±1.47 cm versus 5.15±1.76 cm; p<0.001) and required more stent grafts (p<0.001) with increased intraoperative blood transfusion requirements (p<0.001), and longer procedure times (p<0.001). Univariate analysis demonstrated no difference in postoperative SCI, postoperative hospital LOS, bowel ischemia, or renal ischemia between the two groups. Thirty-day mortality was significantly higher in patients with prior infrarenal repair (p=0.001). On multivariate regression, prior infrarenal aortic repair was not a predictor of postoperative SCI, while aortic dissection (odds ratio [OR] 1.65; 95% confidence interval [CI] 1.26-2.16, p<0.001), number of stent grafts deployed (OR 1.45; 95% CI 1.30-1.62, p<0.001), and units of packed red blood cells transfused intraoperatively (OR 1.33; 95% CI 1.03-1.73, p=0.032) were independent predictors of SCI.

CONCLUSIONS

Although TEVAR/complex EVAR patients with prior infrarenal aortic repair constituted a sicker cohort with higher 30-day mortality, the rate of SCI was comparable to patients without prior repair. Previous infrarenal repair was not associated with risk of SCI.

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.

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.

Complications associated with lumbar drain placement for endovascular aortic repair

OBJECTIVE

We reviewed the complications associated with perioperative lumbar drain (LD) placement for endovascular aortic repair.

METHODS

Patients who had undergone perioperative LD placement for endovascular repair of thoracic and thoracoabdominal aortic pathologies from 2010 to 2019 were reviewed. The primary endpoints were major and minor LD-associated complications. Complications that had resulted in neurological sequelae or had required an intervention or a delay in operation were defined as major. These included intracranial hemorrhage, symptomatic spinal hematoma, cerebrospinal fluid (CSF) leak requiring intervention, meningitis, retained catheter tip, arachnoiditis, and traumatic (or bloody) tap resulting in delayed operation. Minor complications were defined as a bloody tap without a delay in surgery, asymptomatic epidural hematoma, and CSF leak with no intervention required. Isolated headaches were recorded separately owing to the minimal clinical impact.

RESULTS

A total of 309 LDs had been placed in 268 consecutive patients for 222 thoracic endovascular aortic repairs, 85 complex endovascular aortic repairs (EVARs; fenestrated branched EVAR/parallel grafting), and 2 EVARs (age, 65 ± 13 years; 71% male) for aortic pathology, including aneurysm (47%), dissection (49%), penetrating aortic ulcer (3%), and traumatic injury (0.6%). A dedicated neurosurgical team performed all LD procedures; most were performed by the same individual, with a technical success rate of 98%. Radiologic guidance was required in 3%. The reasons for unsuccessful placement were body habitus (n = 2) and severe spinal disease (n = 3). Most were placed prophylactically (96%). The overall complication rate was 8.1% (4.2% major and 3.9% minor). Major complications included spinal hematoma with paraplegia in 1 patient, intracranial hemorrhage in 2, meningitis in 2, arachnoiditis in 3, CSF leak requiring a blood patch in 3, bloody tap delaying the operation in 1, and a retained catheter tip in 1 patient. Patients who had undergone previous LD placement had experienced significantly more major LD-related complications (12.2% vs 3%; P = .019). The rate of total LD-associated complications did not differ between prophylactic and emergent therapeutic placements (8.1% vs 7.7%; P = 1.00) nor between major or minor complications. On multivariate analysis, previous LD placement and an overweight body mass index were the only independent predictors of major LD-related complications.

CONCLUSIONS

The complications associated with LD placement can be severe even when performed by a dedicated team. Previous LD placement and overweight body mass index were associated with a significantly greater risk of complications; however, emergent therapeutic placement was not. Although these risks are justified for therapeutic LD placement, the benefit of prophylactic LD placement to prevent paraplegia should be weighed against these serious complications.

New Preoperative Spinal Cord Ischemia Risk Stratification Model for Patients Undergoing Thoracic Endovascular Aortic Repair

PURPOSE

Our objective was to determine significant predictors of spinal cord ischemia (SCI) following Thoracic Endovascular Aortic Repair (TEVAR) and to further develop a simple and clinically orientated risk score model.

