Spinal cord ischaemia following TEVAR Prediction, Prevention & Management

Oliver Zuzan, MD MPhil FRCA Consultant in Anaesthesia and Critical Care Royal Liverpool University Hospital

Risk factors

n  Length of aorta covered n Hypotension n Previous or concomitant abdominal repair n  +/- Occlusion of left subclavian artery

Prophylactic CSF drainage

n Previous aortic surgery n Combined procedures (e.g. open AAA

repair + TEVAR) n  Long graft needed (20cm and above) n High-risk vascular anatomy on pre-op

angiogram

Prophylactic CSF drainage in open thoracic aneurysm repair

Khan SN, Stansby G. Cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery. Cochrane database of systematic reviews. [Review]. 2004(1):CD003635.

Ann Thorac Surg 2009 Jul;88(1):9-15

Complications of CSF drainage

n  24 of out 486 patients (5%) had bloody spinal fluid: ¨ No evidence of intracranial hemorrhage: 7 (1.4%) ¨  Intracranial blood without neurologic deficit: 14 (2.9%) ¨  Intracranial bleeding with neurologic deficits: 3 (0.6%)

Wynn MM, Mell MW, Tefera G, Hoch JR, Acher CW. Complications of spinal fluid drainage in thoracoabdominal aortic aneurysm repair: a report of 486 patients treated from 1987 to 2008. J Vasc Surgery 2009 Jan;49(1):29-34.

Prophylactic versus therapeutic CSF drainage for thoracic endografts Prophylaxis n  No therapeutic interval,

better chance of complete recovery

n  Higher numbers = safer system

n  Better awareness of problem

n  Strong evidence base in open surgery

Treatment n  Less patients exposed to

procedural risk of CSF drainage

n  Cheaper n  Quicker mobilisation n  Prophylaxis may not

prevent delayed onset SCI

Signs and Symptoms

n Sensory deficits (not necessarily typical “level” distribution, can be unilateral)

n Back pain n  Loss of deep tendon reflexes n Heavy legs n Decreased muscle power n Paraplegia

Management

n EMERGENCY! n Blood pressure augmentation (MAP

>90mmHg) n CSF drainage (CSF pressure <10mmHg)

Induced endoleak n  Branched EVAR for TAAA n  Early post-op leg weakness n  CSF drainage plus BP-augmentation: resolution

of symptoms but further episodes of paraplegia n  Stent between distal end of infra-renal graft and

aortic wall (distal endoleak): complete resolution n  Stent closed/occluded 3.5 months later n  No recurrence of spinal cord ischaemia

Reilly LM, Chuter TA. Reversal of fortune: induced endoleak to resolve neurological deficit after endovascular repair of thoracoabdominal aortic aneurysm. J Endovasc Ther. 2010 Feb;17(1):21-9.

n  We retrieved data from 99 studies incorporating 4906 patients. n  Incidences of left-arm ischaemia (0.0% vs 9.2%, p = 0.002) and stroke

(4.7% vs 7.2%, p < 0.001) were significantly less following revascularisation, although mortality (10.5% vs 3.4%, p = 0.032) and endoleak incidence (25.8% vs 12.6%, p = 0.008) were increased.

n  No significant differences in spinal-cord ischaemia were seen. n  Revascularisation may reduce downstream ischaemic complications but

can cause significant risk. Indications must be carefully considered on an individual patient basis.