Neurologic injury after endovascular stent-graft and bilateral internal iliac artery embolization for infrarenal abdominal aortic aneurysm

Spinal Cord Ischemia Following Endovascular Abdominal Aortic Aneurysm Repair: An Unpredictable Catastrophe

Spinal cord ischemia (SCI) following endovascular abdominal aortic aneurysm (AAA) repair (EVAR) is a rare yet catastrophic complication. The underlying pathophysiological mechanism remains incompletely understood. We present the case of a 75-year-old man with a difficult left common iliac artery (CIA) anatomy that necessitated the coiling of his left internal iliac artery (IIA) to ensure proper sealing of his aortic stent graft. The patient complained of bilateral lower extremity weakness immediately following the procedure. The patient was diagnosed with SCI, which was later confirmed by magnetic resonance imaging (MRI). He was treated with cerebrospinal fluid drainage. The patient's neurological status mildly improved on follow-up one year later.

Spinal Cord Infarction With Prolonged Femoral Venoarterial Extracorporeal Membrane Oxygenation

OBJECTIVES

There have been sporadic reports of ischemic spinal cord injury (SCI) during venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. The authors observed a troubling pattern of this catastrophic complication and evaluated the potential mechanisms of SCI related to ECMO.

DESIGN

This study was a case series.

SETTING

This study was performed at a single institution in a University setting.

PARTICIPANTS

Patients requiring prolonged VA-ECMO were included.

INTERVENTIONS

No interventions were done. This was an observational study.

MEASUREMENTS AND MAIN RESULTS

Four hypotheses of etiology were considered: (1) hypercoagulable state/thromboembolism, (2) regional hypoxia/hypocarbia, (3) hyperperfusion and spinal cord edema, and (4) mechanical coverage of spinal arteries. The SCI involved the lower thoracic (T7-T12 level) spinal cord to the cauda equina in all patients. Seven out of 132 (5.3%) patients with prolonged VA-ECMO support developed SCI. The median time from ECMO cannulation to SCI was 7 (range: 6-17) days.There was no evidence of embolic SCI or extended regional hypoxia or hypocarbia. A unilateral, internal iliac artery was covered by the arterial cannula in 6/7 86%) patients, but flow into the internal iliac was demonstrated on imaging in all available patients. The median total flow (ECMO + intrinsic cardiac output) was 8.5 L/min (LPM), and indexed flow was 4.1 LPM/m². The median central venous oxygen saturation was 88%, and intracranial pressure was measured at 30 mmHg in one patient, suggestive of hyperperfusion and spinal cord edema.

CONCLUSIONS

An SCI is a serious complication of extended peripheral VA-ECMO support. Its etiology remains uncertain, but the authors' preliminary data suggested that spinal cord edema from hyperperfusion or venous congestion could contribute.

[Embolization of the internal iliac artery during endovascular repair of abdominal aortic aneurysms]

An abdominal aortic aneurysm is one of frequently encountered cardiovascular diseases, which is often accompanied by an aneurysm of the common and/or internal iliac arteries. Recent trends are towards increased use of endovascular methods of treatment, associated with a certain risk for the development of type IIa endoleaks. This raises the question as to the necessity of embolization of the internal iliac artery while covering it with a stent graft. Our study included a total of 20 patients operated on for abdominal aortic aneurysms combined with aneurysms of the common and/or internal iliac arteries. In order to evaluate the obtained outcomes, the patients were divided into 4 groups depending on the intervention performed. The scope of the performed operations varied from endoprosthetic repair of an abdominal aortic aneurysm with coverage of one internal iliac artery without embolization to endoprosthetic repair of an abdominal aortic aneurysm with coverage of both internal iliac arteries with embolization. In the latter event, two-stage interventions were performed. The duration of follow up amounted to more than 3 years. We assessed the short- and long-term outcomes, with zero lethality and the absence of either specific or non-specific complications observed. Embolization increases the duration of the operation and X-ray exposure, as well as the amount of the contrast medium, thus casting doubt upon the necessity of carrying it out, since the immediate and remote results do not differ as compared with mere coverage of the internal iliac artery.