METHODS

A retrospective review of data from the Society of Vascular Surgery/Vascular Quality Initiative national data set was performed for all patients undergoing TEVAR from January, 2014 to June 2018. Preoperative demographics, procedure-related variables, and clinical details related to SCI were examined. A SCI risk score was developed utilizing a multivariable logistic regression model.

RESULTS

For the 7889 patients in the final analysis who underwent TEVAR during the study period, the mean age was 67.6 ± 13.9, range 18 to 90 years, and the majority was male (65%). Postoperative outcomes included stroke (3.0%), myocardial infarction (2.9%), inhospital mortality (5.4%), transient SCI (1.5%), and permanent SCI (2.1%). Nearly half of the overall cases were performed in high volume centers. Predictors of increased risk for SCI included age by decade (odds ratio [OR]: 1.2), celiac coverage (OR: 1.5), current smoker (OR: 1.6), dialysis (OR: 1.9), 3 or more aortic implanted devices (OR: 1.7), emergent or urgent surgery (OR: 1.5), adjunct aorta-related procedure (OR: 2.5), adjunct not related (OR: 2.6), total estimated length of aortic device (19-31 cm, OR: 1.9 and ≥32 cm, OR: 3.0), ASA class 4 or 5 (OR: 1.6), and procedure time ≥154 minutes (OR: 1.8). Two predictors decreased the risk of SCI, cases from high-volume centers (OR: 0.6) and eGFR ≥ 60 (OR: 0.6). To evaluate the risk score model, probabilities of SCI from the original regression, raw score, and raw score categories resulted in area under the curve statistics of 0.792, 0.786, and 0.738, respectively.

CONCLUSIONS

Spinal cord ischemia remains one of the most feared complications of TEVAR. Incidence of SCI in this large series of patients with TEVAR was 3.6% with nearly 60% being permanent. The proposed model provides an assessment tool to guide clinical decisions, patient consent process, risk-assessment, and procedural strategy.

Previous thoracic aortic repair is not associated with adverse outcomes after thoracic endovascular aortic repair

BACKGROUND

As many as 20% of patients who have undergone previous thoracic aortic repair will require reintervention, which could entail thoracic endovascular aortic repair (TEVAR). A paucity of data is available on mortality and the incidence of spinal cord ischemia (SCI) and other postoperative complications associated with TEVAR after previous aortic repairs exclusive to the thoracic aorta. The aim of the present study was to assess the effect of previous thoracic aortic repair on the 30-day mortality and SCI outcomes for patients after TEVAR.

METHODS

The Society for Vascular Surgery Vascular Quality Initiative database was queried for all cases of TEVAR from 2012 to 2018. Patients were excluded if they had undergone previous abdominal aortic repair, the TEVAR had extended beyond aortic zone 5, or SCI data were missing. The 3 cohorts compared were TEVAR with previous ascending aortic or aortic arch repair (group 1), TEVAR with previous descending thoracic aortic repair (group 2), and TEVAR without previous repair (group 3). The primary outcomes of interest were 30-day mortality and SCI. The secondary outcomes included stroke, myocardial infarction, cardiac complications, respiratory complications, postoperative length of stay, and reintervention. The patient variables were compared using χ2 tests, analysis of variance, or Kruskal-Wallis tests, as appropriate. Logistic regression analysis was performed to identify the predictors of 30-day mortality and SCI.

RESULTS

A total of 4010 patients met the inclusion criteria, with 470 in group 1, 132 in group 2, and 3408 in group 3. The 30-day mortality was 4% (19 of 470) in group 1, 6% (8 of 132) in group 2, and 6% (213 of 3408) in group 3 (P = .17). The incidence of SCI was 3% (14 of 470) in group 1, 3% (4 of 132) in group 2, and 3.8% (128 of 3408) in group 3 (P = .65). Stroke, reintervention, myocardial infarction, and cardiac complications were not significantly different among the 3 groups. The incidence of respiratory complications was greatest for group 3 (11%; 360 of 3408) compared with groups 1 (9%; 44 of 470) and 2 (4%; 5 of 132; P = .034). Similarly, the postoperative length of stay was longest for group 3 (9.6 ± 19.4 days vs 8.2 ± 18.3 days for group 1 and 5.9 ± 8.6 days for group 2; P = .038). The independent predictors of 30-day mortality for all TEVAR patients included units of packed red blood cells transfused intraoperatively, urgent or emergent repairs, older age, increasing serum creatinine level, inability to perform self-care, total procedure time, occlusion of the left subclavian artery intraoperatively, distal endograft landing zone 5, and diabetes. The predictors of SCI included the total procedure time, urgent and emergent repairs, and increasing serum creatinine level.

