Intraoperative neuromonitoring in major vascular surgery

So, Vincent; Poon, Clara

doi:10.1093/bja/aew218

Cited by 30 publications

(19 citation statements)

References 80 publications

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“…22 It is known that the T4-T8 segment of the spinal cord is particularly susceptible to reduced perfusion during aortic procedures. 23 A number of other potential factors, such as the operating and fluoroscopy times, the clinical presentation of the aneurysm, the use of spinal drainage, and the score of postoperative occlusion areas according to the territory principle, were also highlighted in this study, even in the subanalysis regarding the urgency of presentation and the type of aneurysm. Longer operating time (and consequently fluoroscopy time) has been associated with the presence of SCI in the past.…”

Section: Discussionmentioning

confidence: 88%

“…Recently, the potential benefits of using intraoperative neuromonitoring in high-risk aortic surgery patients have been highlighted, including the following: detection of intraoperative cerebral ischemia and SCI, which can assist in optimization of perfusion (such as finetuning hemodynamic targets for controlled hypertension, providing an indication for CSF drainage); and real-time feedback to the surgeon regarding surgical technique and need for surgical salvage (such as selective intercostal artery reimplantation or ligation of backbleeding arteries to prevent steal phenomenon). 23 In our center, the practice has significantly changed dramatically in past years with ongoing experience as well as with the valuable published literature addressing SCI. One important point is the neurologic assessment of the patient as soon as possible.…”

Section: Discussionmentioning

confidence: 99%

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Risk of spinal cord ischemia after fenestrated or branched endovascular repair of complex aortic aneurysms

Σπανός¹,

Kölbel²,

Kubitz³

et al. 2019

Journal of Vascular Surgery

118

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Objective: The aim of our study was to analyze the incidence of spinal cord ischemia (SCI) in patients presenting with complex aortic aneurysms treated with endovascular aneurysm repair (EVAR) and to identify risk factors associated with this complication.Methods: A retrospective study was undertaken of prospectively collected data including patients presenting with complex aortic aneurysm (pararenal abdominal aortic aneurysm and thoracoabdominal aortic aneurysm) treated with fenestrated EVAR (F-EVAR) or branched EVAR (B-EVAR). The primary end point was the incidence of SCI and the assessment of any associated factors.Results: Between January 2011 and August 2017, a total of 243 patients (mean aneurysm diameter, 65.2 6 15.3 mm; mean age, 72.4 6 7.5 years; 73% male) were treated with F-EVAR or B-EVAR. Asymptomatic patients were treated in 73% of the cases (177/243, in contrast to 27% urgent), and 52% (126/243) were treated for thoracoabdominal aortic aneurysm (in contrast to 48% for pararenal abdominal aortic aneurysm). F-EVAR (mean number of fenestrations, 3.3/case) and B-EVAR (mean number of branches, 3.7/case) were undertaken in 67% (164/243) and 33% (79/243), respectively. The total incidence of SCI was 17.7% [43/243; paraplegia in 4% (10/243) and paraparesis in 13.7% (33/243)]. Most of the patients with SCI presented with immediate postoperative symptoms (72% [31/43]). A spinal drain was preoperatively placed in 53% (130/243) and was associated with the prevention of SCI (SCI with spinal drainage, 12% [16/130]; SCI without spinal drainage, 24% [27/113]; P ¼ .018). The 30-day mortality rate was 9% (21/243). After multiple logistic regression analysis, SCI was associated with preoperative renal function (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m 2 : odds ratio [OR], 2.43; 95% confidence interval [CI], 1.18-4.99; P ¼ .016) and the number of vertebral segments covered (SCI with higher position of proximal stent in terms of vertebra: OR, 1.2; 95% CI, 1.1-1.3; P ¼ .000). A similar outcome was derived when the height of the proximal end of the stent graft was replaced by the total length of aortic coverage (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m 2 : OR, 2.36 [95% CI, 1.11-5.00; P ¼ .025]; SCI with longer length of aortic coverage: OR, 1.01 [95% CI, 1.003-1.009; P ¼ .000]). Conclusions:The majority of SCI incidence after F-EVAR or B-EVAR of complex aortic aneurysms is manifested immediately postoperatively. The use of preoperative spinal drainage may prevent SCI. Patients with GRF <60 mL/min/1.73 m 2 and with longer aortic stent graft coverage are at higher risk of SCI.

