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Bhatia M, Kumar PA. Con: Lumbar Drains Should Routinely Be Placed by a Landmark Approach and Not by Fluoroscopic Guidance for Elective Thoracic Aortic Repairs. J Cardiothorac Vasc Anesth 2023; 37:183-186. [PMID: 36280577 DOI: 10.1053/j.jvca.2022.09.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/24/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Meena Bhatia
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Priya A Kumar
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
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2
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MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissection. J Thorac Cardiovasc Surg 2022; 163:1231-1249. [PMID: 35090765 DOI: 10.1016/j.jtcvs.2021.11.091] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 01/16/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Md
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
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3
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MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery Clinical Practice Guidelines on the Management of Type B Aortic Dissection. Ann Thorac Surg 2022; 113:1073-1092. [PMID: 35090687 DOI: 10.1016/j.athoracsur.2021.11.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Texas
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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CHAN CH, DESAI SR, HWANG NC. Cerebrospinal Fluid Drains: Risks in Contemporary Practice. J Cardiothorac Vasc Anesth 2022; 36:2685-2699. [DOI: 10.1053/j.jvca.2022.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 01/03/2022] [Accepted: 01/12/2022] [Indexed: 11/11/2022]
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Rizk MAEMAES, Ismail MIM, Gohar KS. Stroke, spinal cord ischemia and upper limb ischemia in patients undergoing TEVAR with coverage of the left subclavian artery: a case series study. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021. [DOI: 10.1186/s43055-021-00654-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
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.
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Lella SK, Waller HD, Pendleton A, Latz CA, Boitano LT, Dua A. A Systematic Review of Spinal Cord Ischemia Prevention and Management After Open and Endovascular Aortic Repair. J Vasc Surg 2021; 75:1091-1106. [PMID: 34740806 DOI: 10.1016/j.jvs.2021.10.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 10/24/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Spinal cord ischemia (SCI) is one of the most devastating complications after descending thoracic aortic (DTA) and thoracoabdominal aortic (TAA) repairs. Patients who develop SCI have a poor prognosis with mortality rates reaching 75% within the first year after surgery. Many factors have been shown to increase the risk of this complication, including extent of TAA repair, length of aortic and collateral network coverage, embolization, and reduced spinal cord perfusion pressure. As a result, a variety of treatment strategies have evolved. We aimed to provide an up-to-date review of SCI rates with associated treatment algorithms from open and endovascular DTA and TAA repairs. METHODS Using PRISMA guidelines, a literature review with the Medical Subject Headings (MeSH) terms "spinal cord ischemia; spinal cord ischemia prevention and mitigation strategies; spinal cord ischemia rates; spinal cord infarction" was performed in the Cochrane and PubMed databases to seek all peer-reviewed studies of DTA and TAA repairs with SCI complications, limited to 2012-2021 and the English language. MeSH subheadings including diagnosis, complications, physiopathology, surgery, mortality, and therapy were used to further restrict the articles. Studies were excluded if they were not in humans, not pertaining to SCI in DTA/TAA operative repairs, and if the study primarily discussed neuromonitoring techniques. Additionally, studies with <40 patients or limited information regarding SCI protection strategies were excluded. Each study was individually reviewed by two researchers to assess for type and extent of aortic pathology, operative technique, SCI protection or mitigation strategies, rates of overall and permanent SCI symptoms, associations with SCI on multivariate analysis, and mortality. RESULTS Of 450 studies returned by the MeSH search strategy, 41 met inclusion criteria and were included in the final analysis. For endovascular DTA repair patients, overall SCI rates ranged from 0-10.6% with permanent SCI symptoms ranging from 0-5.1%. Endovascular and open TAA repairs had rates of overall SCI of 0-35%. Permanent SCI symptom rate was reported by only one open study at 1.1% while endovascular TAA repairs had between 2-20.5%. CONCLUSION This review provides an up-to-date review of current rates of SCI as well as prevention and mitigation strategies for DTA and TAA repairs. We find that a multimodal approach, including a bundled institutional protocol, staging of multiple repairs, preservation of collateral blood flow network, augmented spinal cord perfusion, selective cerebrospinal fluid drainage, and distal aortic perfusion in open TAA repairs, appears to be important in reducing the risk of SCI.
