Spinal cord protection practices used during endovascular repair of complex aortic aneurysms by the U.S. Aortic Research Consortium

Aucoin, Victoria J.; Eagleton, Matthew J.; Oderich, Gustavo S.; Schanzer, Andres; Timaran, Carlos H.; Schneider, Darren B.; Sweet, Matthew P.; Beck, Adam W.

doi:10.1016/j.jvs.2020.07.107

Cited by 68 publications

(36 citation statements)

References 26 publications

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“…drainiert wird. Der Katheter kann dabei bis zu 4 Tage belassen werden[43,48]. Durch moderne Sedativa ist mittlerweile auch bei Intubierten Patienten ggf.…”

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Offener thorakaler und thorakoabdominaler Aortenersatz vs. f/b(T)EVAR – komplementär oder kompetitiv?

et al. 2021

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ZusammenfassungDer offen-chirurgische thorakale und thorakoabdominelle Aortenersatz (open repair, OR) bei Aneurysmen oder Dissektionen hat in der aktuellen Versorgungsrealität im Vergleich zur endovaskulären Versorgung mit einfachen und speziellen Stentprothesen (fenestrated/branched [thoracic] endovascular aortic repair, f/b[T]EVAR) eine deutlich untergeordnete Rolle. Zudem besteht die Notwendigkeit einer hohen technischen Expertise und eines umfangreichen operativen Settings, um ein OR sicher anbieten zu können.Zu Reduktion der spezifischen Komplikationen, wie z. B. perioperative Mortalität, permanente Dialysepflichtigkeit, spinale Ischämie, Schlaganfall oder Mesenterialischämie, ist ein hohes Maß an intraoperativer Protektion, z. B. mittels Liquordrainage, Point-of-Care-Gerinnungstherapie, distaler oder selektiver Aortenperfusion im Sinne eines temporären Linksherzbypasses und sequenziellem Clamping der Aorta erforderlich. Trotz der Dominanz der endovaskulären Therapie ist diese Expertise aber weiterhin nötig, um spezifische Indikationen, wie beispielsweise junges Patientenalter oder Bindegewebserkrankungen bzw. Protheseninfektionen, sicher versorgen zu können. Zusätzlich ist nicht jedes Aneurysma oder jede Dissektion anatomisch langfristig sicher mit einer endovaskulären Behandlung zu therapieren.Die aktuelle Evidenzlage sieht einen geringen, meist nicht statistisch signifikanten Vorteil von TEVAR und f/bEVAR versus OR bei den wichtigsten kurz- und mittelfristigen Ergebnisparametern, bei deutlich geringerer Invasivität und verkürzter Krankenhausliegedauer. Im langfristigen Verlauf sind die Ergebnisse bezüglich Gesamtüberleben und Re-Interventionsraten bzw. sekundärer Komplikationen bei OR deutlich besser.Der offene thorakoabdominelle Aortenersatz ist also nach wie vor mehr als ein exklusives Hobby, sondern vielmehr eine absolute Notwendigkeit im Gesamtspektrum der aortalen Chirurgie, dessen Bedeutung in den nächsten Jahren mutmaßlich wieder zunimmt.

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“…drainiert wird. Der Katheter kann dabei bis zu 4 Tage belassen werden[43,48]. Durch moderne Sedativa ist mittlerweile auch bei Intubierten Patienten ggf.…”

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Offener thorakaler und thorakoabdominaler Aortenersatz vs. f/b(T)EVAR – komplementär oder kompetitiv?

et al. 2021

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“…The prevention of SCI in patients submitted to TAAA endovascular treatment is extremely important. CSFD has been indicated as a possible protection tool by different authors 13,14 ; however, other recent publications highlighted the associated risk of both minor and major complications. 4,15,16 ICH is one of these complications; although rare, it is a devastating event and needs to be carefully considered when treating patients for TAAA, since it is associated with a perioperative mortality as high as 38% of our series.…”

