Protocol implementation of selective postoperative lumbar spinal drainage after thoracic aortic endograft

Keith, Charles J.; Passman, Marc A.; Carignan, Martin J.; Parmar, Gaurav; Nagre, Shardul B.; Patterson, Mark A.; Taylor, Steven M.; Jordan, William D.

doi:10.1016/j.jvs.2011.07.086

Cited by 57 publications

(19 citation statements)

References 22 publications

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Section: Introductionmentioning

confidence: 99%

“…Despite the reduced risk of major morbidity, spinal cord ischemia (SCI) occurs after TEVAR in 2–15% of patients, which can lead to profound long-term disability, and is known to significantly increase the risk of 1-year mortality 5–9 . Various proactive and reactive treatment protocols have been developed in an attempt to identify strategies for reducing the risk of developing this potentially devastating complication 9, 10 . However, some of these interventions, such as pharmacologic adjuncts and/or spinal drainage, have their own risk of complications and lead to increased resource utilization, which argues for a selective approach for initiation of these therapies 9, 11 .…”

Section: Introductionmentioning

confidence: 99%

“…Various proactive and reactive treatment protocols have been developed in an attempt to identify strategies for reducing the risk of developing this potentially devastating complication 9, 10 . However, some of these interventions, such as pharmacologic adjuncts and/or spinal drainage, have their own risk of complications and lead to increased resource utilization, which argues for a selective approach for initiation of these therapies 9, 11 .…”

Section: Introductionmentioning

confidence: 99%

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Preoperative prediction of spinal cord ischemia after thoracic endovascular aortic repair

Scali

Wang

Feezor

et al. 2014

Journal of Vascular Surgery

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Objective Spinal cord ischemia (SCI) is a devastating, but potentially preventable, complication of thoracic endovascular aortic repair (TEVAR). The purpose of this analysis was to determine what factors predict SCI after TEVAR. Methods All TEVAR procedures at a single institution were reviewed for patient characteristics, prior aortic repair history, aortic centerline of flow analysis, and procedural characteristics. SCI was defined as any lower extremity neurologic deficit that was not attributable to an intracranial process or peripheral neuropathy. Forty-three patient and procedural variables were evaluated individually for association with SCI. Those with the strongest relationships to SCI (P < .1) were included in a multivariable logistic regression model, and a stepwise variable elimination algorithm was bootstrapped to derive a best subset of predictors from this model. Results From 2002–13, 741 patients underwent TEVAR for various indications and 68 (9.2%) developed SCI (permanent: N = 38; 5.1%). Due to lack of adequate imaging for centerline analysis, 586 patients (any SCI, N = 43; 7.4%) were subsequently analyzed. Patients experiencing SCI after TEVAR were older (SCI 72±11 vs. No SCI, 65±15 years; P < .0001) and had significantly higher rates of multiple cardiovascular risk factors. The stepwise selection procedure identified five variables as the most important predictors of SCI: age (odds ratio, OR, multiplies by 1.3 per 10 years; 95% CI 0.9–1.8, P = .06), aortic coverage length (OR multiplies by 1.3 per 5cm; CI 1.1–1.6, P = .002), chronic obstructive pulmonary disease (OR, 1.9; CI .9–4.1, P = .1), chronic renal insufficiency(creatinine ≥ 1.6; OR, 1.9; CI .8–4.2, P = .1), and hypertension (defined as chart history and/or medication; OR, 6.4; CI 2.6–18, P < .0001). A logistic regression model with just these five covariates had excellent discrimination (AUC = .83) and calibration (χ2 = 9.8; P = .28). Conclusion This analysis generated a simple model that reliably predicts SCI after TEVAR. This clinical tool can assist decision-making regarding when to proceed with TEVAR, guide discussions about intervention risk, and help determine when maneuvers to mitigate SCI risk should be implemented.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Preoperative prediction of spinal cord ischemia after thoracic endovascular aortic repair

Scali

Wang

Feezor

et al. 2014

Journal of Vascular Surgery

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“…Although lumbar drains are commonly used for traumatic and iatrogenic dural tears [3], after skull base surgery [2], and following some aortic aneurysm operations [11-12], they are risk-laden, require frequent nursing interventions, and are typically used only in an ICU setting. Houle, et al developed an early, flow-regulated, electronic system using a device similar to an intravenous fluid pump [14].…”

Section: Discussionmentioning

confidence: 99%

“…ELD is used to treat spontaneous and iatrogenic dural openings [2-3], to determine if shunting might be of benefit in patients with ventriculomegaly or pseudotumor [4-6], for patients following subarachnoid hemorrhage [7-9], and to decrease intracranial pressure [10]. It is used by vascular surgeons to lower the risk of spinal cord injury during aortic repair [11-12]. Reported complication rates are high and include over- and under-drainage, mechanical failure, and infection [2-3, 9, 13].…”

Section: Introductionmentioning

confidence: 99%

An Automated, Gravity-driven CSF Drainage System Decreases Complications and Lowers Costs

Lieberson

Eckermann

Meyer

et al. 2017

Cureus

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Background: FlowSafeTM (BeckerSmith Medical, Irvine, CA, USA) is a novel, robotic, external lumbar drainage (ELD) system, which was designed to control cerebrospinal fluid (CSF) drainage, reduce complications, and decrease treatment costs.Methods: Forty-seven consecutive neurosurgical patients requiring ELD were treated using the FlowSafe system.Results: In 39 of 40 patients with traumatic and surgical dural openings, potential CSF leaks were avoided. In seven patients with suspected normal pressure hydrocephalus, post-infectious ventriculomegaly, or pseudotumor cerebrum, we were able to assess the likelihood of improvement with shunting. The system, therefore, produced what we considered to be the “desired result” in 46 of 47 patients (98%). Our one treatment failure (2%) involved a patient with unrecognized hydrocephalus who, following a Chiari repair with a dural patch graft, was drained for six days. A persistent CSF leak eventually required a reoperation. Two patients (4%) described low-pressure headaches during treatment. Both responded to temporarily suspending or reducing the drainage rate. We saw no complications. Required nursing interventions were minimal. Conclusions: The FlowSafe system was safe and effective. In our experience, there were fewer complications compared to currently available ELD systems. The FlowSafe was well tolerated by our patients. The near elimination of nursing interventions should allow lumbar drainage to be delivered in less costly, non-intensive care unit settings. Larger trials will be needed.

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Endovascular Management of Thoracoabdominal Aneurysms

Beckerman¹,

McKinsey²

2018

Endovascular Interventions

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Protocol implementation of selective postoperative lumbar spinal drainage after thoracic aortic endograft

Abstract: A protocol utilizing selective postoperative lumbar spinal drainage can be used safely for patients developing SCI after TEVAR with acceptably low permanent neurologic deficit, although overall survival of patients experiencing SCI after TEVAR is diminished relative to non-SCI patients.

Cited by 57 publications

References 22 publications

Preoperative prediction of spinal cord ischemia after thoracic endovascular aortic repair

Preoperative prediction of spinal cord ischemia after thoracic endovascular aortic repair

An Automated, Gravity-driven CSF Drainage System Decreases Complications and Lowers Costs

Endovascular Management of Thoracoabdominal Aneurysms

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