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Affiliation(s)
- Srihari K Lella
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass.
| | - Harold D Waller
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Alaska Pendleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Christopher A Latz
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
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7
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Khemlani KH, Schurink GW, Buhre W, Schreiber JU. Cerebrospinal Fluid Drainage in Thoracic and Thoracoabdominal Endovascular Aortic Repair: A Survey of Current Clinical Practice in European Medical Centers. J Cardiothorac Vasc Anesth 2021; 36:1318-1325. [PMID: 34507885 DOI: 10.1053/j.jvca.2021.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/17/2021] [Accepted: 08/01/2021] [Indexed: 01/16/2023]
Abstract
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.
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Affiliation(s)
- Kavita Houthoff Khemlani
- Department of Anesthesia and Pain Management, Maastricht University Medical Center, Maastricht, The Netherlands; Department of Anesthesia, Maxima Medical Center, Veldhoven, The Netherlands.
| | - Geert Willem Schurink
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wolfgang Buhre
- Department of Anesthesia and Pain Management, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan Uwe Schreiber
- Department of Anesthesia and Pain Management, Maastricht University Medical Center, Maastricht, The Netherlands
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Miller LK, Patel VI, Wagener G. Spinal Cord Protection for Thoracoabdominal Aortic Surgery. J Cardiothorac Vasc Anesth 2021; 36:577-586. [PMID: 34366215 DOI: 10.1053/j.jvca.2021.06.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/15/2021] [Accepted: 06/20/2021] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- Lydia K Miller
- Department of Anesthesiology, Columbia University, New York, NY
| | | | - Gebhard Wagener
- Department of Anesthesiology, Columbia University, New York, NY.
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9
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Oftadeh M, Ural N, LeVan P, Prabhu V, Haske M. The Evolution and Future of Spinal Drain for Thoracic Aortic Aneurysm Repair: A Review. J Cardiothorac Vasc Anesth 2021; 35:3362-3373. [PMID: 34154920 DOI: 10.1053/j.jvca.2021.04.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 11/11/2022]
Abstract
For decades, spinal drains for cerebrospinal fluid (CSF) pressure monitoring and drainage have been used as adjuncts to protect against spinal cord injury resulting from thoracic aortic aneurysm repair. There are many different approaches to placement and management of CSF drains, with no true consensus on best practice. Furthermore, the incidence of complications resulting from spinal drains largely has been stagnant. This review describes the history and rationale behind placement of CSF drains, explore various considerations, techniques, and equipment, and discuss potential considerations for developing more comprehensive protocols.
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Affiliation(s)
- Mina Oftadeh
- Department of Anesthesiology, Loyola University Medical Center, Maywood, IL.