Monomelic Ischemic Neuropathy of the Tibial and Peroneal Nerve After Onyx Embolization of Vasa Nervorum Supplying a Surgically Excluded Popliteal Artery Aneurysm

Ischemic neuropathy is an exceedingly rare complication after peripheral artery embolization. We report a case of ischemic damage to the tibial and peroneal nerve after embolization of the vasa nervorum that served as feeding collaterals to a surgically excluded popliteal artery aneurysm.

Spinal Cord Ischemia following Elective Endovascular Repair of Infrarenal Aortic Aneurysms: A Systematic Review

BACKGROUND

Spinal cord ischemia (SCI) after abdominal aortic aneurysm (AAA) endovascular abdominal aortic aneurysm repair (EVAR) is a rare but devastating complication. The mechanism underlying the occurrence of SCI after EVAR seems to be multifactorial and is underreported and not fully elucidated. The aim of the study was to investigate the clinical outcomes in patients with this serious complication.

METHODS

A systematic review of the current literature, as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines, was performed to evaluate the incidence of SCI after elective EVAR. PubMed and Scopus databases were systematically searched. Studies reporting on thoracic endovascular aneurysm repair, open repair of AAAs, and symptomatic or ruptured AAAs were excluded.

RESULTS

In total, 18 articles reporting 25 cases were included. The mean age was 74.6 ± 7.6 (range: 60-90) years. The mean diameter of AAAs was 5.96 ± 1.0 cm (range: 4.7-8.3). Six cases also had aneurysms in the common iliac arteries. Seventy-one percent of AAAs had characteristics that made EVAR difficult and technically demanding. The mean operative time was prolonged, 254 ± 104.6 min, and associated with extensive intravascular handling. In 41.6% of cases, additional procedures were performed because of the difficult anatomy. Thirty-two percent of the cases had 1 internal iliac artery (IIA) embolized with coils or covered with the stent graft, and 14% had both IIAs compromised. In most of the cases, SCI symptoms presented immediately after the operation, and in 14.8% of patients, the symptoms had late presentation. Almost all cases had motor loss in the form of paraparesis or paraplegia, 54% of the cases also had diminished sensation, and 29.1% of the cases had urinary and/or fecal incontinence. Heterogeneity was observed regarding the management of the disease; in 6 of the cases, cerebrospinal fluid (CSF) drainage was performed, steroids were administered in 5, and in the other cases, an expectant strategy was selected. In 50% of the cases, only small improvement was seen at follow-up. In 25% of the cases, no improvement was seen, and 25% had almost complete recovery.

CONCLUSIONS

Our study identified a common pattern among patients who present SCI after EVAR: difficult anatomy, prolonged operative time, additional procedures, and extensive intravascular handling that may have led to embolization. Patency of pelvic circulation preoperatively is also of importance. Regarding outcomes, only 25% of patients recovered, and in certain cases, CSF drainage may have significantly improved chances for recovery.

Anesthetic considerations for endovascular abdominal aortic aneurysm repair

Aneurysm is defined as a localized and permanent dilatation with an increase in normal diameter by more than 50%. It is more common in males and can affect up to 8% of elderly men. Smoking is the greatest risk factor for abdominal aortic aneurysm (AAA) and other risk factors include hypertension, hyperlipidemia, family history of aneurysms, inflammatory vasculitis, and trauma. Endovascular Aneurysm Repair [EVAR] is a common procedure performed for AAA, because of its minimal invasiveness as compared with open surgical repair. Patients undergoing EVAR have a greater incidence of major co-morbidities and should undergo comprehensive preoperative assessment and optimization within the multidisciplinary settings. In majority of cases, EVAR is extremely well-tolerated. The aim of this article is to outline the Anesthetic considerations related to EVAR.

