Effects of preemptive cerebrospinal fluid drainage on spinal cord protection during thoracic endovascular aortic repair

Abstract

Background: Spinal cord injury (SCI) is reported to occur in 3-12% of thoracic endovascular aortic repair (TEVAR) cases, but is a potentially preventable complication of TEVAR for thoracoabdominal pathologies.Although many strategies have been devised to reduce the incidence of SCI, the effectiveness of prophylactic cerebrospinal fluid drainage (CSFD) and left subclavian artery (LSA) revascularization remains controversial.Methods: From 2012 to 2014, 162 patients underwent TEVAR at a single institution. We prospectively collected and retrospectively reviewed the data of 81 patients who underwent preoperative CSFD among the 162 patients. LSA revascularization was routinely used when LSA need to be covered. Preoperative characteristics, intraoperative variables, and outcomes were analyzed.Results: The mean (SD) age of the patients was 60.6 (12.5) years, and 57 patients (70%) were male.Twenty-five patients (31%) presented with degenerative aneurysm; 48 (59%), type B dissection; 5, (6%) penetrating aortic ulcer; and 3 (4%), intramural hematoma. Thirty-six patients (44%) underwent LSA revascularization before TEVAR. Two (2.5%) of the patients who underwent preoperative CSFD had SCI, of whom one recovered ambulatory status at discharge after hypertensive therapy and another had a permanent disability. Prior abdominal aortic aneurysm (AAA) repair tended to relate to SCI (P=0.065), and preoperative aortic rupture was a significant independent risk factor of SCI (P=0.002).Conclusions: Preemptive CSFD as an adjunctive procedure to TEVAR proved to be more effective than selective use of CSFD in other prior reports of SCI cases. Preoperative CSFD is recommended as a prophylactic procedure in patients at high risk of SCI during TEVAR.

Editor's Choice – Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS)

“…125,126 However, the use of lumbar CSF pressure monitoring and drainage may be considered based on individualized risk assessment for spinal cord ischaemia. 127,128 In situations of delayed SCI, selective secondary insertion of drainage as part of a treatment bundle is recommended. 126,129 As imaging is still not able to provide us with a detailed description of intraspinal collateralization, which might be the answer to who is at increased risk for SCI, risk prediction models remain approximations, e.g.…”

Cerebrospinal Fluid Drainage During Endovascular Aortic Aneurysm Repair: A Systematic Review of the Literature and Treatment Recommendations

“…4,5 Indications for CSF drain placement included: all patients being treated with TEVAR (n ¼ 1), all patients being treated with TEVAR without specific contraindications (n ¼ 1), and patients determined by the authors to be high risk for SCI (n ¼ 6). 3,[11][12][13][14][15][16][17] Methods of risk stratification varied between studies but generally were based on the size of the aneurysm and/or involvement of branching or segmental arteries.…”

“…Seven of 8 protocols for CSF drainage involved drainage of CSF to a target pressure, between 7 and 12 mm Hg. 3,11,[13][14][15][16][17] Three had limits of CSF volume drained, of 10 to 20 mL/h. 11,12,16 Three studies lowered the target CSF pressure if symptoms of SCI became evident.…”

“…11,12,16 Three studies lowered the target CSF pressure if symptoms of SCI became evident. 3,11,17 In the postoperative period, most continued their intraoperative protocol until removal of the drain at 24 to 72 hours after the operation. Hiraoka et al 15 and Mazzeffi et al 16 were the only studies that limited postoperative CSF drainage to only symptomatic patients.…”

“…Since 2016, several studies have been published on the use of CSFD in TEVAR procedures. 2,3,[12][13][14][15][16][17] The aim of this systematic literature review is to provide an updated summary of the current literature regarding CSFD in endovascular aortic aneurysm repair. The primary objective of the review is to examine the utility of CSFD in adult patients who underwent endovascular aortic aneurysm repair in decreasing rates of SCI, and the secondary objective is to catalog the variations in CSFD protocols used within these studies.…”