1
|
Berger C, Greiner A, Brandhorst P, Reimers SC, Kniesel O, Omran S, Treskatsch S. How Would I Treat My Own Thoracoabdominal Aortic Aneurysm: Perioperative Considerations From the Anesthesiologist Perspective. J Cardiothorac Vasc Anesth 2024; 38:1092-1102. [PMID: 38310068 DOI: 10.1053/j.jvca.2023.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 12/12/2023] [Accepted: 12/16/2023] [Indexed: 02/05/2024]
Abstract
A thoracoabdominal aortic aneurysm (TAAA) can be potentially life-threatening due to its associated risk of rupture. Thoracoabdominal aortic aneurysm repair, performed as endovascular repair and/or open surgery, is the recommended therapy of choice. Hemodynamic instability, severe blood loss, and spinal cord or cerebral ischemia are some potential hazards the perioperative team has to face during these procedures. Therefore, preoperative risk assessment and intraoperative anesthesia management addressing these potential hazards are essential to improving patients' outcomes. Based on a presented index case, an overview focusing on anesthetic measures to identify perioperatively and manage these risks in TAAA repair is provided.
Collapse
Affiliation(s)
- Christian Berger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Berlin, Germany
| | - Andreas Greiner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Vascular Surgery, Berlin, Germany
| | - Philipp Brandhorst
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Berlin, Germany
| | - Sophie Claire Reimers
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Berlin, Germany
| | - Olaf Kniesel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Berlin, Germany
| | - Safwan Omran
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Vascular Surgery, Berlin, Germany
| | - Sascha Treskatsch
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Berlin, Germany.
| |
Collapse
|
2
|
Raulli SJ, Gomes VC, Parodi FE, Vasan P, Sun D, Marston WA, Pascarella L, McGinigle KL, Wood JC, Farber MA. Five-year outcomes of fenestrated and branched endovascular repair of complex aortic aneurysms based on aneurysm extent. J Vasc Surg 2024:S0741-5214(24)00959-5. [PMID: 38608964 DOI: 10.1016/j.jvs.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/31/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE The aim of this study was to evaluate the 5-year outcomes of fenestrated/branched endovascular aortic repair (F/BEVAR) for the treatment of complex aortic aneurysms stratified by the aneurysm extent. METHODS Patients with the diagnosis of complex aortic aneurysm, who underwent F/BEVAR at a single center were included in this study and retrospectively analyzed. The cohort was divided according to the aneurysm extent, comparing group 1 (types I-III thoracoabdominal aneurysms [TAAAs]), group 2 (type IV TAAAs), and group 3 (juxtarenal [JRAAs], pararenal [PRAAs], or paravisceral [PVAAs] aortic aneurysms). The primary endpoints were 30-day and 5-year survival. The secondary endpoints were technical success, occurrence of spinal cord ischemia, primary patency of the visceral arteries, freedom from target vessel instability, and secondary interventions. RESULTS Of 436 patients who underwent F/BEVAR between July 2012 and May 2023, 131 presented with types I to III TAAAs, 69 with type IV TAAAs, and 236 with JRAAs, PRAAs, or PVAAs. All cases were treated under a physician-sponsored investigational device exemption protocol with a patient-specific company-manufactured or off-the-shelf device. Group 1 had significantly younger patients than group 2 or 3 respectively (69.6 ± 8.7 vs 72.4 ± 7.1 vs 73.2 ± 7.3 years; P < .001) and had a higher percentage of females (50.4% vs 21.7% vs 17.8%; P < .001). Prior history of aortic dissection was significantly more common among patients in group 1 (26% vs 1.4% vs 0.9%; P < .001), and mean aneurysm diameter was larger in group 1 (64.5 vs 60.7 vs 63.2 mm; P = .033). Comorbidities were similar between groups, except for coronary artery disease (P < .001) and tobacco use (P = .003), which were less prevalent in group 1. Technical success was similar in the three groups (98.5% vs 98.6% vs 98.7%; P > .99). The 30-day mortality was 4.5%, 1.4%, and 0.4%, in groups 1, 2, and 3, respectively, and was significantly higher in group 1 when compared with group 3 (P = .01). The incidence of spinal cord ischemia was significantly higher in group 1 compared with group 3 (5.3% vs 4.3% vs 0.4%; P = .004). The 5-year survival was significantly higher in group 3 when compared with group 1 (P = .01). Freedom from secondary intervention was significantly higher in group 3 when compared with group 1 (P = .003). At 5 years, there was no significant difference in freedom from target vessel instability between groups or primary patency in the 1652 target vessels examined. CONCLUSIONS Larger aneurysm extent was associated with lower 5-year survival, higher 30-day mortality, incidence of secondary interventions, and spinal cord ischemia. The prevalence of secondary interventions in all groups makes meticulous follow-up paramount in patients with complex aortic aneurysm treated with F/BEVAR.
Collapse
Affiliation(s)
- Stephen J Raulli
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.
| | - Vivian Carla Gomes
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - F Ezequiel Parodi
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Priya Vasan
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Dichen Sun
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - William A Marston
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Luigi Pascarella
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Katharine L McGinigle
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Jacob C Wood
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| |
Collapse
|
3
|
Blakeslee-Carter J, Novak Z, Jansen JO, Schanzer A, Eagleton MJ, Farber MA, Gasper W, Lee WA, Oderich GS, Timaran CH, Schneider DB, Sweet MP, Beck AW. Prospective randomized pilot trial comparing prophylactic vs therapeutic cerebrospinal fluid drainage during complex endovascular thoracoabdominal aortic aneurysm repair. J Vasc Surg 2024:S0741-5214(24)00429-4. [PMID: 38614137 DOI: 10.1016/j.jvs.2024.02.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Endovascular techniques have transformed the management of thoracoabdominal aortic aneurysms (TAAAs). However, spinal cord ischemia (SCI) remains a prevalent and devastating complication. Prophylactic drainage of cerebrospinal fluid (CSF) is among the proposed strategies for prevention of SCI. Although prophylactic CSF drainage is widely used and conceptually attractive, prophylactic CSF drains have not been demonstrated to definitively prevent the occurrence nor mitigate the severity of SCI in endovascular TAAA repair. Whether or not outcomes of prophylactic drains are superior to therapeutic drains remains unknown. This pilot study was performed to determine the feasibility of a randomized clinical trial designed to investigate the role of prophylactic vs therapeutic CSF drains in the prevention of SCI in patients undergoing endovascular TAAA repair using branched and fenestrated endovascular aortic repair (FBEVAR). METHODS This was a prospective multicenter randomized pilot clinical trial conducted at The University of Alabama at Birmingham and The University of Massachusetts. Twenty patients were enrolled and randomized to either the prophylactic drainage or therapeutic drainage groups, prior to undergoing FBEVAR for extensive TAAAs and arch aortic aneurysms. This was a pilot feasibility study that was not powered to detect statistical differences in clinical outcomes. The primary outcome was feasibility of randomization and compliance with a shared lumbar drain protocol. Secondary outcomes included rate of drain complications and SCI. RESULTS Twenty patients were enrolled and successfully randomized, without any crossovers, to either the control cohort (n = 10), without prophylactic drains, or the experimental cohort (n = 10), with prophylactic drains. There were no differences in age, comorbidities, or history of prior aortic surgery across the cohorts. All patients were treated with FBEVAR. Aneurysm classifications were as follows: Extent I (10%), Extent II (50%), Extent III (35%), and Extent IV (5%). The average length of aortic coverage was 207 ± 21.6 mm. The length of aortic coverage did not vary across cohorts, nor did procedural times or blood loss volume. Compliance with the SCI prevention protocol was 100% across both groups. Within the prophylactic drain cohort, one patient experienced an adverse event related to lumbar drain placement, manifested as an epidural hematoma requiring laminectomy, without neurologic deficit (n = 1/10; 10%). There was one SCI event (n = 1/20; 5%), which occurred in the prophylactic drain cohort on postoperative day 9 following an episode of hypotension related to a gastrointestinal bleed. CONCLUSIONS The role of prophylactic CSF drains for the prevention of SCI following endovascular TAAA repair is a topic of ongoing research, with many current practices based on expert opinion and experience, rather than rigorous scientific data. This study demonstrates the feasibility of a multicenter randomized clinical trial to evaluate the role of prophylactic vs therapeutic CSF drains in the prevention of SCI in patients undergoing endovascular TAAA repair.
Collapse
Affiliation(s)
| | - Zdenek Novak
- Division of Vascular Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jan O Jansen
- Division of Vascular Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Andres Schanzer
- Division of Vascular Surgery, University of Massachusetts (UMass) Memorial Medical Center, Worcester, MA
| | - Matthew J Eagleton
- Division of Vascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Mark A Farber
- Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC
| | - Warren Gasper
- Division of Vascular Surgery, University of California at San Francisco, San Franscisco, CA
| | - W Anthony Lee
- Division of Vascular Surgery, Baptist Health Medical Group, Boca Raton, FL
| | - Gustavo S Oderich
- Division of Vascular Surgery, University of Texas Health Science Center, Houston, TX
| | - Carlos H Timaran
- Division of Vascular Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Darren B Schneider
- Division of Vascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Matthew P Sweet
- Division of Vascular Surgery, University of Washington Medical Center, Seattle, WA
| | - Adam W Beck
- Division of Vascular Surgery, University of Alabama at Birmingham, Birmingham, AL.
| |
Collapse
|
4
|
Lee A, Katznelson R, Ouzounian M, Au D, Chung J, Djaiani G, Lindsay T. Adjunctive hyperbaric oxygen therapy for spinal cord ischemia after complex aortic repair. J Vasc Surg 2024; 79:478-484. [PMID: 37925040 DOI: 10.1016/j.jvs.2023.10.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/17/2023] [Accepted: 10/20/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVE Spinal cord ischemia (SCI) with paraplegia or paraparesis is a devastating complication of complex aortic repair (CAR). Treatment includes cerebrospinal fluid drainage, maintenance of hemoglobin concentration (>10 g/L), and elevating mean arterial blood pressure. Animal and human case series have reported improvements in SCI outcomes with hyperbaric oxygen therapy (HBOT). We reviewed our center's experience with HBOT as a rescue treatment for spinal cord ischemia post-CAR in addition to standard treatment. METHODS A retrospective review of the University Health Network's Hyperbaric Medicine Unit treatment database identified HBOT sessions for patients with SCI post-CAR between January 2013 and June 2021. Mean estimates of overall motor function scores were determined for postoperative, pre-HBOT, post-HBOT (within 4 hours of the final HBOT session), and at the final assessment (last available in-hospital evaluation) using a linear mixed model. A subgroup analysis compared the mean estimates of overall motor function scores between improvement and non-improvement groups at given timepoints. Improvement of motor function was defined as either a ≥2 point increase in overall muscle function score in patients with paraparesis or an upward change in motor deficit categorization (para/monoplegia, paraparesis, and no deficit). Subgroup analysis was performed by stratifying by improvement or non-improvement of motor function from pre-HBOT to final evaluation. RESULTS Thirty patients were treated for SCI. Pre-HBOT, the motor deficit categorization was 10 paraplegia, three monoplegia, 16 paraparesis, and one unable to assess. At the final assessment, 14 patients demonstrated variable degrees of motor function improvement; eight patients demonstrated full motor function recovery. Seven of the 10 patients with paraplegia remained paraplegic despite HBOT. The estimated mean of overall muscle function score for pre-HBOT was 16.6 ± 2.9 (95% confidence interval [CI], 10.9-22.3) and for final assessment was 23.4 ± 2.9 (95% CI, 17.7-29.1). The estimated mean difference between pre-HBOT and final assessment overall muscle function score was 6.7 ± 3.1 (95% CI, 0.6-16.1). The estimated mean difference of the overall muscle function score between pre-HBOT and final assessment for the improved group was 16.6 ± 3.5 (95% CI, 7.5-25.7) vs -4.9 ± 4.2 (95% CI, -16.0 to 6.2) for the non-improved group. CONCLUSIONS HBOT, in addition to standard treatment, may potentially improve recovery in spinal cord function following SCI post-CAR. However, the potential benefits of HBOT are not equally distributed among subgroups.