Endovascular treatment of an anastomotic iliac pseudoaneurysm after surgical aortic repair using a Cardiatis multilayer stent

The Cardiatis multilayer stent (Cardiatis, Isnes, Belgium) is a cobalt, self-expandable bare stent made of two interconnected layers without any covering that allows a pressure decrease and thrombus formation into an aneurysmal sac, while improving laminar flow in the main artery and surrounding vital branches. We report a case of an anastomotic iliac pseudoaneurysm successfully treated with the deployment of a Cardiatis multilayer stent.

Spinal cord ischemia after endovascular repair of infrarenal abdominal aortic aneurysm: a rare complication

Neurologic deficit secondary to spinal cord ischemia after elective infrarenal, endovascular aneurysm repair (EVAR), consists a rare and rather disastrous complication. The etiology of such neurologic complication seems to be multifactorial, making this event unpredictable and foremost unpreventable. We report a case of paraparesis and bladder dysfunction that occurred immediately after the EVAR procedure. Prompt management by conservative or invasive methods seems to be important for the reversal of the neurologic deficit and the optimization of patient's outcome.

Spinal cord ischemia following external iliac artery angioplasty: a case report

Spinal cord ischemia (SCI) is a rare disease that leads to variable degrees of neurological deficit including permanent paraplegia. It has been reported after open and endovascular interventions of the thoracic and abdominal aorta, but it is extremely rare after interventions involving peripheral vessels. We present a case of permanent paraplegia after iliac angioplasty and stenting for critical limb ischemia and a related review of the literature.

A report of spinal cord ischemia following endovascular aneurysm repair of an aneurysm with a large thrombus burden and complex iliac anatomy

We report a case of paraplegia occurring after an elective endovascular aneurysm repair (EVAR) that was reversed by cerebrospinal fluid (CSF) drainage. This case report highlights the reality that the endovascular management of abdominal aortic aneurysms (AAAs) with large volumes of mural thrombus and complex iliac anatomy can be complicated by spinal cord ischemia (SCI). The presumed mechanism of SCI is dissemination of atherosclerotic material during protracted catheter and wire manipulations. Embolization of internal iliac arteries (IIAs), profunda femoral arteries, and possibly other arterial networks may explain the delayed presentation. The complex iliac anatomy necessitating covering of one and reconstruction of the other hypogastric artery and the prolonged operative time may be 2 other contributing factors. The prompt CSF drainage may reverse the neurologic deficit.

Incidence of soft tissue injury and neuropathy after embolo/sclerotherapy for congenital vascular malformation

PURPOSE

Embolo/sclerotherapy is an important treatment modality for vascular malformations, but the rates and results of the complications associated with embolo/sclerotherapy are not well known. We report the incidence and outcome of soft tissue injury and neuropathy after performing embolo/sclerotherapy for congenital vascular malformations (CVMs) classified according to the Hamburg classification.

METHODS

Among 1823 patients with CVM, 573 were treated with embolo/sclerotherapy. We retrospectively reviewed 68 patients (31 males, 37 females; mean age, 20.0 years) with soft tissue injury and 49 patients (16 males, 33 females; mean age, 21.2 years) with neuropathy. The indications for embolo/sclerotherapy for CVM were that the CVMs affected the quality of life, such as a symptomatic or trauma-prone lesion or a lesion that was impairing the function of a limb, and the lesions that were located near a life-threatening vital area, including the airway. As embolo/sclerotherapy agents, absolute or 80% ethanol, N-butyl cyanoacrylate (NBCA), and various types of coils or contour particles were used in various combinations, either at the same time or in phases, depending on the location, severity, and extent of the CVM.

RESULTS

The incidence of soft tissue injury was 29.4% (42 of 143) for the arteriovenous shunting type and 8% (22 of 273) for the venous type. No soft tissue injuries occurred in the patients with arterial and lymphatic malformations. Of the 68 patients with soft tissue injury, 40 lesions healed with conservative management, and 28 lesions needed surgery, including escharectomy, skin graft, or amputation. The incidence of neuropathy was 10.9% (30 of 273) for the venous CVM. No neuropathy occurred in the patients with arterial malformations. Of the 49 patients with neuropathy, 42 recovered at a mean period of 5.3 months, but seven did not.

