Mid-term follow-up of patients with permanent sequel due to spinal cord ischemia after advanced endovascular therapy for extensive aortic disease

Complications associated with lumbar drain placement for endovascular aortic repair

OBJECTIVE

We reviewed the complications associated with perioperative lumbar drain (LD) placement for endovascular aortic repair.

METHODS

Patients who had undergone perioperative LD placement for endovascular repair of thoracic and thoracoabdominal aortic pathologies from 2010 to 2019 were reviewed. The primary endpoints were major and minor LD-associated complications. Complications that had resulted in neurological sequelae or had required an intervention or a delay in operation were defined as major. These included intracranial hemorrhage, symptomatic spinal hematoma, cerebrospinal fluid (CSF) leak requiring intervention, meningitis, retained catheter tip, arachnoiditis, and traumatic (or bloody) tap resulting in delayed operation. Minor complications were defined as a bloody tap without a delay in surgery, asymptomatic epidural hematoma, and CSF leak with no intervention required. Isolated headaches were recorded separately owing to the minimal clinical impact.

RESULTS

A total of 309 LDs had been placed in 268 consecutive patients for 222 thoracic endovascular aortic repairs, 85 complex endovascular aortic repairs (EVARs; fenestrated branched EVAR/parallel grafting), and 2 EVARs (age, 65 ± 13 years; 71% male) for aortic pathology, including aneurysm (47%), dissection (49%), penetrating aortic ulcer (3%), and traumatic injury (0.6%). A dedicated neurosurgical team performed all LD procedures; most were performed by the same individual, with a technical success rate of 98%. Radiologic guidance was required in 3%. The reasons for unsuccessful placement were body habitus (n = 2) and severe spinal disease (n = 3). Most were placed prophylactically (96%). The overall complication rate was 8.1% (4.2% major and 3.9% minor). Major complications included spinal hematoma with paraplegia in 1 patient, intracranial hemorrhage in 2, meningitis in 2, arachnoiditis in 3, CSF leak requiring a blood patch in 3, bloody tap delaying the operation in 1, and a retained catheter tip in 1 patient. Patients who had undergone previous LD placement had experienced significantly more major LD-related complications (12.2% vs 3%; P = .019). The rate of total LD-associated complications did not differ between prophylactic and emergent therapeutic placements (8.1% vs 7.7%; P = 1.00) nor between major or minor complications. On multivariate analysis, previous LD placement and an overweight body mass index were the only independent predictors of major LD-related complications.

CONCLUSIONS

The complications associated with LD placement can be severe even when performed by a dedicated team. Previous LD placement and overweight body mass index were associated with a significantly greater risk of complications; however, emergent therapeutic placement was not. Although these risks are justified for therapeutic LD placement, the benefit of prophylactic LD placement to prevent paraplegia should be weighed against these serious complications.

Quadriplegia and quadriparesis after endovascular aortic procedures: a catastrophic and under-reported complication?

In this study are presented three cases of spinal cord ischemia (SCI) involving the cervical-dorsal level and leading to quadriplegia and quadriparesis, following thoraco-abdominal aortic aneurysm (TAAA) endovascular repair. A 79-year-old woman with an extent III TAAA was scheduled for a multi-step fenestrated/branched endovascular aortic repair. Immediately after the first step, consisting of standard proximal thoracic stent-graft implantation, she developed quadriplegia that did not resolve despite all therapeutic actions, and died therefore on postoperative day 32. A 72-year old male with an extent IV TAAA underwent endovascular repair, using a customized fenestrated aortic stent-graft. Five hours after the procedure, he developed an asymmetric quadriparesis, that progressively resolved after spinal fluid drainage and arterial pressure increase, even if signs of SCI were documented at magnetic resonance imaging (MRI). A 79-year old man, referred for a type II TAAA with rapid enlargement, underwent a one-stage endovascular repair, using a customized branched aortic stent-graft. As soon as the procedure was completed, the patient presented inferior limbs paralysis and upper limbs paresis. Although no signs of SCI were documented at MRI, the patient did not recover and died therefore three months after the procedure. Although rare, cervical-dorsal SCI may develop during TAAA endovascular aortic repair. This possibly catastrophic event should be considered in the decisional process of TAAA repair and considered to allow prompt recognition and treatment.

Engaging patients and caregivers in establishing research priorities for aortic dissection

Objectives:

The aim of this study was to establish the top 10 research uncertainties in aortic dissection together with the patient organization Aortic Dissection Association Scandinavia using the James Lind Alliance concept.

Methods:

A pilot survey aiming to identify uncertainties sent to 12 patients was found to have high content validity (scale content validity index = 0.91). An online version of the survey was thereafter sent to 30 patients in Aortic Dissection Association Scandinavia and 45 caregivers in the field of aortic dissection. Research uncertainties of aortic dissection were gathered, collated and processed.

Results:

Together with research priorities retrieved from five different current guidelines, 94 uncertainties were expressed. A shortlist of 24 uncertainties remained after processing for the final workshop. After the priority-setting process, using facilitated group format technique, the ranked final top 10 research uncertainties included diagnostic tests for aortic dissection; patient information and care continuity; quality of life; endovascular and medical treatment; surgical complications; rehabilitation; psychological consequences; self-care; and how to improve prognosis.

Conclusion:

These ranked top 10 important research priorities may be used to justify specific research in aortic dissection and to inform healthcare research funding decisions.

Spinal cord injury after thoracic endovascular aortic aneurysm repair

PURPOSE

Thoracic endovascular aortic aneurysm repair (TEVAR) has become a mainstay of therapy for aneurysms and other disorders of the thoracic aorta. The purpose of this narrative review article is to summarize the current literature on the risk factors for and pathophysiology of spinal cord injury (SCI) following TEVAR, and to discuss various intraoperative monitoring and treatment strategies.

SOURCE

The articles considered in this review were identified through PubMed using the following search terms: thoracic aortic aneurysm, TEVAR, paralysis+TEVAR, risk factors+TEVAR, spinal cord ischemia+TEVAR, neuromonitoring+thoracic aortic aneurysm, spinal drain, cerebrospinal fluid drainage, treatment of spinal cord ischemia.

PRINCIPAL FINDINGS

Spinal cord injury continues to be a challenging complication after TEVAR. Its incidence after TEVAR is not significantly reduced when compared with open thoracoabdominal aortic aneurysm repair. Nevertheless, compared with open procedures, delayed paralysis/paresis is the predominant presentation of SCI after TEVAR. The pathophysiology of SCI is complex and not fully understood, though the evolving concept of the importance of the spinal cord's collateral blood supply network and its imbalance after TEVAR is emerging as a leading factor in the development of SCI. Cerebrospinal fluid drainage, optimal blood pressure management, and newer surgical techniques are important components of the most up-to-date strategies for spinal cord protection.

CONCLUSION

Further experimental and clinical research is needed to aid in the discovery of novel neuroprotective strategies for the protection and treatment of SCI following TEVAR.