Collapse
Affiliation(s)
- Angela Lee
- Division of Vascular Surgery, Toronto General Hospital, Toronto, Ontario, Canada.
| | - Rita Katznelson
- Hyperbaric Medicine Unit, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Darren Au
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jennifer Chung
- Division of Cardiac Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - George Djaiani
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Thomas Lindsay
- Division of Vascular Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| |
Collapse
|
5
|
Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K, Siepe M, Estrera AL, Bavaria JE, Pacini D, Okita Y, Evangelista A, Harrington KB, Kachroo P, Hughes GC. EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ. Ann Thorac Surg 2024:S0003-4975(24)00077-8. [PMID: 38416090 DOI: 10.1016/j.athoracsur.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany.
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria; Medical Faculty, Sigmund Freud Private University, Vienna, Austria.
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France; EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy; Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, Texas
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany; The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany; Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
| | - Matthias Siepe
- EACTS Review Coordinator; Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Anthony L Estrera
- STS Review Coordinator; Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Joseph E Bavaria
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Davide Pacini
- Division of Cardiac Surgery, S. Orsola University Hospital, IRCCS Bologna, Bologna, Italy
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Barcelona, Spain; Biomedical Research Networking Center on Cardiovascular Diseases, Instituto de Salud Carlos III, Madrid, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; Instituto del Corazón, Quirónsalud-Teknon, Barcelona, Spain
| | - Katherine B Harrington
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Puja Kachroo
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Duke University, Durham, North Carolina
| |
Collapse
|
6
|
Mahmood DN, Rocha R, Ouzounian M, Teng Tan K, Forbes SM, Chung JCY, Lindsay TF. Thoracoabdominal Aortic Aneurysm Repair Using Fenestrated and Branched Endovascular Grafts for High-Risk Patients: Evolving yet Safe. J Endovasc Ther 2024:15266028241229005. [PMID: 38339966 DOI: 10.1177/15266028241229005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
PURPOSE The purpose was to investigate outcomes of high-risk patients undergoing thoracoabdominal aortic aneurysm (TAAA) repair using fenestrated or branched endovascular aneurysm repair (F/BEVAR) devices at a single center in Canada. MATERIALS AND METHODS A retrospective review of all patients undergoing endovascular TAAA repair with F/BEVAR from June 2007 to July 2020. Imaging and clinical endpoints of interest including death, reintervention, and target vessel patency were reported. RESULTS Ninety-five consecutive patients underwent endovascular TAAA repair using F/BEVAR stent grafts (63 males, median age 74 [interquartile range 70, 78] years). Repairs included 81 elective and 14 urgent/emergent cases (6 ruptures and 8 symptomatic). Graft deployment was 100% successful. Intraoperative target vessel revascularization was successful in 336/355 (94.6%) vessels with the celiac having the lowest success rate 72/82 (87.8%). In-hospital mortality was 9.5% (7.4% elective and 21.4% urgent/emergent, p=0.125) and permanent paraplegia was 4.2% (3.7% elective and 7.1% urgent/emergent, p=0.458). In-hospital complications included stroke in 5.3%, acute myocardial infarction in 8.4%, and bowel ischemia in 5.3%. No patients required permanent dialysis or tracheostomy during their hospital stay. However, 22 (23.2%) patients required additional unplanned procedures for various indications (branch occlusion, endoleaks, realignment) during their hospital stay. Patients were followed up for a mean of 3.6 ± 3.0 years. Clinical follow-up was 100%, with 80/86 (93%) having surveillance imaging. On follow-up imaging, 43 (50%) patients had at least 1 endoleak identified and 337/341 (98.8%) of the target vessels were found to be patent. At 5 years, cumulative probability of reintervention was 46.3% (95% confidence interval [CI], 36.1-56.4). Survival at 5 and 8 years was 50.1% (95% CI, 38.4-65.4) and 34.4% (95% CI, 22.5-52.8), respectively. Progression of aneurysmal disease leading to rupture on follow-up was confirmed in 1 patient at 10 years. CONCLUSION Endovascular TAAA repair provides a safe treatment option with a high technical success rate and low pulmonary and renal complications. Long-term survival is similar to previous literature; however, high rates of secondary reintervention reaffirm the need for ongoing patient follow-up and further technical improvements. CLINICAL IMPACT This study demonstrates that endovascular repair of TAAAs can be performed in a high-risk elderly population with acceptable rates of mortality, TALE and SCI, using evolving technology. The incidences of post-operative respiratory failure and renal dysfunction were lower in patients who underwent endovascular repair compared with open repair. Future technical and procedural refinements in addition to increasing surgical experience are expected to lead to further improvements in short- and long-term outcomes exceeding those of open repair.
Collapse
Affiliation(s)
- Daniyal N Mahmood
- Division of Vascular Surgery, Department of Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Rodolfo Rocha
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kong Teng Tan
- Division of Interventional Radiology, Toronto General Hospital, Toronto, ON, Canada
| | - Samantha M Forbes
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jennifer C-Y Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Department of Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
7
|
Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K. EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg 2024; 65:ezad426. [PMID: 38408364 DOI: 10.1093/ejcts/ezad426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/15/2023] [Accepted: 12/19/2023] [Indexed: 02/28/2024] Open
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria
- Medical Faculty, Sigmund Freud Private University, Vienna, Austria
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France
- EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
- Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, TX, USA
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany
- The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
| |
Collapse
|
8
|
Jadhav AP. Vascular Myelopathies. Continuum (Minneap Minn) 2024; 30:160-179. [PMID: 38330477 DOI: 10.1212/con.0000000000001378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE Vascular injuries of the spinal cord are less common than those involving the brain; however, they can be equally devastating. This article discusses the diagnosis and management of ischemic and hemorrhagic vascular disorders of the spinal cord. LATEST DEVELOPMENTS Clinical suspicion remains the mainstay for recognizing vascular myelopathies, yet diagnoses are often delayed and challenging in part because of their rarity and atypical manifestations. Noninvasive imaging such as CT and MRI continues to improve in spatial resolution and diagnostic precision; however, catheter-based spinal angiography remains the gold standard for defining the spinal angioarchitecture. In addition to hemorrhagic and ischemic disease, the contribution of venous dysfunction is increasingly appreciated and informs treatment strategies in conditions such as intracranial hypotension. ESSENTIAL POINTS Vascular disorders of the spine manifest in variable and often atypical ways, which may lead to delayed diagnosis. Increased awareness of these conditions is critical for early recognition and treatment. The goal of treatment is to minimize long-term morbidity and mortality.
Collapse
|
9
|
Sulzer TAL, Vacirca A, Mesnard T, Baghbani-Oskouei A, Savadi S, Kanamori LR, van Lier F, de Bruin JL, Verhagen HJM, Oderich GS. How We Would Treat Our Own Thoracoabdominal Aortic Aneurysm. J Cardiothorac Vasc Anesth 2024; 38:379-387. [PMID: 38042741 DOI: 10.1053/j.jvca.2023.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/15/2023] [Accepted: 10/24/2023] [Indexed: 12/04/2023]
Abstract
This manuscript is intended to provide a comprehensive review of the current state of knowledge on endovascular repair of thoracoabdominal aortic aneurysms (TAAAs). The management of these complex aneurysms requires an interdisciplinary and patient-specific approach in high-volume centers. An index case is used to discuss the diagnosis and treatment of a patient undergoing fenestrated-branched endovascular aneurysm repair for a TAAA.
Collapse
Affiliation(s)
- Titia A L Sulzer
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Andrea Vacirca
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Thomas Mesnard
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Aidin Baghbani-Oskouei
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Safa Savadi
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Lucas Ruiter Kanamori
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Felix van Lier
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gustavo S Oderich
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX.
| |
Collapse
|
10
|
Katsarou M, Auyang PL, Chinnadurai P, Bismuth J. "Octafen": A Noninvestigational Alternative Endograft Configuration for the Treatment of Thoracoabdominal Aortic Aneurysms. J Endovasc Ther 2024; 31:19-25. [PMID: 35869618 DOI: 10.1177/15266028221113752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Abstract
PURPOSE To demonstrate the feasibility of Octafen technique, a novel endovascular configuration for the treatment of thoracoabdominal aortic aneurysms (TAAA). TECHNIQUE Two patients with complex TAAA and high surgical risk were treated with Octafen endograft configuration in a hybrid operating room with computed tomography (CT)-fluoroscopy image fusion guidance, using 3D-3D fusion techniques to facilitate procedural success. The procedure is a modification of the previously-described Octopus technique for endovascular repair of TAAA. The main advantage of this technique is the ability to use devices to repair a TAAA with the combination of off-the-shelf and noninvestigational custom-made devices. The devices used are readily available to most practicing vascular surgeons, which provides an alternative treatment in case of limited access to investigational devices, in time-sensitive cases, and in patients with limited functional capacity who cannot undergo open repair. In the modification described herein, we use a combination of standard bifurcated endovascular aneurysm repair (EVAR) devices (Excluder; W.L. Gore & Associates, Flagstaff, Arizona) in combination with a 2-vessel renal fenestrated device (Z-Fen; Cook Medical, Bloomington, Indiana). The article describes a step-by-step approach to this technique to elucidate pitfalls, benefits, and advantages. CONCLUSION The Octafen technique might offer an alternative option for thoracoabdominal aneurysm treatment circumventing the need for access to custom-made, investigational devices. CLINICAL IMPACT In this manuscript, we describe a technique for endovascular repair of thoraco-abdominal aortic aneurysms that involves the combination of off-the-shelf and non-investigational, custom-made devices. The 'Octafen' technique provides a treatment alternative in case of limited access to investigational devices and can be adjusted according to patient anatomy.
Collapse
Affiliation(s)
- Maria Katsarou
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
- Section of Vascular Surgery, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Philip L Auyang
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Ponraj Chinnadurai
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
- Advanced Therapies, Siemens Medical Solutions, Malvern, PA, USA
| | - Jean Bismuth
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| |
Collapse
|
11
|
Seike Y, Nishii T, Yoshida K, Yokawa K, Masada K, Inoue Y, Fukuda T, Matsuda H. Covering the intercostal artery branching of the Adamkiewicz artery during endovascular aortic repair increases the risk of spinal cord ischemia. JTCVS OPEN 2024; 17:14-22. [PMID: 38420547 PMCID: PMC10897655 DOI: 10.1016/j.xjon.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/14/2023] [Accepted: 11/20/2023] [Indexed: 03/02/2024]
Abstract
Objectives This study aimed to determine the relationship between covering the intercostal artery branching of the Adamkiewicz artery (ICA-AKA) and spinal cord ischemia (SCI) during thoracic endovascular aortic repair (TEVAR). Methods Patients who underwent TEVAR from 2008 to 2022 were enrolled. Stent grafts covered the ICA-AKA in 108 patients (covered AKA group) and stent grafts didn't cover the ICA-AKA in 114 patients (uncovered AKA group). The characteristics of 58 patients from each group were matched based on propensity scores. Results No significant differences in SCI rates were detected between the covered AKA (10%; 11/108) and uncovered AKA (3.5%; 4/114) groups (P = .061). Shaggy aorta (odds ratio [OR], 5.16; 95% confidence interval [CI], 1.74-15.3, P = .003), iliac artery access (OR, 6.81; 95% CI, 2.22-20.9, P = .001), and procedural time (OR, 1.01; 95% CI, 1.00-1.02, P = .003) were risk factors for SCI in the entire cohort. Although covering the ICA-AKA (OR, 2.60; 95% CI, 0.86-7.88, P = .058) was not a significant risk factor, shaggy aorta (OR, 8.15; 95% CI, 2.07-32.1, P = .003), iliac artery access (OR, 9.09; 95% CI, 2.22-37.2, P = .002), and procedural time (OR, 1.01; 95% CI, 1.01-1.02, P = .008) were risk factors for SCI in the covered AKA group. No significant risk factors were detected in the uncovered AKA group. Conclusions Covering the ICA-AKA was not an independent risk for SCI in TEVAR. However, covering the ICA-AKA was indirectly associated with the risk of SCI in patients with shaggy aorta, iliac access, and procedural time.