| | - Nil Ural
- Department of Anesthesiology, Loyola University Medical Center, Maywood, IL
| | - Pierre LeVan
- Department of Anesthesiology, Franciscan Health Olympia Fields, Olympia Fields, IL
| | - Vikram Prabhu
- Department of Anesthesiology, Loyola University Medical Center, Maywood, IL
| | - Michael Haske
- Department of Anesthesiology, Loyola University Medical Center, Maywood, IL
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10
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Protocolized Based Management of Cerebrospinal Fluid Drains in Thoracic Endovascular Aortic Aneurysm Repair Procedures. Ann Vasc Surg 2021; 72:409-418. [DOI: 10.1016/j.avsg.2020.08.134] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 08/12/2020] [Accepted: 08/17/2020] [Indexed: 01/04/2023]
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11
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Seike Y, Fukuda T, Yokawa K, Horinouchi H, Inoue Y, Shijo T, Uehara K, Sasaki H, Matsuda H. Severe intraluminal atheroma and iliac artery access affect spinal cord ischemia after thoracic endovascular aortic repair for degenerative descending aortic aneurysm. Gen Thorac Cardiovasc Surg 2021; 69:1367-1375. [PMID: 33569712 DOI: 10.1007/s11748-021-01593-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/09/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES This study aimed to reveal additional factors potentially contributing to the multifactorial ethiopathogenesis of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (TAA). METHODS The medical records of 293 patients who underwent TEVAR without debranching procedures for descending TAA between 2011 and 2018 were retrospectively reviewed. We excluded the following cases from the study: 72 patients with aortic dissection; 15 with rupture; 14 with anastomotic pseudoaneurysm; 22 with re-TEVAR; 34 without evaluation of the artery of Adamkiewicz (AKA). Sufficient data were available for 136 patients (79% men; mean age of 76 ± 7.4 years). We conducted univariable and multivariable analyzes using the logistic regression analysis to assess the relationship between pre-/intraoperative factors and postoperative SCI. RESULTS SCI was observed in nine patients (6.8%). Severe intraluminal atheroma [odds ratio (OR), 6.23; p = 0.014] and iliac artery access (OR 4.65; p = 0.043) were identified as the positive predictors of SCI by univariable analysis. Risk factors of SCI were determined additionally as follows: coverage of the intercostal artery branching AKA (ICA-AKA) (OR 4.89; p = 0.054); coverage of the ICA-AKA combined with iliac access (OR 10.1; p = 0.002); that combined with severe intraluminal atheroma (OR 13.7; p = 0.001). CONCLUSION Severe intraluminal atheroma and iliac artery access were the independent predicting factors of SCI after TEVAR for degenerative descending TAA. In patients with complicated aortoiliofemoral access route, coverage of the ICA-AKA is associated with the risk of SCI.
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Affiliation(s)
- Yoshimasa Seike
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Koki Yokawa
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Hiroki Horinouchi
- Department of Radiology, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Yosuke Inoue
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Takayuki Shijo
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Kyokun Uehara
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan.
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Haunschild J, VON Aspern K, Misfeld M, Davierwala P, Borger MA, Etz CD. Spinal cord protection in thoracoabdominal aortic aneurysm surgery: a multimodal approach. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:316-325. [PMID: 33496426 DOI: 10.23736/s0021-9509.21.11783-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Spinal cord injury (SCI) is one major complication of open and endovascular thoracic and thoracoabdominal aortic aneurysm repair. Despite numerous neuroprotective adjuncts, the incidence of SCI remains high. This review article discusses established and novel adjuncts for spinal cord protection, including priming and preconditioning of the paraspinal collateral network, intraoperative systemic hypothermia, distal aortic perfusion, motor- and somatosensory evoked potentials and noninvasive cnNIRS monitoring as well as peri- and postoperative drainage of cerebrospinal fluid. Regardless of the positive influence of many of these strategies on neurologic outcome, to date no strategy assures definitive preservation of spinal cord integrity during and after aortic aneurysm repair.
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Affiliation(s)
| | | | - Martin Misfeld
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Medicine and Health, Central Clinical School, University of Sydney, Sydney, Australia.,Institute of Academic Surgery, RPAH, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia
| | - Piroze Davierwala
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Christian D Etz
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany -
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13
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Hayden AM, Arora L, Hobbs RA, Sharafuddin MJ. The Use of Cangrelor Infusions After Endovascular Aortic Repair With Prophylactic Lumbar Drain Placement. J Cardiothorac Vasc Anesth 2020; 35:3723-3726. [DOI: 10.1053/j.jvca.2020.11.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 11/11/2022]
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14
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Haunschild J, von Aspern K, Khachatryan Z, Bianchi E, Friedheim T, Wipper S, Trepte CJ, Ossmann S, Borger MA, Etz CD. Detrimental effects of cerebrospinal fluid pressure elevation on spinal cord perfusion: first-time direct detection in a large animal model. Eur J Cardiothorac Surg 2020; 58:286-293. [DOI: 10.1093/ejcts/ezaa038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/11/2020] [Accepted: 01/17/2020] [Indexed: 12/14/2022] Open
Abstract
Abstract
OBJECTIVES
Cerebrospinal fluid (CSF) drainage is routinely utilized to mitigate perioperative and postoperative spinal cord ischaemia in open and endovascular thoraco-abdominal aortic aneurysm repair to prevent permanent paraplegia. Clinical decision-making in the vulnerable perioperative period, however, is still based on limited clinical and experimental data. Our aim was to investigate the isolated effect of CSF pressure elevation on spinal cord perfusion in an established large animal model.