CONCLUSIONS

TEVAR after previous thoracic aortic repair was not associated with an increased risk of SCI or 30-day mortality compared with TEVAR without previous aortic repair.

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.

Cerebrospinal fluid drains reduce risk of spinal cord injury for thoracic/thoracoabdominal aneurysm surgery: A review

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.

Spinal cord injury after thoracic endovascular aortic aneurysm repair

PURPOSE

Thoracic endovascular aortic aneurysm repair (TEVAR) has become a mainstay of therapy for aneurysms and other disorders of the thoracic aorta. The purpose of this narrative review article is to summarize the current literature on the risk factors for and pathophysiology of spinal cord injury (SCI) following TEVAR, and to discuss various intraoperative monitoring and treatment strategies.

SOURCE

The articles considered in this review were identified through PubMed using the following search terms: thoracic aortic aneurysm, TEVAR, paralysis+TEVAR, risk factors+TEVAR, spinal cord ischemia+TEVAR, neuromonitoring+thoracic aortic aneurysm, spinal drain, cerebrospinal fluid drainage, treatment of spinal cord ischemia.

PRINCIPAL FINDINGS

Spinal cord injury continues to be a challenging complication after TEVAR. Its incidence after TEVAR is not significantly reduced when compared with open thoracoabdominal aortic aneurysm repair. Nevertheless, compared with open procedures, delayed paralysis/paresis is the predominant presentation of SCI after TEVAR. The pathophysiology of SCI is complex and not fully understood, though the evolving concept of the importance of the spinal cord's collateral blood supply network and its imbalance after TEVAR is emerging as a leading factor in the development of SCI. Cerebrospinal fluid drainage, optimal blood pressure management, and newer surgical techniques are important components of the most up-to-date strategies for spinal cord protection.

CONCLUSION

Further experimental and clinical research is needed to aid in the discovery of novel neuroprotective strategies for the protection and treatment of SCI following TEVAR.

Complications and Perioperative Management of Patients Undergoing Thoracic Endovascular Aortic Repair

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.

Reversal of Spinal Cord Ischemia Following Endovascular Thoracic Aortic Aneurysm Repair With Hyperbaric Oxygen and Therapeutic Hypothermia

BACKGROUND

Neurological adverse events with spinal cord ischemia (SCI) remain one of the most feared complications in patients undergoing thoracic endovascular aortic repair (TEVAR). These patients can develop irreversible paraplegia with lifelong consequences with physical and psychological agony.

CASE PRESENTATION

We herein present a patient who developed SCI with bilateral lower leg paraplegia on the third postoperative day following TEVAR. Spinal catheter was inserted for spinal fluid drainage. A hyperbaric oxygen therapy was initiated for 90 minutes for 2 days, which was followed by therapeutic hypothermia for 24 hours with a target temperature of 33°C. The patient exhibited significant neurological recovery following these treatments, and he ultimately regained full neurological function without spinal deficit.

DISCUSSION

This represents the first reported case of full neurological recovery of a patient who developed complete SCI following TEVAR procedure. The neurological recovery was due in part to immediate therapeutic hypothermia and hyperbaric oxygen therapy which reversed the spinal ischemia.

Strategies to prevent TEVAR-related spinal cord ischemia

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.

Preoperative prediction of spinal cord ischemia after thoracic endovascular aortic repair

OBJECTIVE

Spinal cord ischemia (SCI) is a devastating but potentially preventable complication of thoracic endovascular aortic repair (TEVAR). The purpose of this analysis was to determine what factors predict SCI after TEVAR.