Collapse
Affiliation(s)
- Yoshimasa Seike
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tatsuya Nishii
- Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazufumi Yoshida
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Koki Yokawa
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kenta Masada
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yosuke Inoue
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| |
Collapse
|
12
|
Kelly H, Herman D, Loo K, Narangoli A, Watson E, Berlant C, Huerta M, Labak CM, Zhou X. Recognition of Significantly Delayed Spinal Cord Ischemia Following Thoracic Endovascular Aortic Repair: A Case Report and Review of the Literature. Cureus 2024; 16:e51522. [PMID: 38304669 PMCID: PMC10831204 DOI: 10.7759/cureus.51522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2023] [Indexed: 02/03/2024] Open
Abstract
Spinal cord ischemia (SCI) is an uncommon but serious complication of thoracic endovascular aortic repair (TEVAR). SCI after TEVAR is thought to result from decreased segmental blood supply to an important network of collateral blood flow in the spinal cord. Little is known about the prevalence and optimal treatment of SCI that occurs beyond the periprocedural period. We report a case of delayed SCI in a 67-year-old patient who underwent TEVAR. The patient presented almost two years after TEVAR with acute paraplegia preceded by pre-syncope. The delayed SCI was likely triggered by pre-syncope, a thrombosed endoleak shown on imaging, and the patient's vascular risk factors. Treatments included cerebrospinal fluid (CSF) drainage, mean arterial pressure (MAP) augmentation, and a naloxone infusion, which resulted in moderate recovery in lower extremity motor function. This case highlights the tenuous nature of spinal cord perfusion after TEVAR and that prompt recognition and early treatment of SCI are critical in preventing the progression from ischemia to infarction.
Collapse
Affiliation(s)
- Hannah Kelly
- Neurology, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Danielle Herman
- Neurology, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Kiana Loo
- Neurology, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Adeeb Narangoli
- Neurology, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Emily Watson
- Neurology, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Corey Berlant
- Emergency Medicine, University Hospitals St. John Medical Center, Westlake, USA
| | - Mina Huerta
- Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Collin M Labak
- Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Xiaofei Zhou
- Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, USA
| |
Collapse
|
13
|
Brisard L, El Batti S, Borghese O, Maurel B. Risk Factors for Spinal Cord Injury during Endovascular Repair of Thoracoabdominal Aneurysm: Review of the Literature and Proposal of a Prognostic Score. J Clin Med 2023; 12:7520. [PMID: 38137589 PMCID: PMC10743399 DOI: 10.3390/jcm12247520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
Despite recent improvements, spinal cord ischemia remains the most feared and dramatic complication following extensive aortic repair. Although endovascular procedures are associated with a lower risk compared with open procedures, this risk is still significant and must be considered. A combined medical and surgical approach may help to optimize the tolerance of the spinal cord to ischemia. The aim of this review is to describe the underlying mechanism involved in spinal cord injury during extensive endovascular aortic repair, to describe the different techniques used to improve spinal cord tolerance to ischemia-including the prophylactic or curative use of spinal drainage-and to propose our algorithm for spinal cord protection and the rational use of spinal drainage.
Collapse
Affiliation(s)
- Laurent Brisard
- Department of Anesthesiology and Critical Care, Laënnec Hospital, University Hospital of Nantes, F-44000 Nantes, France;
| | - Salma El Batti
- Department of Vascular and Endovascular Surgery, Hôpital Européen Georges Pompidou—Hôpitaux de Paris, Université de Paris Cité, F-75015 Paris, France;
| | - Ottavia Borghese
- Department of Cardiac and Vascular Surgery, L’Institut du Thorax, Nantes University Hospital, F-44093 Nantes, France;
| | - Blandine Maurel
- Department of Cardiac and Vascular Surgery, L’Institut du Thorax, Nantes University Hospital, F-44093 Nantes, France;
- Inserm UMR 1087/CNRS UMR 6291, L’Institut du Thorax, Université de Nantes, F-44000 Nantes, France
| |
Collapse
|
14
|
Reinfeld ST, Blakeslee-Carter J, Beck AW. Retrograde aortic dissection following fenestrated and branched endovascular aortic repair for an extent III thoracoabdominal aneurysm. J Vasc Surg Cases Innov Tech 2023; 9:101329. [PMID: 37928560 PMCID: PMC10624575 DOI: 10.1016/j.jvscit.2023.101329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 08/31/2023] [Indexed: 11/07/2023] Open
Abstract
Retrograde aortic dissection is a rare but potentially catastrophic complication after endovascular aortic repair. Reports in the literature regarding retrograde dissection after fenestrated and branched endovascular abdominal aortic repair are rare, and the incidence, risk factors, and treatment options for this complication have not yet been clearly established. Additionally, retrograde dissection after previous intervention can pose technical challenges and increases the risk of spinal cord ischemia during subsequent repair. We present a patient with an acute retrograde dissection after a fenestrated and branched endovascular aortic repair for an extent III thoracoabdominal aortic aneurysm successfully managed with proximal endovascular extension.
Collapse
Affiliation(s)
- Susanne T. Reinfeld
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Juliet Blakeslee-Carter
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Adam W. Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| |
Collapse
|
15
|
Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
Collapse
|
16
|
Locatelli F, Nana P, Le Houérou T, Guirimand A, Nader M, Gaudin A, Bosse C, Fabre D, Haulon S. Spinal cord ischemia rates and prophylactic spinal drainage in patients treated with fenestrated/branched endovascular repair for thoracoabdominal aneurysms. J Vasc Surg 2023; 78:883-891.e1. [PMID: 37315908 DOI: 10.1016/j.jvs.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/01/2023] [Accepted: 06/03/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Spinal cord ischemia (SCI) is a devastating complication after thoracoabdominal aortic aneurysm (TAAA) repair. The benefit of prophylactic cerebrospinal fluid drainage (pCSFD) to prevent SCI is still under investigation. The aim of this study was to evaluate the SCI rate and the impact of pCSFD following complex endovascular repair (fenestrated or branched endovascular repair [F/BEVAR]) for type I to IV TAAA. METHODS The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement was followed. A single-center retrospective study was conducted, including all consecutive patients, managed for TAAA type I to IV using F/BEVAR, between January 1, 2018, and November 1, 2022, for degenerative and post-dissection aneurysms. Patients with juxta- or pararenal aneurysms were excluded, as well as cases managed urgently for aortic rupture or acute dissection. After 2020, pCSFD in type I to III TAAAs was abandoned and replaced by therapeutic CSFD (tCSFD), performed only in patients presenting SCI. The primary outcome was the perioperative SCI rate for the entire cohort and the role of pCSFD for type I to III TAAAs. RESULTS In total, 198 patients were included (mean age, 71.1±3.4 years; 81.8% males), including 50.5% with type I to III TAAA. The primary technical success was 94.9%. The perioperative mortality was 2.5%. and the major adverse cardiovascular event (MACE) rate was 10.6%; 4.5% presented SCI of any type (2.5% paraplegia). When comparing the SCI group with the remaining cohort, patients with SCI presented higher MACE (66.7% vs 7.9%; P < .001) rate and longer intensive care unit stay (3.5 vs 1 day; P = .002). Following type I to III repair, similar SCI, paraplegia, and paraplegia with no recovery rates were reported in the pCSFD and tCSFD groups (7.3% vs 5.1%; P = .66; 4.8% vs 3.3%; P = .72; and 2% vs 0%; P = .37). CONCLUSIONS The incidence of SCI after TAAA I to IV endovascular repair was low. SCI was associated with significantly increased MACE and intensive care unit stay. The prophylactic use of CSFD in type I to III TAAAs was not associated with lower SCI rates and may not be justified routinely.
Collapse
Affiliation(s)
- Federica Locatelli
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France
| | - Petroula Nana
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France
| | - Thomas Le Houérou
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France
| | - Avit Guirimand
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France
| | - Marwan Nader
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France
| | - Antoine Gaudin
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France
| | - Côme Bosse
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France
| | - Dominique Fabre
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France
| | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France.
| |
Collapse
|
17
|
Cirillo-Penn NC, Mendes BC, Tenorio ER, Cajas-Monson LC, D'Oria M, Oderich GS, DeMartino RR. Incidence and risk factors for interval aortic events during staged fenestrated-branched endovascular aortic repair. J Vasc Surg 2023; 78:874-882. [PMID: 37290733 DOI: 10.1016/j.jvs.2023.05.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/26/2023] [Accepted: 05/27/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Staged endovascular repair of complex aortic aneurysms with first-stage thoracic endovascular aortic repair may decrease the risk of spinal cord ischemia (SCI) associated with fenestrated-branched endovascular aortic repair (FB-EVAR) of thoracoabdominal aortic aneurysms or optimize the proximal landing zone in the cases requiring total aortic arch repair. However, a limitation of multistaged procedures is the risk of interval aortic events (IAEs) including mortality from a ruptured aneurysm. We aim to identify the incidence of and risk factors associated with IAEs during staged FB-EVAR. METHODS This was a single-center, retrospective review of patients who underwent planned staged FB-EVAR from 2013 to 2021. Clinical and procedural details were reviewed. End points were the incidence of and risk factors associated with IAEs (defined as rupture, symptoms, and unexplained death) and outcomes in patients with or without IAEs. RESULTS Of 591 planned FB-EVAR patients, 142 underwent first-stage repairs. Twenty-two did not have a planned second stage because of frailty, preference, severe comorbidities, or complications after the first stage and were excluded. The remaining 120 patients (mean age: 73 ± 6 years, 51% female) were planned for second-stage completion FB-EVAR and comprised our cohort. The incidence of IAEs was 13% (16 of 120). This included confirmed rupture in 6 patients, possible rupture in 4, symptomatic presentation in 4, and early unexplained interval death with possible rupture in 2. The median time to IAEs was 17 days (range: 2-101 days), and the median time to uncomplicated completion repairs was 82 days (interquartile range: 30-147 days). Age, sex, and comorbidities were similar between the groups. There were no differences in familial aortic disease, genetically triggered aneurysms, aneurysm extent, or presence of chronic dissection. Patients with IAEs had significantly larger aneurysm diameters than those without IAEs (76.6 vs 66.5 mm, P ≤ .001). This difference persisted with indexing for body surface area (aortic size index: 3.9 vs 3.5 cm/m2, P = .04) and height (aortic height index: 4.5 vs 3.9 cm/m, P ≤ .001). IAE mortality was 69% (11 of 16) compared with no perioperative deaths for those with uncomplicated completion repairs. CONCLUSIONS The incidence of IAEs was 13% in patients planned for staged FB-EVAR. This represented a notable morbidity, including rupture, which must be balanced with SCI and landing zone optimization when planning repair. Larger aneurysms, especially when adjusted for body surface area, are associated with IAEs. Minimizing time between stages vs single-stage repairs for larger (>7 cm) complex aortic aneurysms in patients with reasonable SCI risk should be considered when planning repair.