METHODS
Ten juvenile pigs with normal (native) arterial inflow (patent segmental arteries and collaterals) underwent iatrogenic CSF pressure elevation (×2, ×3, ×4 from their individual baseline pressure). Each pressure level was maintained for 30 min to mimic clinical response time. After the quadrupling of CSF pressure, the dural sac was slowly depressurized against gravity allowing CSF pressure to passively return to baseline values. Measurements were taken 30 and 60 min after normalization, and microspheres for regional blood flow analysis were injected at each time point.
RESULTS
Spinal cord perfusion decreased significantly at all mid-thoracic to lumbar cord segments at the doubling of CSF pressure and declined to values <53% compared to baseline when pressure was quadrupled. Normalizing CSF pressure led to an intense hyperperfusion of up to 186% at the cervical level and 151% within the lumbar region.
CONCLUSIONS
CSF pressure elevation results in a relevant impairment of spinal cord blood supply. Close perioperative and postoperative monitoring of CSF pressure is crucial for maintaining sufficient spinal cord perfusion. Radical and rapid withdrawal of CSF is followed by significant hyperperfusion in all spinal cord segments and may lead to ‘drainage-related’ iatrogenic reperfusion injury—aggravating the risk of delayed spinal cord injury—and should therefore be avoided.
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Affiliation(s)
- Josephina Haunschild
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | | | - Zara Khachatryan
- Heisenberg Working Group for Aortic Surgery, Saxonian Incubator for Clinical Translation, University of Leipzig, Leipzig, Germany
| | - Edoardo Bianchi
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Till Friedheim
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sabine Wipper
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Constantin J Trepte
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susann Ossmann
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Michael A Borger
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Christian D Etz
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
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Malloy PC, Raghavan A, Elder T, Wright J, Wright CH, Burant C, Sajatovic M, Hoffer A. Cerebrospinal Fluid Drainage During Endovascular Aortic Aneurysm Repair: A Systematic Review of the Literature and Treatment Recommendations. Vasc Endovascular Surg 2019; 54:205-213. [DOI: 10.1177/1538574419896525] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Spinal cord injury (SCI) is a known complication of aortic aneurysm repair. Previous reports indicate that cerebrospinal fluid drainage (CSFD) may reduce incidence of SCI during open aortic aneurysm repair but its utility in endovascular repair remains poorly understood. We performed a systematic review of the literature to examine the protocols and outcomes of CSFD in patients undergoing endovascular aortic aneurysm repair. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were utilized to conduct a systematic literature review. PubMed, Scopus, Ovid, Cochrane, and EMBASE were queried for articles published since 2016 using search terms “(cerebrospinal fluid diversion OR CSF diversion OR lumbar drain OR subarachnoid drain OR spinal) AND (aortic aneurysm AND thoracic AND endovascular OR TEVAR).” Ninety-two articles were identified and screened by 2 independent reviewers, and 23 studies met criteria for full-text review after initial screening. Results: A total of 8 studies met full inclusion criteria for final analysis. Six studies reported incidence of SCI in patients with CSFD and 2 compared SCI incidence between patients with and without CSFD. Protocols for drainage most commonly included draining to a target pressure intra- and postoperatively, between 8 and 12 mm Hg. Incidence of SCI ranged from 0% to 17% in patients with CSFD, and from 0% to 50% in those without CSFD. Rates of CSFD-related complications ranged from <1% to 28%. Conclusion: There may be a protective benefit of CSFD in preventing SCI, but there remains significant variation in drain placement protocols. Significant potential bias exists in the reviewed data. Higher quality studies on the role of CSFD in endovascular aortic aneurysm repair are needed.