METHODS

All TEVAR procedures at a single institution were reviewed for patient characteristics, prior aortic repair history, aortic centerline of flow analysis, and procedural characteristics. SCI was defined as any lower extremity neurologic deficit that was not attributable to an intracranial process or peripheral neuropathy. Forty-three patient and procedural variables were evaluated individually for association with SCI. Those with the strongest relationships to SCI (P < .1) were included in a multivariable logistic regression model, and a stepwise variable elimination algorithm was bootstrapped to derive a best subset of predictors from this model.

RESULTS

From 2002 to 2013, 741 patients underwent TEVAR for various indications, and 68 (9.2%) developed SCI (permanent: n = 38; 5.1%). Because of the lack of adequate imaging for centerline analysis, 586 patients (any SCI, n = 43; 7.4%) were subsequently analyzed. Patients experiencing SCI after TEVAR were older (SCI, 72 ± 11 years; no SCI, 65 ± 15 years; P < .0001) and had significantly higher rates of multiple cardiovascular risk factors. The stepwise selection procedure identified five variables as the most important predictors of SCI: age (odds ratio [OR] multiplies by 1.3 per 10 years; 95% confidence interval [CI], 0.9-1.8, P = .06), aortic coverage length (OR multiplies by 1.3 per 5 cm; CI, 1.1-1.6; P = .002), chronic obstructive pulmonary disease (OR, 1.9; CI, 0.9-4.1; P = .1), chronic renal insufficiency (creatinine concentration ≥ 1.6 mg/dL; OR, 1.9; CI, 0.8-4.2; P = .1), and hypertension (defined as chart history or medication; OR, 6.4; CI, 2.6-18; P < .0001). A logistic regression model with just these five covariates had excellent discrimination (area under the receiver operating characteristic curve = .83) and calibration (χ(2) = 9.8; P = .28).

CONCLUSIONS

This analysis generated a simple model that reliably predicts SCI after TEVAR. This clinical tool can assist decision-making about when to proceed with TEVAR, guide discussions about intervention risk, and help determine when maneuvers to mitigate SCI risk should be implemented.

How to prevent spinal cord injury during endovascular repair of thoracic aortic disease

The incidence of spinal cord injury in thoracic endovascular aortic repair (TEVAR) has been 3-5 % from recent major papers where sacrifice of the critical intercostal arteries is inevitable by a stent graft. Hemodynamic stability, which depends on a network of blood vessels around the cord is most important not only during but also after stent-graft deployment. High risk factors of spinal cord injury during endovascular aortic repair are (1) coverage of the left subclavian artery, (2) extensive coverage of long segments of the thoracic aorta, (3) prior downstream aortic repair, (4) compromising important intercostal (T8-L1), vertebral, pelvic and hypogastric collaterals, and (5) shaggy aorta. Preoperative, intraoperative, and postoperative managements have been required to prevent spinal cord injury with TEVAR. For imaging assessment of blood supply to spinal cord including Adamkiewicz artery, prophylactic cerebrospinal fluid drainage is mandatory, and monitoring motor-evoked potential is recommended for high risk factors of spinal cord injury. Mean arterial pressure should be maintained over 90 mmHg after stent-graft placement for a while to prevent delayed spinal cord ischemia in high-risk patients of spinal cord ischemia. Finally, because spinal cord injury during TEVAR is not rare and negligible, perioperative care during TEVAR should be strictly performed according to the protocol proposed by each cardiovascular team.

Spinal cord ischemia after simultaneous and sequential treatment of multilevel aortic disease

OBJECTIVES

The aim of the present study is to report a risk analysis for spinal cord injury in a recent cohort of patients with simultaneous and sequential treatment of multilevel aortic disease.

METHODS

We performed a multicenter study with a retrospective data analysis. Simultaneous treatment refers to descending thoracic and infrarenal aortic lesions treated during the same operation, and sequential treatment refers to separate operations. All descending replacements were managed with endovascular repair.

RESULTS

Of 4320 patients, multilevel aortic disease was detected in 77 (1.8%). Simultaneous repair was performed in 32 patients (41.5%), and a sequential repair was performed in 45 patients (58.4%). Postoperative spinal cord injury developed in 6 patients (7.8%). At multivariable analysis, the distance of the distal aortic neck from the celiac trunk was the only independent predictor of postoperative spinal cord injury (odds ratio, 0.75; 95% confidence interval, 0.56-0.99; P=.046); open surgical repair of the abdominal aortic disease was associated with a higher risk of spinal cord injury but did not reach statistical significance (odds ratio, 0.16; 95% confidence interval, 0.02-1.06; P=.057). Actuarial survival estimates at 1, 2, and 5 years after the procedure were 80%±5%, 68%±6%, and 63%±7%, respectively. Spinal cord injury did not impair survival (P=.885).