Collapse
Affiliation(s)
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN; Mayo Clinic Center for Aortic Disorders, Mayo Clinic, Rochester, MN
| | - Emanuel R Tenorio
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, Houston, TX
| | | | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Trieste University Hospital ASUGI, Trieste, Italy
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, Houston, TX
| | - Randall R DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN; Mayo Clinic Center for Aortic Disorders, Mayo Clinic, Rochester, MN.
| |
Collapse
|
18
|
Gedney R, Wooster M. Thoracic Aortic Aneurysms and Arch Disease. Surg Clin North Am 2023; 103:615-627. [PMID: 37455028 DOI: 10.1016/j.suc.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Aortic arch and descending thoracic pathology have historically remained in the realm of open surgical repair. Technology is quickly pushing to bring these under the endovascular umbrella, with lower morbidity repairs proving safe in their early experience. Much work remains particularly for acute aortic syndromes, however, to understand who is best treated medically, surgically, endovascularly, or with hybrid approaches.
Collapse
Affiliation(s)
- Ryan Gedney
- Medical University of South Carolina, 30 Courtenay Drive, MSC 25, STE 654, Charleston, SC 29924, USA
| | - Mathew Wooster
- Division of Vascular Surgery, Medical University of South Carolina, 30 Courtenay Drive, MSC 25, Suite 654, Charleston, SC 29924, USA.
| |
Collapse
|
19
|
Aucoin VJ, Motyl CM, Novak Z, Eagleton MJ, Farber MA, Gasper W, Oderich GS, Mendes B, Schanzer A, Tenorio E, Timaran CH, Schneider DB, Sweet MP, Zettervall SL, Beck AW. Predictors and Outcomes of Spinal Cord Injury following Complex Branched/Fenestrated Endovascular Aortic Repair in the US Aortic Research Consortium. J Vasc Surg 2023; 77:1578-1587. [PMID: 37059239 DOI: 10.1016/j.jvs.2023.01.205] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/22/2023] [Accepted: 01/23/2023] [Indexed: 04/16/2023]
Abstract
OBJECTIVE Spinal cord ischemia (SCI) is a well-known complication of thoracoabdominal aortic aneurysm (TAAA) repair and is associated with profound morbidity and mortality. The purpose of this study was to describe predictors for the development of SCI, as well as outcomes for patients who develop SCI, after branched/fenestrated endovascular aortic repair (FB-EVAR) in a large cohort of centers with adjudicated physician-sponsored investigational device exemption studies. METHODS We utilized a pooled dataset from 9 United States Aortic Research Consortium (US ARC) centers involved in investigational device exemption (IDE) trials for treatment of suprarenal and thoracoabdominal aortic aneurysms. SCI was defined as new transient weakness (paraparesis) or permanent paraplegia after repair without other potential neurologic etiologies. Multivariable analysis was performed to identify predictors of SCI, and life-table analysis and Kaplan-Meier methodology were used to evaluate survival differences. RESULTS A total of 1,681 patients underwent FB-EVAR over the period 2005-2020. The overall rate of SCI was 7.1% (3% transient and 4.1% permanent). Predictors of SCI on multivariable analysis were Crawford Extent I, II, and III distribution of aortic disease (OR 4.79 95% CI 4.77- 4.81, P<.001), age ≥70 (OR 1.64, 95% CI, 1.63-1.64, P=.029), packed red blood cell transfusion (OR 2.00, 95% CI, 1.99-2.00, P=.001), and history of PVD (OR 1.65, 95% CI, 1.64-1.65, P=.034). Median survival was significantly worse for patients with any degree of SCI compared to those without SCI (any SCI - 40.4 vs no SCI - 60.3 months, Log Rank <.001), and also worse in those with a permanent deficit (24.1 months) vs. those with a transient deficit (62.4 months) (Log Rank <0.001). One year survival for patients who developed no SCI was 90.8%, compared to 73.9% in patients who developed any SCI. When stratified by degree of deficit, survival was 84.8% at one year for those who developed paraparesis, and 66.2% for those who developed permanent deficits. CONCLUSIONS The overall rates of any SCI at 7.1% and permanent deficit at 4.1% observed in this study compare favorably to those reported in contemporary literature. Our findings confirm that increased length of aortic disease is associated with SCI and those with Crawford Extent I-III TAAAs are at highest risk. The long-term impact on patient mortality underscores the importance of preventive measures and rapid implementation of rescue protocols if and when deficits develop.
Collapse
Affiliation(s)
| | - Claire M Motyl
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Zdenek Novak
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - Warren Gasper
- University of California at San Francisco, San Franscisco, CA, USA
| | | | | | - Andres Schanzer
- University of Massachusetts (UMass) Memorial Medical Center, MA, USA
| | | | | | | | | | | | - Adam W Beck
- University of Alabama at Birmingham, Birmingham, AL, USA.
| |
Collapse
|
20
|
Rand A, Busch A, Held H, Reeps C, Koch T. [Intensive care management of acute diseases of the aorta]. DIE ANAESTHESIOLOGIE 2023; 72:275-281. [PMID: 36735023 DOI: 10.1007/s00101-023-01253-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/02/2023] [Indexed: 06/18/2023]
Abstract
Acute aortic diseases represent a group of complex severe and often fatal medical conditions. Although they are significantly rarer than cardiac or thromboembolic events, they are an important differential diagnosis to be ruled out, e.g., in the clinical work-up of acute chest pain.Treatment, especially surgical interventions, depends on the progression, extent and size of the pathology and whenever possible should be performed in specialized centers with the appropriate experience.Intensive care monitoring is advisable as a range of peracute complications can occur even in initially stable patients. Depending on the clinical presentation and affected structures, a number of severe complications need to be anticipated by critical care physicians. Additionally, a notable symptom is severe and refractory hypertension, especially in the acute phase. This article provides a summary of the most frequent clinical pictures and corresponding treatment options. Furthermore, the principles of initial patient stabilization and treatment as well as the perioperative management of complex surgical procedures on the aorta are discussed.
Collapse
Affiliation(s)
- A Rand
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland.
| | - A Busch
- Klinik und Poliklinik für Viszeral‑, Thorax- und Gefäßchirurgie (VTG), Bereich Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland
| | - H Held
- Klinik und Poliklinik für Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland
| | - C Reeps
- Klinik und Poliklinik für Viszeral‑, Thorax- und Gefäßchirurgie (VTG), Bereich Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland
| | - T Koch
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland
| |
Collapse
|
21
|
Ghoweba M, Moussa S, Chastain O, Hanna-Moussa S. Spinal Cord Ischemia Following Endovascular Abdominal Aortic Aneurysm Repair: An Unpredictable Catastrophe. Cureus 2023; 15:e35953. [PMID: 37038570 PMCID: PMC10082666 DOI: 10.7759/cureus.35953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 04/12/2023] Open
Abstract
Spinal cord ischemia (SCI) following endovascular abdominal aortic aneurysm (AAA) repair (EVAR) is a rare yet catastrophic complication. The underlying pathophysiological mechanism remains incompletely understood. We present the case of a 75-year-old man with a difficult left common iliac artery (CIA) anatomy that necessitated the coiling of his left internal iliac artery (IIA) to ensure proper sealing of his aortic stent graft. The patient complained of bilateral lower extremity weakness immediately following the procedure. The patient was diagnosed with SCI, which was later confirmed by magnetic resonance imaging (MRI). He was treated with cerebrospinal fluid drainage. The patient's neurological status mildly improved on follow-up one year later.
Collapse
Affiliation(s)
- Mohamed Ghoweba
- Internal Medicine, Texas A&M College of Medicine/CHRISTUS Good Shepherd Medical Center, Longview, USA
| | - Shaza Moussa
- Internal Medicine, Special Health Resources, Tyler Health Clinic, Tyler, USA
| | - Oscar Chastain
- Cardiothoracic Surgery, CHRISTUS Good Shepherd Medical Center, Longivew, USA
| | - Shafik Hanna-Moussa
- Cardiology, Texas A&M College of Medicine/CHRISTUS Good Shepherd Medical Center, Longview, USA
| |
Collapse
|
22
|
Schanzer A. Creating a bold new future for vascular surgery: It's go time. J Vasc Surg 2023; 77:669-676. [PMID: 36822761 DOI: 10.1016/j.jvs.2022.10.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 02/25/2023]
|
23
|
Bastug N, Worrall E, Webb L, Larson R. Spinal drain for aortic aneurysm repairs: tool or toy? Curr Opin Anaesthesiol 2023; 36:30-34. [PMID: 36374196 DOI: 10.1097/aco.0000000000001210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE OF REVIEW Spinal cord injury (SCI) is one of the biggest complications in open and endovascular aortic repairs. Historically, cerebrospinal fluid drains (CSFD) have been one of the most effective modalities in reducing SCI and one of the most studied. CSFD placement also carries its' own set of procedural risks. This editorial intends to evaluate recent literature to determine whether CSFDs remain a valuable tool in aortic repair. RECENT FINDINGS As the surgical management of thoracic aortic aneurysms has evolved, there has been an increasing number of endovascular repairs. Current recommendations emphasize prophylactic CSFD placement in endovascular repair cases deemed 'high risk.' However, several meta-analyses differ on whether prophylactic CSFD placement reduced the risk of SCI. The incidence of SCI decreased between 2014 and 2018, despite a similar rate of prophylactic CSFD placement suggesting other techniques are being performed and may be effective in spinal cord protection as well. SUMMARY There has been conflicting data on whether CSFDs have a role in reducing the risk of SCI in endovascular aortic repair. Some studies suggest that there is no benefit to placement while others suggest that routine prophylactic drains should be placed for all endovascular cases. Despite this, efforts have been made to selectively place CSFDs in those patients deemed at 'high risk' for SCI. CSFDs also remain a part of rescue treatment for postoperative SCI. This suggests that CSFDs continue to be a valuable tool that we need to better comprehend. Future research is necessary to better understand how patient risk factors can be balanced with perioperative management to help identify patients who may benefit from CSFD placement.