CONCLUSION

Soft tissue injuries occurred in 11.9% of patients (68 of 573) and neuropathies occurred in 8.6% (49 of 573) after undergoing embolo/sclerotherapy. Most of these complications recovered by themselves (58.9% from soft tissue injury and 85.1% from neuropathy). Our results suggest that embolo/sclerotherapy has an acceptable incidence of soft tissue injury and neuropathy, when considering the effect that the CVM had on the quality of life before treatment, so embolo/sclerotherapy is recommended as a treatment modality for CVM.

Delayed Neurologic Deficit after Infrarenal Endovascular Aortic Aneurysm Repair

Spinal cord ischemia is a rare and devastating complication after elective abdominal aortic aneurysm repair. It has recently been reported to occur after endovascular aortic aneurysm repair. We report the first case of delayed neurologic deficit after endovascular aortic aneurysm repair using the Zenith (Cook) device.

Sciatic neuropathy following endovascular treatment of a limb vascular malformation

Background

Endovascular therapy for vascular malformations is one of the treatment options for limb vascular malformations.

Case presentation

A patient with a vascular malformation of the hip developed ipsilateral leg weakness immediately after endovascular embolization and sclerotherapy. Clinical and electrodiagnostic findings later confirmed an incomplete sciatic neuropathy.

Conclusion

We propose that endovascular treatment compromised the patient's sciatic nerve either through direct neurotoxicity of the sclerosing agent or ischemic injury.

Vascular stenting

An explosion of technology has occurred in the last 10 years, intended to make treatment of vascular diseases less invasive. Once the exclusive domain of the interventional cardiologist and the coronary circulation, now in 2001 nearly every vascular system has been explored as a site for endovascular treatment of aneurysmal and atherosclerotic disease. This review will focus on endovascular treatment of abdominal aortic aneurysmal disease and carotid artery disease, and relevant issues for the anesthesiologist encountering these patients and procedures.

Complications of Endovascular Repair of Abdominal Aortic Aneurysms: A Review

The endovascular procedure for repair of abdominal aortic aneurysms has had an enormous impact on the treatment of this challenging disease. Complications, however, do occur and it is important to have a thorough understanding of the array of complications and appropriate management strategies. In this review of endovascular complications, we describe early and late complications paying particular attention to preventive, treatment and surveillance strategies.

Unilateral lower extremity paralysis after coil embolization of an internal iliac artery aneurysm

Neurologic complications after treatment of internal iliac artery (IIA) aneurysms are rare, especially if confined to one IIA. We report a patient in whom profound right lower extremity paresis developed after unilateral right IIA coil embolization for treatment of a 4-cm IIA aneurysm, despite the presence of a patent contralateral IIA. This case illustrates the important, yet unpredictable, nature of pelvic blood flow to the distal spinal cord and lumbosacral plexus and the unpredictable consequence of IIA occlusion.

Hypotension-induced loss of intraoperative monitoring data during surgical correction of scheuermann kyphosis: a case report

STUDY DESIGN

Presentation of a case report of Scheuermann kyphosis surgical correction.

OBJECTIVE

To describe a scenario where both neurogenic mixed evoked potentials and somatosensory-evoked potentials were lost due solely to hypotension before any correction of a kyphotic spinal deformity was performed.

SUMMARY OF BACKGROUND DATA

Multimodality intraoperative neurophysiologic monitoring of the spinal cord has become widely utilized during surgical correction of scoliotic and kyphotic deformities. Most spinal surgeries also benefit from a state of hypotension to minimize blood loss, but unchecked and persistent hypotension may lead to inadequate perfusion to the spinal cord, resulting in spinal cord dysfunction noted by diminution of neuromonitoring data.

METHODS

An 18-year-old boy with a 95 degrees Scheuermann kyphosis underwent a posterior spinal fusion for correction of his deformity. Intraoperative neurophysiologic monitoring consisting of neurogenic mixed evoked potentials and somatosensory-evoked potentials were performed throughout surgery.