CONCLUSIONS

In our experience, the risk of spinal cord injury is still substantial at 8% in patients with multilevel aortic disease. The distance of the distal landing zone from the celiac trunk is a significant predictor of spinal cord ischemia.

Endovascular coil embolization of segmental arteries prevents paraplegia after subsequent thoracoabdominal aneurysm repair: an experimental model

OBJECTIVES

To test a strategy for minimizing ischemic spinal cord injury after extensive thoracoabdominal aneurysm (TAAA) repair, we occluded a small number of segmental arteries (SAs) endovascularly 1 week before simulated aneurysm repair in an experimental model.

METHODS

Thirty juvenile Yorkshire pigs (25.2 ± 1.7 kg) were randomized into 3 groups. All SAs, both intercostal and lumbar, were killed by a combination of surgical ligation of the lumbar SAs and occlusion of intercostal SAs with thoracic endovascular stent grafting. Seven to 10 days before this simulated TAAA replacement, SAs in the lower thoracic/upper lumbar region were occluded using embolization coils: 1.5 ± 0.5 SAs in group 1 (T13/L1), and 4.5 ± 0.5 SAs in group 2 (T11-L3). No SAs were coiled in the controls. Hind limb function was evaluated blindly from daily videotapes using a modified Tarlov score (0 = paraplegia, 9 = full recovery). After death, each segment of spinal cord was graded histologically using the 9-point Kleinman score (0 = normal, 8 = complete necrosis).

RESULTS

Hind limb function remained normal after coil embolization. After simulated TAAA repair, paraplegia occurred in 6 of 10 control pigs, but in only 2 of 10 pigs in group 1; no pigs in group 2 had a spinal cord injury. Tarlov scores were significantly better in group 2 (control vs group 1, P = .06; control vs group 2, P = .0002; group 1 vs group 2, P = .05). A dramatic reduction in histologic damage, most prominently in the coiled region, was seen when SAs were embolized before simulated TAAA repair.

CONCLUSIONS

Endovascular coiling of 2 to 4 SAs prevented paraplegia in an experimental model of extensive hybrid TAAA repair, and helped protect the spinal cord from ischemic histopathologic injury. A clinical trial in a selected patient population at high risk for postoperative spinal cord injury may be appropriate.

Fate of patients with spinal cord ischemia complicating thoracic endovascular aortic repair

OBJECTIVE

Spinal cord ischemia (SCI) is a potentially devastating complication of thoracic endovascular aortic repair (TEVAR) that can result in varying degrees of short-term and permanent disability. This study was undertaken to describe the clinical outcomes, long-term functional impact, and influence on survival of SCI after TEVAR.

METHODS

A retrospective review of all TEVAR patients at the University of Florida from 2000 to 2011 was performed to identify individuals experiencing SCI, defined by any new lower extremity neurologic deficit not attributable to another cause. SCI was dichotomized into immediate or delayed onset, with immediate onset defined as SCI noted upon awakening from anesthesia, and delayed characterized as a period of normal function, followed by development of neurologic injury. Ambulatory status was determined using database query, record review, and phone interviews with patients and/or family. Mortality was estimated using life-table analysis.

