Staged repair significantly reduces paraplegia rate after extensive thoracoabdominal aortic aneurysm repair

Etz, Christian D.; Zoli, Stefano; Mueller, Christoph; Bodian, Carol; Luozzo, Gabriele Di; Lazala, Ricardo; Plestis, Konstadinos A.; Griepp, Randall B.

doi:10.1016/j.jtcvs.2010.02.037

Cited by 182 publications

(87 citation statements)

References 26 publications

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“…7, 26 Additionally, it has been previously demonstrated that staged open procedures, first thoracic aneurysm repair followed by distal abdominal repair, was associated with a decreased rate of spinal cord injury from 17% to 0%. 27 Our results demonstrate that this outcome can be replicated using TEVAR. An additional benefit may come from temporary aneurysm sac perfusion associated with type 1b endoleaks partially perfusing the spinal cord until the open surgery.…”

Section: Discussionsupporting

confidence: 57%

Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair

Hawkins

Mehaffey

Narahari

et al. 2017

Journal of Vascular Surgery

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Objective Complex Crawford extent II thoracoabdominal aortic aneurysms (TAAA) can be treated in a hybrid manner with proximal thoracic endovascular aneurysm repair, followed by staged distal open thoracoabdominal repair. The purpose of this study was to evaluate the outcomes and healthcare associated value of this new method compared to traditional open repair over 10 years. Methods A prospectively collected database was used to identify all patients with extent II TAAA undergoing repair at a single institution between 2005 and 2015. Patient characteristics, post-operative outcomes, and incidence of major adverse events (MAE = renal failure, spinal cord ischemia, death) were compared. After adjusting for time since surgery, value was analyzed looking at quality (1/MAE) divided by cost (total health system cost). This is multiplied by a constant to set the value of open TAAA repair to 100. Results A total of 113 consecutive patients underwent extent II TAAA repairs, of which 25 (22.1%) had a staged hybrid approach with a median of 129 days between procedures. No baseline differences in demographic or comorbidity variables existed between groups (p>0.05). The hybrid group had shorter operative time (255 vs 306 minutes; p=0.01), shorter postoperative length of stay (LOS) (10.1 vs 13.3 days; p=0.02), as well as reduced blood loss (1300 vs 2600 mL; p=0.01) at the time of open operation. Despite higher rates of acute kidney injury in the hybrid group (76.0%vs 51.1%, p=0.03) there was no difference in renal failure (8.0% vs 4.5%, p=0.84) The incidence of MAE was lower in the staged hybrid group (20.0% vs 48.9%; p=0.01), without a difference in hospital mortality (4.0 vs 3.4%, p=0.89). Median total cost was higher in the hybrid group ($112,920 vs $72,037, p=0.003). Value was improved in the hybrid group by 56% using mean cost and 178% by median cost. Conclusions The 20% major adverse event rate associated with staged hybrid repair of extent II TAAA was significantly decreased compared to open repair, with a relative reduction of over 50%. Despite higher total hospital costs, staged hybrid repair had 56% to 178% higher healthcare related value compared to standard open repair. In an era of increasing focus on costs and quality, staged hybrid repair of extensive TAAAs is associated with fewer complications than open TAAA repair resulting in a good value investment from a resource utilization perspective.

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Section: Discussionsupporting

confidence: 57%

Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair

Hawkins

Mehaffey

Narahari

et al. 2017

Journal of Vascular Surgery

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“…This improved outcome was observed both in staged open procedures and staged hybrid procedures in an animal model (4, 5, 12). In these experimental studies, an interval of 7 days between procedures was sufficient to improve outcome dramatically: from 40–50% paraplegia to 0%.…”

Section: Commentmentioning

confidence: 76%

“…Clinical observations of open surgical experience added to the credibility of this experiment: patients who underwent TAAA repair in two stages suffered paraplegia at much lower rates than patients with comparable operations done in a single stage (5). …”

Section: Introductionmentioning

confidence: 99%

Endovascular coil embolization of segmental arteries prevents paraplegia after subsequent thoracoabdominal aneurysm repair: An experimental model

