The Impact of Early Pelvic and Lower Limb Reperfusion and Attentive Peri-operative Management on the Incidence of Spinal Cord Ischemia During Thoracoabdominal Aortic Aneurysm Endovascular Repair

Abstract

Objective/background: Spinal cord ischemia (SCI) is a devastating complication following endovascular thoracoabdominal aortic aneurysm (TAAA) repair. In an attempt to reduce its incidence two peri-procedural changes were implemented by the authors in January 2010: (i) all large sheaths are withdrawn from the iliac arteries immediately after deploying the central device and before cannulation and branch extension to the visceral vessels; (ii) the peri-operative protocol has been modified in an attempt to optimize oxygen delivery to the sensitive cells of the cord (aggressive blood and platelet transfusion, median arterial pressure monitoring >85 mmHg, and systematic cerebrospinal fluid drainage).Methods: Between October 2004 and December 2013, 204 endovascular TAAA repairs were performed using custom made devices manufactured with branches and fenestrations to maintain visceral vessel perfusion. Data from all of these procedures were prospectively collected in an electronic database. Early post-operative results in patients treated before (group 1, n ¼ 43) and after (group 2, n ¼ 161 patients) implementation of the modified implantation and peri-operative protocols were compared.Results: Patients in groups 1 and 2 had similar comorbidities (median age at repair 70.9 years [range 65.2e77.0 years]), aneurysm characteristics (median diameter 58.5 mm [range 53e65 mm]), and length of procedure (median 190 minutes [range 150e240 minutes]). The 30 day mortality rate was 11.6% in group 1 versus 5.6% in group 2 (p ¼ .09). The SCI rate was 14.0% versus 1.2% (p < .01). If type IV TAAAs were excluded from this analysis, the SCI rate was 25.0% (6/24 patients) in group 1 versus 2.1% (2/95 patients) in group 2 (p < .01). Conclusion:The early restoration of arterial flow to the pelvis and lower limbs, and aggressive peri-operative management significantly reduces SCI following type IeIII TAAA endovascular repair. With the use of these modified protocols, extensive TAAA endovascular repairs are associated with low rates of SCI.

Standard “off-the-shelf” multibranched thoracoabdominal endograft in urgent and elective patients with single and staged procedures in a multicenter experience

“…The outcome was also lower than in other CSG cohorts (range, 7%-11.6%). 18,[21][22][23] At a mean follow-up of 18 months, eight (11%) additional deaths of patients were recorded. Independent factors associated with mortality were urgent/emergent repair and female gender.…”

“…The authors, in accordance with others, 14,27 advise 24-to 48-hour postoperative intensive care for all patients. Interesting techniques designed to reduce SCI risk have been reported, 18,22 including the temporary perfusion sac concept (staged approach) 18 and early perfusion restoration to the pelvis and lower limbs. 22 Furthermore, Bisdas et al 27 demonstrated that prophylactic CSFD did not prevent all cases of SCI.…”

Editor's Choice – Management of Descending Thoracic Aorta Diseases

“…The rationale for this approach grew out of the promising initial experience with fenestrated grafts, which were developed to treat juxta-renal aneurysms by endovascular means. 239 Preservation of visceral flow is achieved by means of either fenestrations or branches or a combination of both on the component deployed in the region of the visceral arteries. The aortic anatomy is still a limiting factor, but the progress in imaging and device conception has begun to overcome this challenge.…”

Strategies to Minimize Risk of Spinal Cord Injury During Complex Endovascular Aortic Repair

“…Improvements in device design, techniques of implantation, adjunctive measures, and better perioperative care have resulted in substantial improvements in morbidity and mortality [1]. Contemporary reports by experienced operators indicate that 30-day mortality ranges from 5 to 9 %, which compares favorably to the largest open surgical experiences in centers with over thousands of repairs [1][2][3][4][5]. Nonetheless, spinal cord injury (SCI) continues to be the most devastating complication of these procedures with rates reaching up to 35 % in some series [1].…”

“…These collaterals include the carotid, subclavian, vertebral, intercostal, lumbar, hypogastric, and deep femoral arteries ( Fig. 20.1) [2,5,10,11]. As such, pre-operative, intraoperative, and post-operative strategies can be applied to maximize spinal cord perfusion and decrease risk of SCI.…”