RESULTS

A total of 607 TEVARs were performed for various indications, with 57 patients (9.4%) noted to have postoperative SCI (4.3% permanent). SCI patients were more likely to be older (63.9 ± 15.6 vs 70.5 ± 11.2 years; P = .002) and have a number of comorbidities, including chronic obstructive pulmonary disease, hypertension, dyslipidemia, and cerebrovascular disease (P < .0001). At some point in their care, a cerebrospinal fluid drain was placed in 54 patients (95%), with 54% placed postoperatively. In-hospital mortality was 8.8% for the entire cohort (SCI vs no SCI; P = .45). SCI developed immediately in 12 patients, delayed onset in 40, and indeterminate in five patients due to indiscriminate timing from postoperative sedation. Three patients (25%) with immediate SCI had measurable functional improvement (FI), whereas 28 (70%) of the delayed-onset patients experienced some degree of neurologic recovery (P = .04). Of the 34 patients with complete data available, 26 (76%) reported quantifiable FI, but only 13 (38%) experienced return to their preoperative baseline. Estimated mean (± standard error) survival for patients with and without SCI was 37.2 ± 4.5 and 71.6 ± 3.9 months (P < .0006), respectively. Patients with FI had a mean survival of 53.9 ± 5.9 months compared with 9.6 ± 3.6 months for those without improvement (P < .0001). Survival and return of neurologic function were not significantly different when patients with preoperative and postoperative cerebrospinal fluid drains were compared.

CONCLUSIONS

The minority of patients experience complete return to baseline function after SCI with TEVAR, and outcomes in patients without early functional recovery are particularly dismal. Patients experiencing delayed SCI are more likely to have FI and may anticipate similar life-expectancy with neurologic recovery compared with patients without SCI. Timing of drain placement does not appear to have an impact on postdischarge FI or long-term mortality.

Efficacy of thoracic endovascular stent repair for chronic type B aortic dissection with aneurysmal degeneration

BACKGROUND

The Food and Drug Administration has approved devices for endovascular management of thoracic endovascular aortic aneurysm repair (TEVAR); however, limited data exist describing the outcomes of TEVAR for aneurysms attributable to chronic type B aortic dissection (cTBAD). This study was undertaken to determine the results of endovascular treatment of cTBAD with aneurysmal degeneration.

METHODS

A retrospective analysis of all patients treated for cTBAD with aneurysmal degeneration at the University of Florida from 2004 to 2011 was performed. Computed tomograms with centerline reconstruction were analyzed to determine change in aortic diameter, relative proportions of aortic treatment lengths, and false lumen perfusion status. Reintervention and mortality were estimated using life-tables. Cox regression analysis was completed to predict mortality.

RESULTS

Eighty patients underwent TEVAR for aneurysm due to cTBAD (mean age [± standard deviation], 60 ± 13 years [male, 87.5%; n = 70]; median follow-up, 26 [range, 1-74] months). Median time from diagnosis of TBAD to TEVAR was 16 (range, 1-72) months. Prior aortic root/arch replacement had been performed in 29% (n = 23) at a median interval of 28.5 (range, 0.5-312) months. Mean preoperative aneurysm diameter was 62.0 ± 9.9 mm. In 75% (n = 60) of cases, coverage was proximal to zone 3, and 24% (n = 19) underwent carotid-subclavian bypass or other arch debranching procedure. Spinal drains were used in 78% (pre-op 71%, n = 57; post-op 6%, n = 5). Length of stay was 6.5 ± 4.7 days with a composite morbidity of 26% and in-hospital mortality of 2.5% (n = 2). Overall neurologic event rate was 17% (spinal cord ischemia 10% [n = 8], with a permanent deficit observed in 6.2% [n = 5]; stroke 7.5%). Aneurysm diameter reduced or stabilized in 65%. The false lumen thrombosed completely within the thoracic aorta in 52%, and reintervention within the treated aortic segment was required in 16% (n = 13).One- and 3-year freedom from reintervention (with 95% confidence interval [CI]) was 80% (range, 68%-88%) and 70% (range, 57%-80%), respectively. Survival at 1 and 5 years was 89% (range, 80%-94%) and 70% (range, 55%-81%) and was not significantly different among patients requiring reintervention or experiencing favorable aortic remodeling. Multivariable analysis identified coronary artery disease (hazard ratio [HR], 6.4; 95% CI, 2.3-17.7; P < .005), prior infrarenal aortic surgery (HR, 8.6; 95% CI, 2.3-31.7; P = .001), and congestive heart failure (HR, 11.9; 95% CI, 1.9-73.8; P = .008) as independent risk factors for mortality. Hyperlipidemia was found to be protective (HR, 0.2; 95% CI, 0.05-0.6; P = .004). No significant difference in predictors of mortality were found between patients who underwent reintervention vs those who did not (P = .2).