RESULTS

After placement of segmental pedicle screw fixation points and multiple osteotomies, before any instrumented correction of the deformity, all lower extremity neuromonitoring data were acutely lost. The surgeon was immediately warned of the data loss, with the mean arterial pressure noted to be 50 mm Hg. The mean arterial pressure was raised with the use of epinephrine bolus and dopamine infusion. Subsequently, all lower extremity neuromonitoring data returned. A Stagnara wake-up test was performed, which the patient passed, and the surgical correction was performed with his pressure maintained on a dopamine infusion. He awakened without neurologic deficits and had an uneventful recovery.

CONCLUSIONS

Although a state of mild hypotension may be beneficial to limit blood loss during spinal deformity corrective surgery, acute and/or prolonged hypotension may jeopardize spinal cord vascularity and should be avoided especially during surgical treatment of high-risk deformities such as kyphosis. Early warning by multimodality physiologic neuromonitoring appears to be a useful method to alert surgeons of the potentially devastating problem of hypotension-induced spinal cord dysfunction and allows immediate corrective actions.

Distal internal iliac artery embolization: a procedure to avoid

OBJECTIVES

Internal iliac artery (IIA) coil embolization as an adjunct to endovascular stent grafting (ESG) is common practice for treating abdominal aortic aneurysm (AAA) in patients with a substantially enlarged common iliac artery requiring extension of the stent-graft limb into the external iliac artery. The literature describing pelvic ischemia in association with IIA coil embolization contains conflicting reports of symptom severity. We studied IIA occlusion outcome as a function of coil placement in the IIA.

METHODS

From August 1997 to March 2002, 20 patients with AAA underwent ESG with unilateral IIA coil embolization. Coils were placed proximal to the first branch of the IIA in 8 patients and distal to the first branch in 12 patients. Symptoms of pelvic ischemia and mid-term outcome were studied.

RESULTS

Patients included 18 men and 2 women with mean age of 70(1/2) years (range, 53-86 years). Mean diameter of AAA was 54.4 mm (range, 38-80 mm), and of common iliac artery was 24.2 mm (range, 15-48 mm). Ten patients (50%) had new onset of symptoms of pelvic ischemia after endograft procedures: 1 of 8 patients (13%) with proximal IIA embolization had buttock claudication, and 9 of 12 patients (75%) with distal IIA embolization had pelvic ischemic symptoms, including buttock claudication in 8 and impotence in 1 (P =.02, Fisher exact test). No colonic ischemia occurred in this series. At 12-month follow-up, 4 patients with distal IIA embolization were symptom-free. At further follow-up to 24 months, 4 patients remained significantly limited with symptoms of claudication.

CONCLUSIONS

A significantly higher incidence of symptoms of pelvic ischemia occurred with more distal placement of coils for IIA embolization. Failure to control for extent of coil placement may account for the apparently conflicting results in published studies. IIA coil embolization should be performed as proximal as possible to prevent interference with pelvic collateral circulation.

Internal iliac artery embolization with bilateral occlusion before endovascular aortoiliac aneurysm repair-clinical outcome of simultaneous and sequential intervention

PURPOSE

To retrospectively evaluate the clinical outcome of patients after simultaneous or sequential internal iliac artery (IIA) embolization for bilateral IIA occlusion.

MATERIALS AND METHODS

Sixteen patients (65-88 y; mean, 75.6 y; two women), 11 with aortobiiliac aneurysms, three with bilateral common iliac artery (CIA)/IIA aneurysms, and two with unilateral CIA/IIA aneurysms, underwent IIA occlusion before endovascular aortoiliac repair. Eight patients underwent simultaneous bilateral IIA embolization before endovascular aortic repair (EVAR). Eight patients had sequential bilateral IIA occlusion. The outcome was assessed by clinical follow-up.