Geisbüsch

Stefanovic

Koruth

et al. 2014

The Journal of Thoracic and Cardiovascular Surgery

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Objective To test a strategy for minimizing ischemic spinal cord injury (SCI) following extensive thoracoabdominal aneurysm (TAAA) repair, we occluded a small number of segmental arteries (SAs) endovascularly one week before simulated aneurysm repair in an experimental model. Methods 30 juvenile Yorkshire pigs (25.2±1.7kg) were randomized into three groups. All SAs—intercostal and lumbar—were sacrificed by a combination of surgical ligation of the lumbar SAs and occlusion of intercostal SAs with thoracic endovascular stent grafting (TEVAR). 7–10 days before this simulated TAAA replacement, SAs in the lower thoracic/upper lumbar region were occluded using embolization coils: 1.5±0.5 SAs in Group 1 (T13/L1), and 4.5±0.5 in Group 2 (T11-L3). No SAs were coiled in the controls. Hind limb function was evaluated blindly from daily videotapes using a modified Tarlov score: 0=paraplegia; 9=full recovery. After sacrifice, each segment of spinal cord was graded histologically using the 9-point Kleinman score: 0=normal, 8=complete necrosis. Results Hind limb function remained normal after coil embolization. After simulated TAAA repair, paraplegia occurred in 6/10 control pigs, but only 2/10 pigs in Group 1: no pigs in Group 2 had SCI. Tarlov scores were significantly better in Group 2 (Control vs 1 p=0.06; Control vs 2 p= 0.0002; 1 vs 2 p=0.05). A dramatic reduction in histologic damage—most prominently in the coiled region—was seen when SAs were embolized before simulated TAAA repair. Conclusions Endovascular coiling of 2–4 SAs prevents paraplegia in an experimental model of extensive hybrid TAAA repair, and helps protect the spinal cord from ischemic histopathological injury. A clinical trial in a selected patient population at high risk for postoperative SCI may be appropriate.

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“…Although replacement of the entire thoracoabdominal aorta during a single procedure still carries a significant risk of SCI, results from experimental studies as well as clinical experience at our institution suggest that paraplegia and paraparesis are almost never seen— even with an equivalently extensive total resection—if aneurysm repair is carried out in stages, with abdominal replacement following thoracic replacement (or vice versa) after an interval of weeks, months or years (12-14). Various existing reports identify patients undergoing endovascular TA aneurysm repair following previous or concomitant AA repair to be at higher risk for spinal cord injury (15-19).…”

Section: Discussionmentioning

confidence: 99%

Imaging of vascular remodeling after simulated thoracoabdominal aneurysm repair

Geisbüsch

Schray

Bischoff

et al. 2012

The Journal of Thoracic and Cardiovascular Surgery

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Objective A better understanding of the response of the spinal cord blood supply to segmental artery (SA) sacrifice should help minimize the risk of paraplegia following both open and endovascular repair of thoracoabdominal aortic aneurysms (TAAA). Methods 12 female juvenile Yorkshire pigs were randomized into three groups and perfused with a barium-latex solution. Pigs in group 1 (control) had infusion without previous intervention. Pigs in group 2 were infused 48 hours after ligation of all SAs (T4-L5), and those in group 3 at 120 hours after ligation. Post-mortem CT scanning of the entire pig enabled overall comparisons and measurement of vessel diameters in the spinal cord circulation. Results 14.5±0.8 SAs were ligated: all filled retrograde to the ligature. Paraplegia occurred in 38% of operated pigs. A significant increase in the mean diameter of the anterior spinal artery (ASA) was evident after SA sacrifice (p=<0.0001 for 48h and 120h). The internal thoracic and intercostal arteries also increased in diameter. Quantitative assessment showed an increase in vessel density 48h after ligation of SAs, reflected by an obvious increase in small collateral vessels seen on 3-D reconstructions of CT scans at 120h. Conclusions Remodeling of the spinal cord blood supply—including dilatation of the ASA and proliferation of small collateral vessels—is evident at 48 and 120 hours after extensive SA sacrifice. It is likely that exploitation of this process will prove valuable in the quest to eliminate paraplegia after TAAA repair.

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Staged repair significantly reduces paraplegia rate after extensive thoracoabdominal aortic aneurysm repair

Abstract: A staged approach to extensive thoracoabdominal aortic aneurysm repair may reduce the incidence of spinal cord injury. This is of particular importance in designing strategies involving hybrid or entirely endovascular procedures.

Cited by 182 publications

References 26 publications

Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair

Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair

Endovascular coil embolization of segmental arteries prevents paraplegia after subsequent thoracoabdominal aneurysm repair: An experimental model

Imaging of vascular remodeling after simulated thoracoabdominal aneurysm repair

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