CONCLUSIONS

TEVAR for cTBAD with aneurysmal degeneration can be performed safely but spinal cord ischemia rates may be higher than previously reported. Liberal use of procedural adjuncts to reduce this complication, such as spinal drainage, is recommended. Reintervention is common, but long-term survival does not appear to be impacted by remediation.

Imaging of vascular remodeling after simulated thoracoabdominal aneurysm repair

OBJECTIVE

A better understanding of the response of the spinal cord blood supply to segmental artery (SA) sacrifice should help minimize the risk of paraplegia after both open and endovascular repair of thoracoabdominal aortic (TAA) aneurysms.

METHODS

Twelve female juvenile Yorkshire pigs were randomized into 3 groups and perfused with a barium-latex solution. Pigs in group 1 (control) had infusion without previous intervention. Pigs in group 2 were infused 48 hours after ligation of all SAs (T4-L5) and those in group 3 at 120 hours after ligation. Postmortem computed tomographic scanning of the entire pig enabled overall comparisons and measurement of vessel diameters in the spinal cord circulation.

RESULTS

We ligated 14.5 ± 0.8 SAs: all filled retrograde to the ligature. Paraplegia occurred in 38% of operated pigs. A significant increase in the mean diameter of the anterior spinal artery (ASA) was evident after SA sacrifice (P < .0001 for 48 hours and 120 hours). The internal thoracic and intercostal arteries also increased in diameter. Quantitative assessment showed an increase in vessel density 48 hours after ligation of SAs, reflected by an obvious increase in small collateral vessels seen on 3-dimensional reconstructions of computed tomographic scans at 120 hours.

CONCLUSIONS

Remodeling of the spinal cord blood supply--including dilatation of the ASA and proliferation of small collateral vessels--is evident at 48 and 120 hours after extensive SA sacrifice. It is likely that exploitation of this process will prove valuable in the quest to eliminate paraplegia after TAA aneurysm repair.

Neurological complications of thoracic endovascular aortic repair

Thoracic endovascular aortic repair (TEVAR) has decreased the morbidity and mortality associated with open surgical repair of descending thoracic aortic diseases, but important complications unique to the procedure remain. Spinal cord ischemia and infarction is a recognized complication caused by endovascular coverage or injury to spinal cord collateral vessels. Stroke is a consequence of thromboembolism or coverage of aortic arch branch vessels with insufficient collateral circulation. Understanding the risk factors and the pathophysiology of neurological complications of TEVAR are important for the successful anesthetic and surgical management and treatment of patients undergoing endovascular procedures involving the thoracic aorta.

Late Outcomes of a Single-Center Experience of 400 Consecutive Thoracic Endovascular Aortic Repairs

Background—

In this study, we report the late outcomes of a large, decade-long single-center thoracic endovascular aortic repair experience.

Methods and Results—

A prospectively maintained registry and the electronic medical records of 400 consecutive thoracic endovascular aortic repair performed at a tertiary care center were reviewed. The distribution of pathologies treated included aneurysms (198, 49%), dissections (100, 25%), penetrating ulcers (54, 14%), traumatic transections (25, 6%), and other pathologies (23, 6%). Spinal drains were placed prophylactically in 127 cases (32%) of planned extended aortic coverage. There were no acute surgical conversions. Adjunctive surgical procedures were performed on 94 patients (24%). Subclavian revascularizations were performed selectively in only 15% of zone 0 to 2 deployments. The median length of stay was 5 days (limits, 1 and 79 days). Overall 30-day mortality was 6.5% (elective, 2.6%; urgent, 9.5%; and emergent, 20%). Permanent spinal cord ischemia occurred in 4.5% and stroke in 3%. Kaplan-Meier estimates of survival were 82%, 76%, 68%, and 60% and freedom from secondary intervention was 90%, 86%, 81%, and 78% at 6, 12, 24, and 36 months, respectively. Risk factors for mortality included stroke, urgent/emergent repair, age ≥80 years, general anesthesia, and dissection pathology.

Conclusions—

Thoracic endovascular aortic repair may be used to treat a variety of thoracic aortic pathologies with a very low risk of intraoperative conversion. Overall rates of mortality and neurological complications were relatively low but significantly increased in emergent repairs. There appeared to be a substantial number of late deaths, which may represent a combination of poor patient selection and treatment failures.