RESULTS

There were no severe ischemic complications such as buttock necrosis or acute bowel, bladder, or spinal cord ischemia. Early ischemic complications occurred in 25% (buttock/thigh claudication, n = 3, 18.8%; and sexual dysfunction, n = 1, 6.2%) and had an onset not later than 6 months after intervention: buttock claudication resolved (n = 2) or persisted after aggravation by inferior mesenteric artery embolization for type II endoleak (n = 1). Impotence in a fourth patient persisted. The ischemic complication rate after 6 months was 30% (three of 10) because of a fifth patient who developed ischemic colitis with aggravation of ischemic heart disease after 15 months. The mean follow-up duration was 19.7 months. Patients with simultaneous embolization had a lower complication rate than those with sequential embolization (one of eight [12.5%] vs four of eight [50%], respectively).

CONCLUSIONS

IIA embolization for bilateral IIA occlusion can be performed with a complication rate comparable with results of previous studies of unilateral IIA embolization. Chronic buttock claudication may be aggravated by embolization of aortic side branches. Late complications can have an insidious course and be initiated by low-output cardiac failure. Bilateral IIA occlusion is recommended only in patients who are considered unfit for aortic surgery.

Bell-bottom aortoiliac endografts: an alternative that preserves pelvic blood flow

OBJECTIVE

Dilated common iliac arteries that complicate aortic aneurysm stent grafting usually have been managed with endograft extension across the iliac artery bifurcation with internal iliac artery (IIA) occlusion. We studied 25 patients with significant common iliac artery (CIA) dilation treated with two methods: endograft extension across the iliac bifurcation or a new approach with a flared cuff within the CIA that preserves the IIA.

METHODS

Of 86 patients with abdominal aortic aneurysm (AAA) who underwent bifurcated endovascular stent grafting (ESG), 25 (29.1%) had at least one dilated CIA. Two treatment groups had different methods of management of iliac artery dilation. Group 1 underwent ESG with straight extension across the iliac bifurcation and IIA coil embolization before the ESG procedure (n = 2) or simultaneously with ESG (n = 8). Group 2 underwent ESG with flared distal cuff (AneuRx, Medtronic AVE, Santa Rosa, Calif) contained within the CIA, the so-called "bell-bottom" procedure, thus preserving the IIA (n = 15). Iliac artery dimensions, operating room time, fluoroscopy time, and postoperative complications were prospectively gathered.

RESULTS

Two women and 23 men had mean diameters of AAA of 56.6 mm (range, 38 to 98 mm) and of CIA of 21.4 mm (range, 15 to 48 mm). The diameters of CIA treated with device extension into external iliac artery after IIA coil embolization in group 1 and with the bell-bottom procedure in group 2 were not different (mean CIA diameter, 19.9 mm; range, 15 to 26 mm; and mean, 19.1 mm; range, 15 to 24 mm; respectively). However, significantly lower operating room and catheter procedure times were found in group 2 compared with group 1 (137 versus 192 minutes; 58 versus 106 minutes; P =.02 and.02, respectively). No periprocedural type I endoleaks were found in either group. Nine patients in group 2 also had a second contralateral CIA aneurysm, and five patients (mean CIA diameter, 33.0 mm; range, 22 to 48 mm) underwent treatment with extension across the iliac artery bifurcation and IIA occlusion. Use of the bell-bottom procedure on the other side allowed preservation of one IIA. Four cases (mean diameter, 19.3 mm) also underwent contralateral bell-bottom procedure. Two of these group 2 patients had complications, with severe buttock claudication in one and distal embolism necessitating limb salvage bypass after preoperative coil embolization of the IIA in another.

CONCLUSION

Significant CIA ectasia or small aneurysm is often associated with AAA. In such cases, the bell-bottom procedure that preserves IIA circulation is a new alternative to the common practice of placement of endograft extensions across the iliac artery bifurcation in patients with at least one CIA diameter of less than 26 mm. Additional benefits include reduced total procedure time. Early technical success appears to justify continued use. However, long-term evaluation is necessary to determine durability because the risk of rupture as the result of potential expansion of the excluded iliac artery or late failure is unknown.