Collapse
Affiliation(s)
| | | | | | - Robert Larson
- Department of Vascular Surgery, Virginia Commonwealth University Health System, Richmond, VA, USA
| |
Collapse
|
24
|
Dias-Neto M, Tenorio ER, Huang Y, Jakimowicz T, Mendes BC, Kölbel T, Sobocinski J, Bertoglio L, Mees B, Gargiulo M, Dias N, Schanzer A, Gasper W, Beck AW, Farber MA, Mani K, Timaran C, Schneider DB, Pedro LM, Tsilimparis N, Haulon S, Sweet M, Ferreira E, Eagleton M, Yeung KK, Khashram M, Varcica A, Lima GB, Baghbani-Oskouei A, Jama K, Panuccio G, Rohlffs F, Chiesa R, Schurink GW, Lemmens C, Gallitto E, Faggioli G, Karelis A, Parodi E, Gomes V, Wanhainen A, Dean A, Colon JP, Pavarino F, E Melo RG, Crawford S, Garcia R, Ribeiro T, Kappe KO, van Knippenberg SEM, Tran BL, Gormley S, Oderich GS. Comparison of single- and multistage strategies during fenestrated-branched endovascular aortic repair of thoracoabdominal aortic aneurysms. J Vasc Surg 2023; 77:1588-1597.e4. [PMID: 36731757 DOI: 10.1016/j.jvs.2023.01.188] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/15/2023] [Accepted: 01/20/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of this study was to compare outcomes of single or multistage approach during fenestrated-branched endovascular aortic repair (FB-EVAR) of extensive thoracoabdominal aortic aneurysms (TAAAs). METHODS We reviewed the clinical data of consecutive patients treated by FB-EVAR for extent I to III TAAAs in 24 centers (2006-2021). All patients received a single brand manufactured patient-specific or off-the-shelf fenestrated-branched stent grafts. Staging strategies included proximal thoracic aortic repair, minimally invasive segmental artery coil embolization, temporary aneurysm sac perfusion and combinations of these techniques. Endpoints were analyzed for elective repair in patients who had a single- or multistage approach before and after propensity score adjustment for baseline differences, including the composite 30-day/in-hospital mortality and/or permanent paraplegia, major adverse event, patient survival, and freedom from aortic-related mortality. RESULTS A total of 1947 patients (65% male; mean age, 71 ± 8 years) underwent FB-EVAR of 155 extent I (10%), 729 extent II (46%), and 713 extent III TAAAs (44%). A single-stage approach was used in 939 patients (48%) and a multistage approach in 1008 patients (52%). A multistage approach was more frequently used in patients undergoing elective compared with non-elective repair (55% vs 35%; P < .001). Staging strategies were proximal thoracic aortic repair in 743 patients (74%), temporary aneurysm sac perfusion in 128 (13%), minimally invasive segmental artery coil embolization in 10 (1%), and combinations in 127 (12%). Among patients undergoing elective repair (n = 1597), the composite endpoint of 30-day/in-hospital mortality and/or permanent paraplegia rate occurred in 14% of single-stage and 6% of multistage approach patients (P < .001). After adjustment with a propensity score, multistage approach was associated with lower rates of 30-day/in-hospital mortality and/or permanent paraplegia (odds ratio, 0.466; 95% confidence interval, 0.271-0.801; P = .006) and higher patient survival at 1 year (86.9±1.3% vs 79.6±1.7%) and 3 years (72.7±2.1% vs 64.2±2.3%; adjusted hazard ratio, 0.714; 95% confidence interval, 0.528-0.966; P = .029), compared with a single stage approach. CONCLUSION Staging elective FB-EVAR of extent I to III TAAAs was associated with decreased risk of mortality and/or permanent paraplegia at 30 days or within hospital stay, and with higher patient survival at 1 and 3 years.
Collapse
Affiliation(s)
- Marina Dias-Neto
- The University of Texas Health Science Center at Houston, Houston, TX
| | - Emanuel R Tenorio
- The University of Texas Health Science Center at Houston, Houston, TX
| | - Ying Huang
- The University of Texas Health Science Center at Houston, Houston, TX
| | | | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Tilo Kölbel
- University Medical Center Eppendorf (UKE), Hamburg, Germany
| | - Jonathan Sobocinski
- Vascular Surgery, Aortic Centre, Université de Lille, CHU Lille, France; Université de Lille, INSERM, CHU Lille, Lille, France
| | - Luca Bertoglio
- Vita Salute San Raffaele University, San Raffaele Hospital, Milan, Italy
| | - Barend Mees
- Maastricht University Medical Center, Maastricht University, Maastricht, Netherlands
| | - Mauro Gargiulo
- Vascular Surgery, University of Bologna, University Hospital Policlinico S. Orsola, Bologna, Italy
| | - Nuno Dias
- Vascular Centre, Department of Thoracic Surgery and Vascular Diseases, Skåne University hospital and Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | | | - Warren Gasper
- University of California San Francisco, San Francisco CA
| | - Adam W Beck
- University of Alabama at Birmingham, Birmingham, AL
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Kevin Mani
- Department of Surgical Sciences, Division of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Carlos Timaran
- Clinical Heart and Vascular Center, University of Texas Southwestern, Dallas, TX
| | - Darren B Schneider
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Luis Mendes Pedro
- Department of Vascular Surgery of the Hospital Santa Maria (CHULN) and Faculty of Medicine of the University of Lisbon, Lisbon, Portugal
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - Stéphan Haulon
- Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint-Joseph, Université Paris Saclay, Paris, France
| | - Matt Sweet
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Emília Ferreira
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central; NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Matthew Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Kak Khee Yeung
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, location VU medical center, Amsterdam, the Netherlands
| | - Manar Khashram
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand; Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Andrea Varcica
- The University of Texas Health Science Center at Houston, Houston, TX
| | - Guilherme B Lima
- The University of Texas Health Science Center at Houston, Houston, TX
| | | | | | | | - Fiona Rohlffs
- University Medical Center Eppendorf (UKE), Hamburg, Germany
| | - Roberto Chiesa
- Vita Salute San Raffaele University, San Raffaele Hospital, Milan, Italy
| | - Geert Willem Schurink
- Maastricht University Medical Center, Maastricht University, Maastricht, Netherlands
| | - Charlotte Lemmens
- Maastricht University Medical Center, Maastricht University, Maastricht, Netherlands
| | - Enrico Gallitto
- Vascular Surgery, University of Bologna, University Hospital Policlinico S. Orsola, Bologna, Italy
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna, University Hospital Policlinico S. Orsola, Bologna, Italy
| | - Angelos Karelis
- Vascular Centre, Department of Thoracic Surgery and Vascular Diseases, Skåne University hospital and Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Ezequiel Parodi
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Vivian Gomes
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Anders Wanhainen
- Department of Surgical Sciences, Division of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Anastasia Dean
- Department of Surgical Sciences, Division of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Jesus Porras Colon
- Clinical Heart and Vascular Center, University of Texas Southwestern, Dallas, TX
| | - Felipe Pavarino
- Clinical Heart and Vascular Center, University of Texas Southwestern, Dallas, TX
| | - Ryan Gouveia E Melo
- Department of Vascular Surgery of the Hospital Santa Maria (CHULN) and Faculty of Medicine of the University of Lisbon, Lisbon, Portugal; Department of Vascular Surgery, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - Sean Crawford
- Aortic Centre, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint-Joseph, Université Paris Saclay, Paris, France
| | - Rita Garcia
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central; NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Tiago Ribeiro
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central; NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Kaj Olav Kappe
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, location VU medical center, Amsterdam, the Netherlands
| | | | - Bich Lan Tran
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, location VU medical center, Amsterdam, the Netherlands
| | - Sinead Gormley
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand; Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Gustavo S Oderich
- The University of Texas Health Science Center at Houston, Houston, TX.
| | | |
Collapse
|
25
|
Oberhuber A, Raddatz A, Betge S, Ploenes C, Ito W, Janosi RA, Ott C, Langheim E, Czerny M, Puls R, Maßmann A, Zeyer K, Schelzig H. Interdisciplinary German clinical practice guidelines on the management of type B aortic dissection. GEFASSCHIRURGIE 2023; 28:1-28. [PMCID: PMC10123596 DOI: 10.1007/s00772-023-00995-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 08/13/2023]
Affiliation(s)
- A. Oberhuber
- German Society of Vascular Surgery and Vascular Medicine (DGG); Department of Vascular and Endovascular Surgery, University Hospital of Münster, Münster, Germany
| | - A. Raddatz
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI); Department of Anaesthesiology, Critical Care and Pain Medicine, Saarland University Hospital, Homburg, Germany
| | - S. Betge
- German Society of Angiology and Vascular Medicine (DGG); Department of Internal Medicine and Angiology, Helios Hospital Salzgitter, Salzgitter, Germany
| | - C. Ploenes
- German Society of Geriatrics (DGG); Department of Angiology, Schön Klinik Düsseldorf, Düsseldorf, Germany
| | - W. Ito
- German Society of Internal Medicine (GSIM) (DGIM); cardiovascular center Oberallgäu Kempten, Hospital Kempten, Kempten, Germany
| | - R. A. Janosi
- German Cardiac Society (DGK); Department of Cardiology and Angiology, University Hospital Essen, Essen, Germany
| | - C. Ott
- German Society of Nephrology (DGfN); Department of Nephrology and Hypertension, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
- Department of Nephrology and Hypertension, Paracelsus Medical University, Nürnberg, Germany
| | - E. Langheim
- German Society of prevention and rehabilitation of cardiovascular diseaese (DGPR), Reha Center Seehof, Teltow, Germany
| | - M. Czerny
- German Society of Thoracic and Cardiovascular Surgery (DGTHG), Department University Heart Center Freiburg – Bad Krozingen, Freiburg, Germany
- Albert Ludwigs University Freiburg, Freiburg, Germany
| | - R. Puls
- German Radiologic Society (DRG); Institute of Diagnostic an Interventional Radiology and Neuroradiology, Helios Klinikum Erfurt, Erfurt, Germany
| | - A. Maßmann
- German Society of Interventional Radiology (DeGIR); Department of Diagnostic an Interventional Radiology, Saarland University Hospital, Homburg, Germany
| | - K. Zeyer
- Marfanhilfe e. V., Weiden, Germany
| | - H. Schelzig
- German Society of Surgery (DGCH); Department of Vascular and Endovascular Surgery, University Hospital of Düsseldorf, Düsseldorf, Germany
| |
Collapse
|
26
|
Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 296] [Impact Index Per Article: 148.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
| |
Collapse
|
27
|
Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 95] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
Collapse
|
28
|
Ebeling C, Cheruku S. Anesthetic Management for Endovascular Repair of Thoracic and Abdominal Aortic Aneurysms. Anesthesiol Clin 2022; 40:719-735. [PMID: 36328625 DOI: 10.1016/j.anclin.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Aortic aneurysms-both abdominal and thoracic-are a significant cause of death and disability in the United States. Endovascular aneurysm repair has since become the preferred operative treatment of most thoracic and abdominal aneurysms because of a lower rate of complications and better outcomes compared with the open approach. Patients who present for endovascular aneurysm repair often have comorbid conditions related to their aortic pathology. These conditions should be evaluated and optimized before the procedure.
Collapse
Affiliation(s)
- Callie Ebeling
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Mail Code 9068, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
| | - Sreekanth Cheruku
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Mail Code 9068, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| |
Collapse
|
29
|
Arora H, Encarnacion JA, Li Q, Liu Y, Kumar PA, Smeltz AM. Hypothermia and Prolonged Time From Procedure End to Extubation After Endovascular Thoracic Aortic Surgery. J Cardiothorac Vasc Anesth 2022; 36:4320-4326. [PMID: 36216686 DOI: 10.1053/j.jvca.2022.09.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/23/2022] [Accepted: 09/06/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Perioperative hypothermia (core temperature <36°C) occurs in 50%-to-80% of patients recovering from thoracic aortic surgery, though its effects have not been described fully in this context. The authors, therefore, sought to characterize the incidence of perioperative hypothermia and its association with time from procedure end to extubation in endovascular aortic surgical patients. DESIGN A retrospective cohort study. SETTING At a single academic tertiary center. PARTICIPANTS Patients recovering from thoracic aortic surgery with lumbar drains. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS A total of 196 patients were included in this study, 55 of whom were hypothermic with temperatures <35.0°C at the end of surgery. Though the unadjusted time to extubation was not statistically different in the hypothermic group (median 8 minutes, IQR 5-13.5 minutes) compared to the normothermic group (median 7 minutes, IQR 4-12 minutes; p = 0.062), multivariate predictors of increased time from procedure end to extubation included hypothermia (p = 0.011), age (p = 0.009), diabetes (p = 0.015), history of carotid disease (p = 0.040), and crystalloid volume (p = 0.019). CONCLUSIONS Hypothermia in patients recovering from endovascular aortic surgery was associated with prolonged time from procedure end to extubation. Because of the retrospective observational nature of the authors' analysis, it was not possible to determine the extent to which prolonged mechanical ventilation was influenced by low temperature.