Section: Discussionmentioning

confidence: 99%

Intracranial Hemorrhage After Endovascular Repair of Thoracoabdominal Aortic Aneurysm

et al. 2021

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Background Intracranial hemorrhage (ICH) is a rare but devastating complication of thoracoabdominal aortic aneurysm (TAAA) repair with fenestrated/branched endograft (f/bEVAR). The cerebrospinal fluid drainage (CSFD) is considered one of the leading causes; however, other possible concomitant factors have not been individualized yet. The aim of the present work was to evaluate the pattern of ICH events after f/bEVAR for TAAA and to identify possible associated factors. Materials and Methods All f/bEVAR procedures for TAAA performed in a single academic center from 2012 to 2020 were evaluated. ICH was assessed by cerebral computed tomography if neurological symptoms arose. Pre-, intra-, and postoperative characteristics were analyzed in order to identify possible factors associated. Results A total of 135 f/bEVAR were performed for 72 (53%) type I, II, III and 63 (47%) type IV TAAA; 74 (55%) were staged procedures, 101 (73%) required CSFD, and 24 (18%) were performed urgently. The overall 30-day mortality was 8% (5% in elective cases); spinal-cord ischemia occurred in 11(8%) and ICH in 8 (6%) patients. All ICH occurred in patients with CSFD. ICH occurred intraoperatively in 1 case, inter-stage in 4 and after F/BEVAR completion in 3, after a median of 6 days the completion stage. Three (38%) of 8 patients with ICH died at 30 days and ICH was associated with 30-day mortality: odds ratio (OR) 13.2, 95% confidence interval (CI): 2.3–76, p=0.01. The analysis of the perioperative characteristics identified platelet reduction >60% (OR 11, 95% CI 1.6–77, p=0.03), chronic kidney disease (16% vs 0%, p=0.002), and total volume of liquor drained >50 mL (OR 8.1, 95% CI 1.1–69, p=0.03) as associated with ICH. Conclusions Current findings may suggest that ICH is a potential lethal complication of the endovascular treatment for TAAAs and it mainly occurs in patients with CSFD. High-volume liquor drainage, platelet reduction, and chronic kidney disease seems increase significantly the risk of ICH and should be considered during the perioperative period and for further studies.

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“…If placement complications were to be significantly higher, a reexamination of the utility would be warranted as has been reported in other literature. 4 Revascularization of the left subclavian artery to maintain perfusion to the vertebral artery is an established technique to decrease the risk of SCI. 11 Antegrade vertebral flow can be accomplished by carotid-subclavian bypass, subclavian artery transposition onto the carotid artery, or when required a vertebral transposition in cases of an aberrant origin.…”

Section: Discussionmentioning

confidence: 99%

Optimization of factors for the prevention of spinal cord ischemia in thoracic endovascular aortic repair

et al. 2021

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Objectives Spinal cord ischemia following thoracic endovascular aortic repair (TEVAR) is a devastating complication. This study seeks to demonstrate how a standardized protocol to prevent spinal cord ischemia affects incidence in patients undergoing TEVAR. Methods Using CPT codes 33880 and 33881, all TEVAR procedures performed at a single tertiary care center from January 2017 to December 2018 were examined. Patients who had concomitant ascending aortic repairs or a TEVAR for traumatic indications were excluded from analysis, leaving 130 TEVAR procedures. Comorbid conditions, procedural characteristics, extent of coverage, peri-procedural management strategies, and post-operative outcomes were collected and analyzed retrospectively. Results One hundred thirty patients undergoing TEVAR were examined for four perioperative variables: postoperative hemoglobin greater than 10 g/dL, subclavian revascularization, preoperative spinal drain placement, and somatosensory evoked potential monitoring (SSEP). All conditions were met in 46.2% (60/130) of procedures; 37.8% (28/74) in emergent/urgent cases and 61.5% (32/52) in elective cases. Of patients who required subclavian coverage, 87.1% (54/62) underwent subclavian revascularization; 70.8% (92/130) of patients received spinal drains preoperatively; 68.5% (89/130) of patients had SSEP monitoring; 73.8% (93/130) of patients obtained a postoperative hemoglobin of >10 g/dL. Out of all patients, two (1.5%) developed spinal cord ischemia. Conclusion Incidence of spinal cord ischemia in our cohort was low at 1.5% (2/130). Individual and bundled interventions for the prevention of spinal cord ischemia were unable to demonstrate a statistically significant effect given the low rate. Nonetheless, we advocate for a proactive approach for the prevention of spinal cord ischemia given our experience in this complex population.

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Spinal cord protection practices used during endovascular repair of complex aortic aneurysms by the U.S. Aortic Research Consortium

Cited by 68 publications

References 26 publications

Offener thorakaler und thorakoabdominaler Aortenersatz vs. f/b(T)EVAR – komplementär oder kompetitiv?

Offener thorakaler und thorakoabdominaler Aortenersatz vs. f/b(T)EVAR – komplementär oder kompetitiv?

Intracranial Hemorrhage After Endovascular Repair of Thoracoabdominal Aortic Aneurysm

Optimization of factors for the prevention of spinal cord ischemia in thoracic endovascular aortic repair

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