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Section: Discussionmentioning

confidence: 88%

Section: Discussionmentioning

confidence: 99%

Risk of spinal cord ischemia after fenestrated or branched endovascular repair of complex aortic aneurysms

Σπανός¹,

Kölbel²,

Kubitz³

et al. 2019

Journal of Vascular Surgery

118

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“…At this time, IONM is indicated for spinal surgery, intracranial procedures, and thyroidectomies and is controversial with vascular procedures including carotid endarterectomies and aortic procedures. 22 We recommend that it be considered for patients that meet high preoperative risk assessment for position-related neural injuries during r-AWR. This recommendation is based on two observations.…”

Section: Discussionmentioning

confidence: 99%

Neural Monitoring for Robotic Abdominal Wall Reconstruction

Halpern

Liu

Howell

et al. 2020

JSLS

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Introduction: Positioning-related neural injuries are an inherent risk in surgery, particularly in robotic-assisted abdominal wall reconstruction because of unique patient positioning and increased operative times. The implementation of intraoperative neurophysiological monitoring should be considered in such cases.Methods: This was a two-armed study with one prospective intervention group and one retrospective control group. All patients underwent robotic abdominal wall reconstruction at an academic center. The prospective arm underwent robotic reconstruction from January through July 2019. The retrospective database reviewed patients who underwent the same procedure from August 2015 through July 2018. Factors assessed included: demographics (age, gender, body mass index, comorbidities), surgical details (American Society of Anesthesiologists class, procedure, operative time, positioning), outcomes (length of stay, 30-d readmission, reoperation), and any new-onset intraoperative or postoperative neuropathy. Patients were seen in the clinic postoperatively at weeks 1 and 6.Results: Ten patients were included in the prospective arm. All received intraoperative neurophysiological monitoring using somatosensory evoked potentials. They were compared with 47 patients in the retrospective arm who underwent surgery without intraoperative neurophysiological monitoring. One position-related neural response from baseline was detected intraoperatively in the prospective arm; however, there were no peripheral neurological symptoms present postoperatively. Two patients in the control group developed transient peripheral neuropathies that resolved within 6 weeks. Demographics, surgical procedures, and length of surgery were similar in both groups. The prospective group had a higher rate of preoperative neuropathy and intraoperative use of vasopressors. Conclusion:Incorporation of neurophysiological monitoring in robotic surgery is feasible and may lead to the prevention and reduction in positioning-related injuries.

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“…The recording of evoked potentials to assess spinal cord viability is currently the gold standard for neuromonitoring during open surgery for thoracoabdominal aortic aneurysms. 20 Experience suggests that intraoperative neuromonitoring by means of SSEPs and MEPs is an effective method to detect spinal cord ischemia during descending thoracic and thoracoabdominal aortic surgery. 21 22 A reduction in response amplitude, an increase in latency, a total loss of signal, and the need to increase stimulation voltage are some of the signs that indicate possible ischemia.…”

Section: Discussionmentioning

confidence: 99%

Hypogastric Artery Occlusion with Evoked Potentials Monitoring as Bailout Technique to Assess the Risk of Postoperative Spinal Cord Ischemia

D’Oria

Calvagna

Chiarandini

et al. 2019

Aorta

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A 65-year-old man, with previous open surgical repair of an infrarenal abdominal aortic, presented with acute complicated (paraplegia) Type B aortic dissection. He successfully underwent endovascular repair of the descending thoracic and abdominal aorta. Following the procedure, the neurological manifestations resolved. As he had a concomitant aneurysm of the right hypogastric artery (HGA), we executed a 10-minute balloon occlusion of this artery with evoked potential measurements to assess the risk of spinal cord ischemia after exclusion of the right HGA. The examination was interpreted as negative, and we proceeded with coil embolization of the right HGA and subsequent placement of an endograft landing distally within the external iliac artery. The postoperative course was totally uneventful, and the patient was discharged home 4 days after the operation. Computed tomography angiography follow-up at 1, 6, 12 and 24 months showed patency of all endografts without any signs of endoleak and effective remodeling of the descending thoracic aorta with volume reduction of the false lumen.

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Intraoperative neuromonitoring in major vascular surgery

Cited by 30 publications

References 80 publications

Risk of spinal cord ischemia after fenestrated or branched endovascular repair of complex aortic aneurysms

Risk of spinal cord ischemia after fenestrated or branched endovascular repair of complex aortic aneurysms

Neural Monitoring for Robotic Abdominal Wall Reconstruction

Hypogastric Artery Occlusion with Evoked Potentials Monitoring as Bailout Technique to Assess the Risk of Postoperative Spinal Cord Ischemia

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