Collapse
Affiliation(s)
- Harendra Arora
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| | - John A Encarnacion
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Quefeng Li
- Department of Biostatistics, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC
| | - Yutong Liu
- Department of Biostatistics, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC
| | - Priya A Kumar
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| | - Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| |
Collapse
|
30
|
Spratt JR, Walker KL, Neal D, Arnaoutakis GJ, Martin TD, Back MR, Zasimovich Y, Franklin M, Shahid Z, Upchurch GR, Scali ST, Beaver TM. Rescue therapy for symptomatic spinal cord ischemia after thoracic endovascular aortic repair. J Thorac Cardiovasc Surg 2022:S0022-5223(22)01168-0. [PMID: 36509568 DOI: 10.1016/j.jtcvs.2022.10.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/11/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) can cause permanent neurologic deficits and poor long-term survival. Targeted treatment of new SCI symptoms after TEVAR (rescue therapy [RT]) might improve/resolve neurologic symptoms but few data characterize the association of specific interventions with SCI outcomes. We evaluated the effectiveness of post-TEVAR RT at our tertiary aortic center. METHODS Our institutional TEVAR database was reviewed for SCI incidence and details of RT. This included cerebrospinal fluid drainage (CSFD), medical therapy, and optimization of spinal cord oxygen delivery. SCI outcomes were categorized at discharge as paralysis/paraparesis and temporary/permanent. RESULTS Nine hundred forty-three TEVAR procedures were performed in 869 patients from 2011 to 2020. Post-TEVAR SCI occurred in 7.8% (n = 74) with permanent paraplegia in 1.5%. Older patient age, chronic obstructive pulmonary disease, and previous abdominal aortic surgery were predictive of SCI. Half (n = 37) of SCI episodes resulted in only temporary paralysis/paraparesis. Rescue postoperative cerebrospinal fluid drains were implanted in 3.7% (n = 35) of procedures and was predicted by higher American Society of Anesthesiologists class, lower serum hemoglobin level, elevated international normalized ratio, bilateral iliac artery occlusion, nonelective procedures, and penetrating atherosclerotic ulcer/intramural hematoma indication. The most commonly used RTs were emergent placement of or increased drainage from an existing cerebrospinal fluid drain (87.8%), induced/permissive hypertension (77.0%), corticosteroid bolus (36.5%), and naloxone infusion (33.8%). Neurologic improvement occurred in 68.9% (n = 51/74). New/increased drainage was associated with improved SCI outcome. CONCLUSIONS Permanent paraplegia from post-TEVAR SCI is rare (1.5%). Older patients with comorbidities carry greater post-TEVAR SCI risk. SCI symptoms improved/resolved with CSFD and multimodal RT in 68.9% of patients, but no intervention was independently associated with improvement. TEVAR centers should have robust protocols for timely and safe CSFD placement to augment RT strategies for SCI.
Collapse
Affiliation(s)
- John R Spratt
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla.
| | - Kristen L Walker
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Dan Neal
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - George J Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Tomas D Martin
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Martin R Back
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - Yury Zasimovich
- Acute and Perioperative Pain Medicine Division, Department of Anesthesia, University of Florida, Gainesville, Fla
| | - Michael Franklin
- Acute and Perioperative Pain Medicine Division, Department of Anesthesia, University of Florida, Gainesville, Fla
| | - Zain Shahid
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - Gilbert R Upchurch
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| |
Collapse
|
31
|
Dias-Neto M, Tenorio ER, Baumgardt Barbosa Lima G, Baghbani-Oskouei A, Oderich GS. Postoperative management in patients with complex aortic aneurysms. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:587-596. [PMID: 35687066 DOI: 10.23736/s0021-9509.22.12359-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Patients with complex aortic aneurysms (CAA) are often high risk due to advanced age and widespread atherosclerosis affecting numerous vascular territories. Therefore, a thorough perioperative evaluation is needed prior to performing in any type of aortic repair, regardless of whether an endovascular or open surgical approach is selected. Because these operations are technically demanding and often result in end organ ischemia, it is not surprising that complex aortic repair carries significant risk of morbidity and mortality. Disabling complications such as dialysis, major stroke and paraplegia constitute the main limitation of complex aortic repair. The aim of this article was to review postoperative management to mitigate complications after CAA repair.
Collapse
Affiliation(s)
- Marina Dias-Neto
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Emanuel R Tenorio
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Guilherme Baumgardt Barbosa Lima
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Aidin Baghbani-Oskouei
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Gustavo S Oderich
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA -
| |
Collapse
|
32
|
Koda Y, Yamanaka K, Omura A, Gentsu T, Yamaguchi M, Okada K. Spinal cord ischemia after elective endovascular abdominal aortic aneurysm repair in a patient with multiple occlusions of the intercostal and internal iliac arteries. J Vasc Surg Cases Innov Tech 2022; 8:447-449. [PMID: 36016702 PMCID: PMC9395748 DOI: 10.1016/j.jvscit.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 06/15/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Yojiro Koda
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Katsuhiro Yamanaka
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Atsushi Omura
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Tomoyuki Gentsu
- Department of Radiology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Masato Yamaguchi
- Department of Radiology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Kenji Okada
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Hospital, Kobe, Hyogo, Japan
- Correspondence: Kenji Okada, MD, PhD, Professor of Cardiovascular Surgery, Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 chuo-ku Kusunoki-cho, Kobe, Hyogo, 650-0017, Japan
| |
Collapse
|
33
|
Addas JAK, Mafeld S, Mahmood DN, Sidhu A, Ouzounian M, Lindsay TF, Tan KT. Minimally Invasive Segmental Artery Coil Embolization (MISACE) Prior to Endovascular Thoracoabdominal Aortic Aneurysm Repair. Cardiovasc Intervent Radiol 2022; 45:1462-1469. [PMID: 35927497 DOI: 10.1007/s00270-022-03230-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 07/15/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Minimally Invasive Segmental Artery Coil Embolization (MISACE) is a novel approach to reduce paraplegia risk in Thoracoabdominal aortic aneurysm (TAAA) repair with limited data. We report our experience with MISACE as a method of spinal cord pre-conditioning to prevent spinal cord ischemia following endovascular repair of TAAA. MATERIAL AND METHODS A retrospective analysis of 17 patients who had an attempted MISACE prior to endovascular TAAA repair with mean follow-up of 350 days (2017-2020). Baseline patient and aneurysm characteristics along with procedural technique and outcomes were analyzed. RESULTS Mean age of 69 years and 76.5% were males. TAAA Crawford classification were II, n = 6 (35.3%), III, n = 4 (23.5%) and IV, n = 5 (29.4%). The mean aortic diameter was 70.6 ± 10.9 mm. Staged repair was performed on 9 patients. Technically successful embolization occurred in 14 patients (82.4%) and was unsuccessful in 3 patients. The median number of embolized arteries was 3 and 71% of the target arteries were between T9 and T12. Mean fluoroscopy time was 51.5 ± 22.5 min and mean contrast volume used was 132.8 ± 56.1 mL. Average number of catheters used was 4.6 and 3.5 wires. No complications related to the procedure. Mean interval between embolization to endovascular TAAA repair was 51.2 days (5-110 days). All patients received spinal drainage at the time of repair. Postoperatively, 2/14 of patients developed paraparesis in the MISACE successful group and 1/3 patients developed paraplegia in the unsuccessful group. CONCLUSIONS MISACE is a promising strategy to prevent SCI. This data demonstrates the technique is feasible and safe but anatomic challenges remain.
Collapse
Affiliation(s)
- Jamil A K Addas
- Department of Vascular and Interventional Radiology, University Health Network, Toronto, Canada.
| | - Sebastian Mafeld
- Department of Vascular and Interventional Radiology, University Health Network, Toronto, Canada
| | - Daniyal N Mahmood
- Division of Vascular Surgery, University Health Network, Toronto, Canada
| | - Arshdeep Sidhu
- Department of Vascular and Interventional Radiology, University Health Network, Toronto, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, University Health Network, Toronto, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, University Health Network, Toronto, Canada
| | - Kong Teng Tan
- Department of Vascular and Interventional Radiology, University Health Network, Toronto, Canada
| |
Collapse
|
34
|
Parodi FE, Schanzer A, Oderich GS, Timaran CH, Schneider D, Sweet MP, Beck AW, Eagleton MJ, Lee A, Gaspar W, Farber MA. The development and potential implications of the US Fenestrated and Branched Aortic Research Consortium. Semin Vasc Surg 2022; 35:380-384. [DOI: 10.1053/j.semvascsurg.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/19/2022] [Accepted: 08/13/2022] [Indexed: 11/11/2022]
|
35
|
Nana P, Spanos K, Behrendt CA, Dakis K, Brotis A, Kouvelos G, Giannoukas A, Kölbel T. Editor's Choice - Sex Specific Outcomes After Complex Fenestrated and Branched Endovascular Aortic Repair: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2022; 64:200-208. [PMID: 35598720 DOI: 10.1016/j.ejvs.2022.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 04/17/2022] [Accepted: 05/13/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE As females are at higher mortality risk after endovascular aortic repair, this study aimed to compare the 30-day and 12-month mortality, morbidity, and re-intervention rates between the sexes, treated with fenestrated or branched endovascular aortic repair (F/BEVAR). DATA SOURCES A search of the English literature, via Ovid, using MEDLINE, Embase, and CENTRAL, up to 30 July 2021, was performed. REVIEW METHODS This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, and its protocol was registered in PROSPERO (CRD42021273418). Observational studies (2010-21), with ≥ 20 patients, reporting on sex specific outcomes (mortality, acute kidney injury [AKI], spinal cord ischaemia [SCI], and re-intervention, after F/BEVAR), were considered eligible. Risk of bias in the studies was assessed using ROBINS-I, and evidence quality was assessed using GRADE. The primary outcome was the sex specific 30-day mortality rate, AKI, SCI, and re-intervention rates; secondary outcomes were survival and freedom from re-intervention at 12 months after F/BEVAR. The outcomes were summarised as odds ratio (OR) with 95% confidence intervals (CIs). RESULTS Four retrospective and one prospective study (2 421 patients; 26% females) were included. The 30-day mortality rate was 12% in females vs. 3% in males (OR 2.65, 95% CI 1.79 - 3.92; Ι2 = 0%). The 30-day AKI, SCI, and re-intervention rates were similar (OR 1.45, 95% CI 1.03 - 2.03; Ι2 = 0%; OR 1.86, 95% CI 1.27 - 2.74; Ι2 = 38%; and OR 1.06, 95% CI 0.66 - 1.77; Ι2 = 0%, respectively). The 12-month survival rate was lower in females (OR 0.95, 95% CI 0.91 - 0.99; Ι2 = 38%). When excluding 30-day deaths, there was no difference in 12-month survival between sexes (OR 0.99, 95% CI 0.95 - 1.02; Ι2 = 32%). The 12-month freedom from re-intervention was similar between sexes (OR 0.87, 95% CI 0.75 - 1.01; Ι2 = 0%). CONCLUSION Female patients treated by F/BEVAR may present worse outcomes in terms of 30-day and 12-month survival. The high peri-operative mortality rate remains an issue. When excluding 30-day deaths, the 12-month survival rate was similar between the sexes. Early morbidity and re-intervention rates were comparable.