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Affiliation(s)
- Patrick C. Malloy
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Patrick C. Malloy and Alankrita Raghavan contributed equally to the content
| | - Alankrita Raghavan
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Patrick C. Malloy and Alankrita Raghavan contributed equally to the content
| | - Theresa Elder
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - James Wright
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Christina Huang Wright
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Christopher Burant
- Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, OH, USA
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Martha Sajatovic
- Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Alan Hoffer
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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D’Oria M, Chiarandini S, Pipitone M, Calvagna C, Ziani B. Coverage of visible intercostal and lumbar segmental arteries can predict the volume of cerebrospinal fluid drainage in elective endovascular repair of descending thoracic and thoracoabdominal aortic disease: a pilot study. Eur J Cardiothorac Surg 2018; 55:646-652. [DOI: 10.1093/ejcts/ezy371] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/23/2018] [Accepted: 09/26/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Mario D’Oria
- Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Stefano Chiarandini
- Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Marco Pipitone
- Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Cristiano Calvagna
- Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Barbara Ziani
- Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
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17
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Fujikawa T, Yamamoto S, Oshima S, Ozaki K, Shimamura J, Asada H, Wong RHL. Open surgery for descending thoracic aorta in an endovascular era. J Thorac Cardiovasc Surg 2018; 157:2168-2174. [PMID: 30448162 DOI: 10.1016/j.jtcvs.2018.08.094] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 08/02/2018] [Accepted: 08/11/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair has become the preferred treatment for a variety of descending thoracic aortic pathologies. However, there are unresolved issues such as morphologic appearance of chronic dissection, persistent false lumen perfusion, and adequacy of landing zone. Enthusiasm for improving the technique of open aortic repair and perioperative management is fading. In this study, we would like to demonstrate how we improve our surgical outcomes by establishing a dedicated aortic multidisciplinary team at the Kawasaki Aortic Center. METHOD We performed a single-center retrospective study from January 2015 to December 2016. All patients with open descending thoracic aortic replacement were recruited. Preoperative patient demographic data, bypass strategies, operative details, and postoperative outcomes were reviewed. RESULT From January 2015 to December 2016, we treated 168 cases of descending thoracic aortic repair using a left thoracotomy. Median age was 69.0 ± 21.8 years old, and 63.1% were aortic dissection (acute, 4.8%; chronic, 58.3%); 81.3% patients underwent elective operations. Left heart bypass, deep hypothermic circulatory arrest, and partial cardiopulmonary bypass were performed in 88.6%, 9.0%, and 2.4% of patients, respectively. Mean operative time was 312 ± 94 minutes. In-hospital mortality in total was 0.6%. The rate of transient spinal cord injury was 4.7%. CONCLUSIONS Under a dedicated aortic multidisciplinary team, we demonstrated that open descending thoracic aorta replacement can be performed with excellent early outcomes with low reintervention rates, regardless of the nature of the aortic pathologies.
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Affiliation(s)
- Takuya Fujikawa
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan; Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Shin Yamamoto
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Susumu Oshima
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Kensuke Ozaki
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | | | - Hiroaki Asada
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Randolph H L Wong
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.
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18
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Arora H, Kumar PA. Prophylactic Cerebrospinal Fluid Drainage for High-Risk Thoracic Endovascular Aortic Repair: Safe and Effective? J Cardiothorac Vasc Anesth 2018; 32:890-892. [DOI: 10.1053/j.jvca.2018.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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