Impact of intercostal artery occlusion on spinal cord ischemia following thoracic endovascular aortic repair

OBJECTIVE

To evaluate intercostal artery patency following thoracic endovascular aortic repair (TEVAR) and its relationship with spinal cord ischemia (SCI).

METHODS

Patients with SCI (n = 7) and a matched control cohort (n = 18) were identified from a prospectively maintained database. Radiographic analysis of intercostal patency was assessed using 3-dimensional (3-D)-reconstructed images of pre- and postoperative CT angiograms (1-6 months, 6-12 months, and 1-5 years).

RESULTS

Patients with SCI had a higher incidence of perioperative hypotension (P < .01) and longer procedure duration (P = .01). While the mean number of patent intercostal arteries at each time interval was not significantly different between groups, both SCI (P = .002) and control (P <.001) groups demonstrated a significant reduction in patent intercostal arteries in the stented area of the aorta following TEVAR.

CONCLUSION

TEVAR decreases intercostal artery patency in the area of aortic coverage. Our data suggest that intercostal artery patency, in conjunction with perioperative hypotension, is an important contributor to postoperative SCI.

Risk factors, outcomes, and clinical manifestations of spinal cord ischemia following thoracic endovascular aortic repair

OBJECTIVE

The purpose of this study was to assess the incidence, risk factors, and clinical manifestations of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR).

METHODS

A retrospective review of a prospectively collected database was performed for all patients undergoing TEVAR at a single academic institution between July 2002 and June 2010. Preoperative demographics, procedure-related variables, and clinical details related to SCI were examined. Logistic regression analysis was performed to identify risk factors for the development of SCI.

RESULTS

Of the 424 patients who underwent TEVAR during the study period, 12 patients (2.8%) developed SCI. Mean age of this cohort with SCI was 69.6 years (range, 44-84 years), and 7 were women. One-half of these patients had prior open or endovascular aortic repair. Indication for surgery was either degenerative aneurysm (n = 8) or dissection (n = 4). Six TEVARs were performed electively, with the remaining done either urgently or emergently due to contained rupture (n = 2), dissection with malperfusion (n = 2), or severe back pain (n = 2). All 12 patients underwent extent C endovascular coverage. Multivariate regression analysis demonstrated chronic renal insufficiency to be independently associated with SCI (odds ratio [OR], 4.39; 95% confidence interval [CI], 1.2-16.6; P = .029). Onset of SCI occurred at a median of 10.6 hours (range, 0-229 hours) postprocedure and was delayed in 83% (n = 10) of patients. Clinical manifestations of SCI included lower extremity paraparesis in 9 patients and paraplegia in 3 patients. At SCI onset, average mean arterial pressure (MAP) and lumbar cerebrospinal fluid (CSF) pressure was 77 mm Hg and 10 mm Hg, respectively. Therapeutic interventions increased blood pressure to a significantly higher average MAP of 99 mm Hg (P = .001) and decreased lumbar CSF pressure to a mean of 7 mm Hg (P = .30) at the time of neurologic recovery. Thirty-day mortality was 8% (1 of 12 patients). The single patient who expired, never recovered any lower extremity neurologic function. All patients surviving to discharge experienced either complete (n = 9) or incomplete (n = 2) neurologic recovery. At mean follow-up of 49 months, 7 of 9 patients currently alive continued to exhibit complete, sustained neurologic recovery.

CONCLUSION

Spinal cord ischemia after TEVAR is an uncommon, but important complication. Preoperative renal insufficiency was identified as a risk factor for the development of SCI. Early detection and treatment of SCI with blood pressure augmentation alone or in combination with CSF drainage was effective in most patients, with the majority achieving complete, long-term neurologic recovery.

[Acute aortic syndrome and endovascular treatment: good indications of stent-graft, stent and aortic fenestration]

Acute aortic syndrome of the descending aorta can be treated with stent-graft thanks to technical and material development. Ruptured aneurysms, aortic dissection, wall hematoma and penetrating ulcers can be treated with stent-graft. According to the type of initial lesion, and the clinical tolerance, the emergency of treatment can be different. Non covered stent and aortic fenestration are used in case of visceral ischemia in aortic dissection, according to the type of ischemia.