Collapse
Affiliation(s)
- Petroula Nana
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Konstantinos Spanos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; German Aortic Centre, Department of Vascular Medicine, University Heart Centre Hamburg, Hamburg, Germany
| | | | - Konstantinos Dakis
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Alexandros Brotis
- Department of Neurosurgery, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Kouvelos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios Giannoukas
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Tilo Kölbel
- German Aortic Centre, Department of Vascular Medicine, University Heart Centre Hamburg, Hamburg, Germany
| |
Collapse
|
36
|
Motyl CM, Beck AW. Strategies for prevention and treatment of spinal cord ischemia during F/BEVAR. Semin Vasc Surg 2022; 35:297-305. [DOI: 10.1053/j.semvascsurg.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 11/11/2022]
|
37
|
Spratt JR, Walker KL, Wallen TJ, Neal D, Zasimovich Y, Arnaoutakis GJ, Martin TD, Back MR, Scali ST, Beaver TM. Safety of Cerebrospinal Fluid Drainage for Spinal Cord Ischemia Prevention in Thoracic Endovascular Aortic Repair. JTCVS Tech 2022; 14:9-28. [PMID: 35967198 PMCID: PMC9366624 DOI: 10.1016/j.xjtc.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 03/16/2022] [Accepted: 05/02/2022] [Indexed: 11/19/2022] Open
Abstract
Objective Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) is associated with permanent neurologic deficit and decreased survival. Prophylactic cerebrospinal fluid (CSF) drainage (CSFD) in TEVAR is controversial. We evaluated the usage of CSFD in TEVAR at our tertiary aortic center. Methods Our institutional TEVAR database was reviewed to determine the frequency of CSFD usage/complications. Complications were categorized as mild (headache/CSF leak not requiring intervention, urinary retention), moderate (headache/CSF leak requiring intervention, drain malfunction requiring replacement), or severe (intrathecal hemorrhage, CSFD-attributable neurologic deficit). The relationships between CSFD complications and patient/procedural characteristics, CSFD placement timing, and survival were analyzed. Results Nine hundred thirty-six TEVAR procedures were performed in 869 patients from 2011 to 2020. Three hundred ninety CSFD drains were placed in 373 (41.7%) TEVAR patients. Most CSFD drains (89.5%) were pre-TEVAR. Most post-TEVAR drains were placed for new SCI symptoms (n = 21). Twenty-five patients (6.4%) suffered 32 CSFD complications. Most (n = 17) were mild in severity. Severe CSFD complications occurred in 5/432 (1.1% CSF drains) patients. No patient/procedural characteristics were predictive of CSFD complications. Post implant CSFD placement for new SCI symptoms conferred an increased risk of CSFD complication (odds ratio, 6.9; 95% CI, 2.42-19.6; P < .01). The long-term survival of the CSFD complication cohort did not differ from the overall population. Conclusions Post-TEVAR CSFD placement for new SCI symptoms was associated with substantially greater risk of CSFD complications. Avoidance of post-implant therapeutic drain placement might be the key to prevention of CSFD complications, favoring a strategy of selective pre-implant drain placement in patients at higher risk for SCI.
Collapse
Affiliation(s)
- John R. Spratt
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
- Address for reprints: John R. Spratt, MD, MA, Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, 1600 SW Archer Rd, PO Box 100129, Gainesville, FL 32610.
| | - Kristen L. Walker
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Tyler J. Wallen
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Dan Neal
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - Yury Zasimovich
- Acute and Perioperative Pain Medicine Division, Department of Anesthesia, University of Florida, Gainesville, Fla
| | - George J. Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Tomas D. Martin
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Martin R. Back
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - Salvatore T. Scali
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla
| | - Thomas M. Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| |
Collapse
|
38
|
CHAN CH, DESAI SR, HWANG NC. Cerebrospinal Fluid Drains: Risks in Contemporary Practice. J Cardiothorac Vasc Anesth 2022; 36:2685-2699. [DOI: 10.1053/j.jvca.2022.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 01/03/2022] [Accepted: 01/12/2022] [Indexed: 11/11/2022]
|
39
|
Role of historical and procedural staging during elective fenestrated and branched endovascular treatment of extensive thoracoabdominal aortic aneurysms. J Vasc Surg 2021; 75:1501-1511. [PMID: 34861361 DOI: 10.1016/j.jvs.2021.11.056] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 11/08/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Procedural staging is often performed to reduce the incidence of spinal cord ischemia (SCI) during endovascular treatment of extensive thoracoabdominal aortic aneurysms (TAAAs). However, its role in the case of previous thoracic or infrarenal aortic repair (historical staging) has been controversial. In the present study, we evaluated the SCI rates when procedural staging was routinely used and studied its potential benefits when previous aortic repairs had already been performed. METHODS The data from patients treated electively with fenestrated/branched endovascular aortic repair for extent I, II, III, and V TAAAs were retrieved from a multicenter registry (four high-volume national teaching hospitals) and analyzed. The primary endpoint was the rate of SCI and its association with preoperative and postoperative variables, including historical staging, procedural staging, and an impaired collateral network (subclavian or hypogastric stenosis >75% per occlusion). Variables were defined in accordance with the Society for Vascular Surgery reporting standards. A logistic regression model with stepwise selection was used to identify the predictors of SCI. RESULTS A total of 240 patients (76% male; median age, 73 years) were analyzed. Of the 240 patients, 43 (18%) had presented with an impaired collateral network, 136 (57%) had had historical staging, and 157 (65%) had received procedural staging. Preoperative spinal fluid cerebrospinal drainage was performed in 130 patients (54%). Permanent grade 3 SCI was observed in 13 patients (5%) and was negatively affected by both an impaired collateral network (odds ratio [OR], 17.3; 95% confidence interval [CI], 1.7-176; P = .016) and the presence of bilateral iliac occlusive disease (OR, 10.1; 95% CI, 1.1-98.3; P = .046). Both historical (OR, 0.02; 95% CI, 0.001-0.46; P = .014) and procedural (OR, 0.01; 95% CI, 0.02-0.7; P = .019) staging mitigated the permanent SCI rates. The need for postoperative transfusions (OR, 1.4; 95% CI, 1.1-1.8; P = .014) and the occurrence of postoperative renal complications (OR, 6.5; 95% CI, 1.2-35.0; P < .001) were associated with the development of SCI. Among the patients with historical staging, no further benefit from procedural staging was observed (SCI with procedural staging, 1%; vs no staging, 2%; P = NS). CONCLUSIONS For patients with extensive TAAAs treated with fenestrated/branched endovascular aortic repair, both historical and planned procedural staging were associated with reduced permanent SCI rates. However, no additional benefit was observed when procedural staging was performed in patients with historical staging and an intact collateral network. The protective role of preoperative cerebrospinal fluid drainage placement requires further investigation.
Collapse
|
40
|
Lella SK, Waller HD, Pendleton A, Latz CA, Boitano LT, Dua A. A Systematic Review of Spinal Cord Ischemia Prevention and Management After Open and Endovascular Aortic Repair. J Vasc Surg 2021; 75:1091-1106. [PMID: 34740806 DOI: 10.1016/j.jvs.2021.10.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 10/24/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Spinal cord ischemia (SCI) is one of the most devastating complications after descending thoracic aortic (DTA) and thoracoabdominal aortic (TAA) repairs. Patients who develop SCI have a poor prognosis with mortality rates reaching 75% within the first year after surgery. Many factors have been shown to increase the risk of this complication, including extent of TAA repair, length of aortic and collateral network coverage, embolization, and reduced spinal cord perfusion pressure. As a result, a variety of treatment strategies have evolved. We aimed to provide an up-to-date review of SCI rates with associated treatment algorithms from open and endovascular DTA and TAA repairs. METHODS Using PRISMA guidelines, a literature review with the Medical Subject Headings (MeSH) terms "spinal cord ischemia; spinal cord ischemia prevention and mitigation strategies; spinal cord ischemia rates; spinal cord infarction" was performed in the Cochrane and PubMed databases to seek all peer-reviewed studies of DTA and TAA repairs with SCI complications, limited to 2012-2021 and the English language. MeSH subheadings including diagnosis, complications, physiopathology, surgery, mortality, and therapy were used to further restrict the articles. Studies were excluded if they were not in humans, not pertaining to SCI in DTA/TAA operative repairs, and if the study primarily discussed neuromonitoring techniques. Additionally, studies with <40 patients or limited information regarding SCI protection strategies were excluded. Each study was individually reviewed by two researchers to assess for type and extent of aortic pathology, operative technique, SCI protection or mitigation strategies, rates of overall and permanent SCI symptoms, associations with SCI on multivariate analysis, and mortality. RESULTS Of 450 studies returned by the MeSH search strategy, 41 met inclusion criteria and were included in the final analysis. For endovascular DTA repair patients, overall SCI rates ranged from 0-10.6% with permanent SCI symptoms ranging from 0-5.1%. Endovascular and open TAA repairs had rates of overall SCI of 0-35%. Permanent SCI symptom rate was reported by only one open study at 1.1% while endovascular TAA repairs had between 2-20.5%. CONCLUSION This review provides an up-to-date review of current rates of SCI as well as prevention and mitigation strategies for DTA and TAA repairs. We find that a multimodal approach, including a bundled institutional protocol, staging of multiple repairs, preservation of collateral blood flow network, augmented spinal cord perfusion, selective cerebrospinal fluid drainage, and distal aortic perfusion in open TAA repairs, appears to be important in reducing the risk of SCI.
Collapse
Affiliation(s)
- Srihari K Lella
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass.
| | - Harold D Waller
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Alaska Pendleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Christopher A Latz
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| |
Collapse
|
41
|
Busch A, Wolk S, Lutz B, Zimmermann C, Ankudinov M, Klenk D, Ehehalt F, Rössel T, Ludwig S, Reeps C. [Open thoracic and thoracoabdominal aortic repair vs. f/bTEVAR - complementary or competitive?]. Zentralbl Chir 2021; 146:470-478. [PMID: 34666359 DOI: 10.1055/a-1562-2770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The classical approach of open repair (OR) for thoracic and thoracoabdominal aortic pathologies, including aneurysms and dissection, has been outnumbered by the use of fenestrated/branched (thoracic) endovascular aortic repair (f/b[T]EVAR) in recent years. Providing OR for complex cases in an aortic service requires a dedicated surgical setup and a huge body of expertise in this particular field.In order to reduce specific complications, such as perioperative mortality, kidney failure, spinal cord ischemia, stroke or bowel ischemia, it is necessary to apply cerebrospinal-spinal fluid drainage, point-of-care coagulation therapy, distal and retrograde aortic perfusion and sequential clamping. Despite the predominance of endovascular solutions, the specific OR expertise is still needed for specific indications, such as young patients, connective tissue disorder or aortic graft infections.Currently, the short and mid term results for f/b(T)EVAR outweigh those for OR, including the shorter hospital stay and less invasive procedures. However, OR provides better long-term results for overall mortality, re-intervention rates and secondary complications.In conclusion, in our opinion OR is a service that is still necessary for dedicated aortic centres, but will most likely become more frequent again in the years to come.
