Spinal Cord Ischemia After Thoracoabdominal Aortic Aneurysms Endovascular Repair: From the Italian Multicenter Fenestrated/Branched Endovascular Aneurysm Repair Registry

Abstract

Purpose: The aim of this study is to report an Italian multicenter experience analyzing the incidence and the risk factors associated with spinal cord ischemia (SCI) in a large cohort of thoracoabdominal aortic aneurysms (TAAAs) treated by fenestrated-branched endovascular aneurysm repair (F-/B-EVAR). Materials and Methods: All consecutive patients undergoing F-/B-EVAR in 4 Italian university centers between 2008 and 2019 were prospectively recorded and retrospectively analyzed. Spinal cord ischemia, 30 day/in-hospital adverse events, and mortality were assessed as early outcomes. Risk factors for SCI were determined by multivariable analysis. Results: A total of 351 patients received F-/B-EVAR for a TAAA. Twenty-eight (8.0%) patients died within 30 postoperative days or during the hospitalization. Regarding SCI, 47 patients (13.4%) developed neurological symptoms related to spinal cord impaired perfusion. Among them, 17 (4.8%) had a major permanent impairment. The multivariable analysis identified that SCI was associated with Crawford extent I to III (odds ratio [OR]: 20.90, p=0.004, 95% confidence interval [CI]=2.69–162.57), and with endovascular procedures performed for ruptured TAAA (OR: 5.74, p=0.010, 95% CI=1.53–21.57). Spinal cord ischemia was also significantly associated with a grade 3 bleeding during the visceral stage (OR: 4.34, p=0.005, 95% CI=1.55–12.16) and a grade 2 renal insufficiency at 30 days (OR: 7.45, p=0.002, 95% CI=2.12–26.18). Conclusion: The present study indicates that SCI is still an open issue after extent I to III TAAA endovascular repair, while its incidence in extent IV TAAA and pararenal/juxtarenal aneurysms is rare. Thoracoabdominal aortic aneurysms extension, urgent TAAA repair for rupture, severe bleeding, and 30 day renal insufficiency have been identified as significant risk factors for SCI. In the presence of such factors, adjunctive strategies may be considered to reduce SCI rates, while in low-risk patients invasive or potentially-risky maneuvers might not be justified.

Risk Factors for Spinal Cord Injury during Endovascular Repair of Thoracoabdominal Aneurysm: Review of the Literature and Proposal of a Prognostic Score

“…A large extent of aortic coverage is significantly associated with an increased risk of paraplegia, as shown in a recent large analysis by the US Aortic Consortium (n = 1681 patients; OR 4.79; 95% CI 4.77-4.81; p < 0.001) [3] and a multicenter Italian cohort treated for thoracoabdominal aneurysms of Crawford extents I-III (n = 351 patients; OR 20.90; 95% CI 2.69-162.57; p < 0.004) [18]. Feezor et al concluded that the risk of SCI is increased by 30% for every 2 cm of additional thoracic aortic coverage [21].…”

“…In the same retrospective review of the Vascular Quality Initiative database of 9506 patients who had undergone extensive endovascular repair, multivariate regression revealed that aortic dissection was an independent factor for postoperative SCI (OR 1.65; 95% CI 1.26-2.16; p < 0.001). However, the main parameter associated with SCI is the extent of the aneurysm and consequently the length of aortic coverage [3,18]. In addition, preoperative occlusion of one or both hypogastric or subclavian arteries contributes to reducing alternative inflow routes to the spinal collateral network.…”

Endovascular repair for acute aortic syndrome involving the descending aorta

“…Factors contributing to this heightened risk in acute cases include hemodynamic instability, longer aortic coverage for effective disease exclusion, non-staged procedures, and limitations in the usage of the available adjuncts for spinal cord protection. While many risk factors are non-modifiable preoperatively, it is crucial to emphasize vigilant patient monitoring and prompt application of available tools to prevent or mitigate this life-threatening event as swiftly as possible [74][75][76][77] .…”

Outcomes following Management of Complex Thoracoabdominal Aneurysm by an Open Approach

“…Spinal cord ischemia (SCI) is one of the most dreadful complications in patients who undergo TAAA OSR, and it may affect both perioperative and long-term outcomes because of multiple and severe medical complications directly related to the neurologic damage [10][11][12][13]. Cerebrospinal fluid drainage (CSFD) is an adjunct that has been proven to be effective in SCI prevention in TAAA OSR in randomized controlled trials and metaanalyses, and its usage is also suggested by the most recent guidelines [14,15].…”