Incidence and Determinants of Spinal Cord Ischaemia in Stent-graft Repair of the Thoracic Aorta

Amabile, Philippe; Grisoli, Dominique; Giorgi, Roch; Bartoli, J.-M.; Piquet, Philippe

doi:10.1016/j.ejvs.2007.11.005

Cited by 160 publications

(78 citation statements)

References 20 publications

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“…Many previously identified risk factors have been reported including: advanced age, male gender, a history of renal insufficiency, presence (or previous repair) of an abdominal aneurysm, acute dissection, lumbar/hypogastric artery patency, urgency of TEVAR, aortic coverage length, and left subclavian artery coverage 1, 3, 10, 15, 18, 21, 22 . Notably, a prior history of open or endovascular aortic repair was not more frequently associated with the SCI group (P=.23), although an association was found in a previous analysis from our group of repaired or unrepaired AAA with smaller patient numbers 15 .…”

Section: Discussionmentioning

confidence: 99%

“…SCI leads to varying degrees of short and long-term disability, ranging from mild transient paraparesis to permanent flaccid paralysis, and the occurrence of this complication has a known negative impact on long-term survival 1, 10 . Additionally, previous reports have suggested that neurologic recovery with delayed paraplegia compared to immediate paraplegia has a more favorable outcome 7, 9, 11–13 but small sample sizes make it difficult to draw definitive conclusions about the natural history of SCI after TEVAR.…”

Section: Introductionmentioning

confidence: 99%

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

DeSart

Scali

Feezor

et al. 2013

Journal of Vascular Surgery

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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 2000–2011 was performed to identify individuals experiencing SCI as 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, chart review and phone interviews with patients and/or family. Mortality was estimated using life-tables. Results 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;p=.002) and have a number of comorbidities including: COPD, hypertension, dyslipidemia and cerebrovascular disease(P<.0001). Fifty-four patients(95%) had a CSF drain placed at some point in their care, with the majority placed postoperatively(54%). In-hospital mortality was 8.8% for the entire cohort(SCI vs. No SCI;P=.45). Twelve patients developed immediate SCI, 40 had delayed onset, and 5 were indeterminate due to indiscriminate timing from postoperative sedation. Three(25%) immediate SCI patients had measurable functional improvement (FI), while 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, while only 13(38%) experienced return to preoperative baseline. Estimated mean survival(±standard error) 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 to 9.6±3.6 months for those without improvement(P<.0001). Survival and return of neurologic function were not significantly different when comparing patients with pre- and postoperative CSF drains. Conclusions The minority of patients experience complete return to baseline function after suffering 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 to patients without SCI. Timing of drain placement does not appear to have an impact on post-discharge FI or long-term mortality.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

DeSart

Scali

Feezor

et al. 2013

Journal of Vascular Surgery

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“…44 concluded that the risk of SCI is increased by 30% for every 2 cm of additional thoracic aortic coverage. Amabile et al 43 showed that not only aortic coverage of greater than 205 mm is associated with increased risk of SCI, but also the length of the thoracic coverage distal to the celiac artery is an important risk factor.…”

Section: Risk Factors For Spinal Cord Injury After Tevarmentioning

confidence: 99%

Spinal cord injury after thoracic endovascular aortic aneurysm repair

Awad

Ramadan

Sayed

et al. 2017

Can J Anesth/J Can Anesth

103

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Purpose Thoracic endovascular aortic aneurysm repair (TEVAR) has become a mainstay of therapy for aneurysmal and other disorders of the thoracic aorta. The purpose of this narrative review article is to summarize the current literature on the risk factors, pathophysiology of spinal cord injury (SCI) following TEVAR, and to discuss various intraoperative monitoring and treatment strategies. Source 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 compared to open TAAA repair. However, compared to open procedures, delayed paralysis/paresis is the predominant presentation of SCI after TEVAR. The pathophysiology of SCI is complex and remains 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 current spinal cord protection strategies. Conclusion Further experimental and clinical research is needed to aid in the discovery of novel neuroprotective strategies for protection and treatment of SCI following TEVAR.

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“…However, lack of blood flow can lead to blockage of spinal cord arteries during endovascular repair following thoracic aortic aneurysms. The resulting spinal cord ischemia (SCI) reportedly occurs in 1–7.5% of thoracic stent graft cases and causes temporary or permanent paraplegia1516171819, warranting assessments of strategies that avoid SCI during vascular surgery and reduce the occurrence of paraplegia following thoracic stent graft procedures. Herein, we examined the utility of late phase rIPC following SCI and show that rIPC increases plasma VEGF concentrations and reduces the severity of paraplegia following SCI.…”

mentioning

confidence: 99%

Increased plasma VEGF levels following ischemic preconditioning are associated with downregulation of miRNA-762 and miR-3072-5p

Ueno

Samura

Nakamura

et al. 2016

Sci Rep

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Ischemic preconditioning (IPC) has protective effects against ischemia-perfusion injury of organs. In the present study, we investigated the associated mechanisms after performing remote IPC (rIPC) of lower limbs by clamping abdominal aorta in mice. Subsequent experiments showed decreased damage and paralysis of lower limbs following spinal cord injury (SCI). Concomitantly, plasma vascular endothelial growth factor (VEGF) levels were increased 24 h after rIPC compared with those in sham-operated animals. In subsequent microRNA analyses, thirteen microRNAs were downregulated in exosomes 24 h after rIPC. Further studies of femoral CD34-positive bone marrow (BM) cells confirmed downregulation of these seven microRNAs 24 h after rIPC compared with those in sham-operated controls. Subsequent algorithm-based database searches suggested that two of the seven microRNAs bind to the 3′ UTR of VEGF mRNA, and following transfection into CD34-positive BM cells, anti-miR-762, and anti-miR-3072-5p inhibitors led to increased VEGF concentrations. The present data suggest that rIPC transiently increases plasma VEGF levels by downregulating miR-762 and miR-3072-5p in CD34-positive BM cells, leading to protection against organ ischemia.

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Incidence and Determinants of Spinal Cord Ischaemia in Stent-graft Repair of the Thoracic Aorta

Cited by 160 publications

References 20 publications

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

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

Spinal cord injury after thoracic endovascular aortic aneurysm repair

Increased plasma VEGF levels following ischemic preconditioning are associated with downregulation of miRNA-762 and miR-3072-5p

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