Collapse
Affiliation(s)
- Albert Busch
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Steffen Wolk
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Brigitta Lutz
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Carolin Zimmermann
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Miroslav Ankudinov
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - David Klenk
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Florian Ehehalt
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Thomas Rössel
- Department of Anesthesiology and Intensive Care Medicine, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Stefan Ludwig
- General, Thoracic and Vascular Surgery, University of Dresden, Dresden, Germany
| | - Christian Reeps
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| |
Collapse
|
42
|
Zhang S, Yan Y, Wang Y, Sun Z, Han C, Qian X, Ren X, Feng Y, Cai J, Xia C. Inhibition of MALT1 Alleviates Spinal Ischemia/Reperfusion Injury-Induced Neuroinflammation by Modulating Glial Endoplasmic Reticulum Stress in Rats. J Inflamm Res 2021; 14:4329-4345. [PMID: 34511971 PMCID: PMC8423190 DOI: 10.2147/jir.s319023] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/28/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Glial activation and the disorders of cytokine secretion induced by endoplasmic reticulum stress (ERS) are crucial pathogenic processes in establishing ischemia/reperfusion (I/R) injury of the brain and spinal cord. This present study aimed to investigate the effects of mucous-associated lymphoid tissue lymphoma translocation protein 1 (MALT1) on spinal cord ischemia/reperfusion (SCI/R) injury via regulating glial ERS. METHODS SCI/R was induced by thoracic aorta occlusion-reperfusion in rats. The MALT1-specific inhibitor MI-2 or human recombinant MALT1 protein (hrMALT1) was administrated for three consecutive days after the surgery. Immunofluorescent staining was used to detect the localization of MALT1 and ERS profiles in activated astrocyte and microglia of spinal cord. The ultrastructure of endoplasmic reticulum (ER) was examined by transmission electron microscopy. Blood-spinal cord barrier (BSCB) disruption and noninflammatory status were assessed. The neuron loss and demyelination in the spinal cord were monitored, and the hindlimb motor function was evaluated in SCI/R rats. RESULTS Intraperitoneally postoperative MI-2 treatment down-regulated phos-NF-κB (p65) and Bip (ERS marker protein) expression in the spinal cord after SCI/R in rats. Intraperitoneal injection MI-2 attenuated the swelling/dilation of ER of the glia in SCI/R rats. Furthermore, MI-2 attenuated I/R-induced Evans blue (EB) leakage and microglia M1 polarization in spinal cord, implying a role for MALT1 in the BSCB destruction and neuroinflammation after SCI/R in rats. Furthermore, intrathecal injection of hrMALT1 aggravated the fragmentation of neuron, loss of neurofibrils and demyelination caused by I/R, while 4-PBA, an ERS inhibitor, co-treatment with hrMALT1 reversed these effects in SCI/R rats. hrMALT1 administration aggravated the motor deficit index (MDI) scoring, while 4-PBA co-treatment improved SCI/R-induced motor deficits in rats. CONCLUSION Inhibition of MALT1 alleviates SCI/R injury-induced neuroinflammation by modulating glial endoplasmic reticulum stress in rats.
Collapse
Affiliation(s)
- Shutian Zhang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, People’s Republic of China
- Department of Clinical Medicine, Shanghai Medical College, Fudan University, Shanghai, 200032, People’s Republic of China
| | - Yufeng Yan
- Experimental Teaching Center of Basic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, People’s Republic of China
| | - Yongze Wang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, People’s Republic of China
- Department of Clinical Medicine, Shanghai Medical College, Fudan University, Shanghai, 200032, People’s Republic of China
| | - Zhaodong Sun
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, People’s Republic of China
- Department of Clinical Medicine, Shanghai Medical College, Fudan University, Shanghai, 200032, People’s Republic of China
| | - Chengzhi Han
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, People’s Republic of China
- Department of Clinical Medicine, Shanghai Medical College, Fudan University, Shanghai, 200032, People’s Republic of China
| | - Xinyi Qian
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, People’s Republic of China
- Department of Clinical Medicine, Shanghai Medical College, Fudan University, Shanghai, 200032, People’s Republic of China
| | - Xiaorong Ren
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, People’s Republic of China
- Department of Clinical Medicine, Shanghai Medical College, Fudan University, Shanghai, 200032, People’s Republic of China
| | - Yi Feng
- Department of Integrative Medicine and Neurobiology, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, People’s Republic of China
| | - Jian Cai
- Department of Neurology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200240, People’s Republic of China
| | - Chunmei Xia
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, People’s Republic of China
| |
Collapse
|
43
|
Awad H, Raza A, Saklayen S, Bhandary S, Kelani H, Powers C, Bourekas E, Stine I, Milner R, Valentine E, Essandoh M. Combined Stroke and Spinal Cord Ischemia in Hybrid Type I Aortic Arch Debranching and TEVAR and the Dual Role of the Left Subclavian Artery. J Cardiothorac Vasc Anesth 2021; 36:3687-3700. [PMID: 34538558 DOI: 10.1053/j.jvca.2021.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Hamdy Awad
- Department of Anesthesiology at the Wexner Medical Center at the Ohio State University, Columbus, OH.
| | - Arwa Raza
- Ohio State University College of Medicine, Columbus, OH
| | - Samiya Saklayen
- Department of Anesthesiology at the Wexner Medical Center at the Ohio State University, Columbus, OH
| | - Sujatha Bhandary
- Department of Anesthesiology at Emory University School of Medicine, Atlanta, GA
| | - Hesham Kelani
- Department of Anesthesiology at the Wexner Medical Center at the Ohio State University, Columbus, OH
| | - Ciaran Powers
- Department of Neurosurgery at the Wexner Medical Center at the Ohio State University, Columbus, OH
| | - Eric Bourekas
- Department of Radiology at Wexner Medical Center at the Ohio State University, Columbus, OH
| | - Ian Stine
- Department of Surgery at the University of Chicago, Chicago, IL
| | - Ross Milner
- Department of Surgery at the University of Chicago, Chicago, IL
| | - Elizabeth Valentine
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Michael Essandoh
- Department of Anesthesiology at the Wexner Medical Center at the Ohio State University, Columbus, OH
| |
Collapse
|
44
|
Pini R, Faggioli G, Fenelli C, Gallitto E, Mascoli C, Spath P, Gargiulo M. Intracranial Hemorrhage After Endovascular Repair of Thoracoabdominal Aortic Aneurysm. J Endovasc Ther 2021; 28:897-905. [PMID: 34190631 DOI: 10.1177/15266028211028226] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
Collapse
Affiliation(s)
- Rodolfo Pini
- University of Bologna, Hospital of Bologna Sant'Orsola-Malpighi Polyclinic IRCCS, Bologna, Emilia-Romagna, Italy
| | - Gianluca Faggioli
- University of Bologna, Hospital of Bologna Sant'Orsola-Malpighi Polyclinic IRCCS, Bologna, Emilia-Romagna, Italy
| | - Cecilia Fenelli
- University of Bologna, Hospital of Bologna Sant'Orsola-Malpighi Polyclinic IRCCS, Bologna, Emilia-Romagna, Italy
| | - Enrico Gallitto
- University of Bologna, Hospital of Bologna Sant'Orsola-Malpighi Polyclinic IRCCS, Bologna, Emilia-Romagna, Italy
| | - Chiara Mascoli
- University of Bologna, Hospital of Bologna Sant'Orsola-Malpighi Polyclinic IRCCS, Bologna, Emilia-Romagna, Italy
| | - Paolo Spath
- University of Bologna, Hospital of Bologna Sant'Orsola-Malpighi Polyclinic IRCCS, Bologna, Emilia-Romagna, Italy
| | - Mauro Gargiulo
- University of Bologna, Hospital of Bologna Sant'Orsola-Malpighi Polyclinic IRCCS, Bologna, Emilia-Romagna, Italy
| |
Collapse
|
45
|
Jónsson GG, Marklund N, Blennow K, Zetterberg H, Wanhainen A, Lindström D, Eriksson J, Mani K. Dynamics of Selected Biomarkers in Cerebrospinal Fluid During Complex Endovascular Aortic Repair - A Pilot Study. Ann Vasc Surg 2021; 78:141-151. [PMID: 34175417 DOI: 10.1016/j.avsg.2021.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Ischemic spinal cord injury (SCI) is a serious complication of complex aortic repair. Prophylactic cerebrospinal fluid (CSF) drainage, used to decrease lumbar cerebrospinal fluid (CSF) pressure, enables monitoring of CSF biomarkers that may aid in detecting impending SCI. We hypothesized that biomarkers, previously evaluated in traumatic SCI and brain injury, would be altered in CSF over time following complex endovascular aortic repair (cEVAR). OBJECTIVES To examine if a chosen cohort of CSF biomarker correlates to SCI and warrants further research. METHODS A prospective observational study on patients undergoing cEVAR with extensive aortic coverage. Vital parameters and CSF samples were collected on ten occasions during 72 hours post-surgery. A panel of ten biomarkers were analyzed (Neurofilament Light Polypeptide (NFL), Tau, Glial Fibrillary Acidic Protein (GFAP), Soluble Amyloid Precursos Protein (APP) α and β, Amyloid β 38, 40 and 42 (Aβ38, 40 and 42), Chitinase-3-like protein 1 (CHI3LI or YKL-40), Heart-type fatty acid binding protein (H-FABP).). RESULTS Nine patients (mean age 69, 7 males) were included. Median total aortic coverage was 68% [33, 98]. One patient died during the 30-day post-operative period. After an initial stable phase for the first few postoperative hours, most biomarkers showed an upward trend compared with baseline in all patients with >50% increase in value for NFL in 5/9 patients, in 7/9 patients for Tau and in 5/9 patients for GFAP. One patient developed spinal cord and supratentorial brain ischemia, confirmed with MRI. In this case, NF-L, GFAP and tau were markedly elevated compared with non-SCI patients (maximum increase compared with baseline in the SCI patient versus mean value of the maximal increase for all other patients: NF-L 367% vs 79%%, GFAP 95608% versus 3433%, tau 1020% vs 192%). CONCLUSION This study suggests an increase in all ten studied CSF biomarkers after coverage of spinal arteries during endovascular aortic repair. However, the pilot study was not able to establish a specific correlation between spinal fluid biomarker elevation and clinical symptoms of SCI due to small sample size and event rate.
Collapse
Affiliation(s)
- Gísli Gunnar Jónsson
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.
| | - Niklas Marklund
- Department of Neuroscience, Section of Neurosurgery, Uppsala University and Uppsala University Hospital; Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Neurosurgery, Lund, Sweden
| | - Kaj Blennow
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK; UK Dementia Research Institute at UCL, London, UK
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Surgical and Perioperative Sciences, Umeå University, Sweden
| | - David Lindström
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Jacob Eriksson
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| |
Collapse
|
46
|
Sulzinski MC, Rossi MJ, Alfawaz AA, Reynolds KB, Maloni KC, Kiguchi MM, Dearing JA, Abramowitz SD, Vallabhaneni R, Woo EY, Fatima J. Optimization of factors for the prevention of spinal cord ischemia in thoracic endovascular aortic repair. Vascular 2021; 30:199-205. [PMID: 33853456 DOI: 10.1177/17085381211007623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
Collapse
Affiliation(s)
| | - Matthew John Rossi
- Department of Vascular Surgery, Medstar Washington Hospital Center, Washington, DC, USA
| | - Abdullah A Alfawaz
- Department of Vascular Surgery, Medstar Washington Hospital Center, Washington, DC, USA
| | - Kyle B Reynolds
- Department of Vascular Surgery, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Krystal C Maloni
- Department of Vascular Surgery, Medstar Washington Hospital Center, Washington, DC, USA
| | - Misaki M Kiguchi
- Department of Vascular Surgery, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Joshua A Dearing
- Department of Vascular Surgery, Medstar Washington Hospital Center, Washington, DC, USA
| | - Steven D Abramowitz
- Department of Vascular Surgery, Medstar Washington Hospital Center, Washington, DC, USA
| | | | - Edward Y Woo
- Department of Vascular Surgery, Medstar Washington Hospital Center, Washington, DC, USA
| | - Javairiah Fatima
- Department of Vascular Surgery, Medstar Washington Hospital Center, Washington, DC, USA
| |
Collapse
|