Incidence, predictors, and outcomes of spinal cord ischemia in elective complex endovascular aortic repair: An analysis of health insurance claims

J Vasc Surg. 2020 Sep;72(3):837-848. doi: 10.1016/j.jvs.2019.10.095. Epub 2020 Jan 28.

Abstract

Objective: This study aimed to determine predictors and outcomes associated with spinal cord ischemia (SCI) after elective fenestrated or branched endovascular aneurysm repair (F/BEVAR) of thoracoabdominal aortic aneurysm (TAAA), abdominal aortic aneurysm (AAA), or aortic dissection.

Methods: Health insurance claims data of Germany's third largest insurance provider, DAK-Gesundheit, were used to investigate SCI in elective F/BEVAR performed between 2008 and 2017. The International Classification of Diseases and German Operation and Procedure Classification System were used. We stratified the results into F/BEVAR with one or two (AAA) vs three or more (TAAA) fenestrations or branches.

Results: A total of 877 patients (18.9% female; 5.8% with SCI) matching the inclusion criteria were identified during the study period. SCI occurred more often after F/BEVAR of TAAA vs AAA (10.7% vs 3.0%; P < .001). SCI was associated with female sex in the AAA group (odds ratio, 3.87; 95% confidence interval [CI], 1.25-11.15; P = .014) and with cardiac arrhythmias in the TAAA group (odds ratio, 2.98; 95% CI, 1.24-7.06; P = .013). Compared with patients without SCI, SCI patients were more likely to suffer from drug use disorders (eg, opioids, cannabinoids, sedatives) in the TAAA group (17.6% vs 2.1%; P < .05). After F/BEVAR of TAAA, the occurrence of SCI was associated with higher 90-day mortality (14.7% vs 1.1%; P < .05), longer postoperative hospital stay (22 vs 9 days; P < .05), and severe adverse events, such as acute respiratory insufficiency (44.1% vs 12.7%), acute renal failure (35.3% vs 11.3%), and pneumonia (29.4% vs 4.9%; all P < .05). In adjusted analyses, SCI was associated with worse long-term survival after F/BEVAR for TAAA (hazard ratio, 2.54; 95% CI, 1.37-4.73; P < .003).

Conclusions: Female AAA patients and TAAA patients with cardiac arrhythmias are at highest risk for development of SCI after F/BEVAR. The occurrence of this event was strongly associated with higher major complication rates and worse short-term and long-term survival. This emphasizes a need to further illuminate the value of spinal cord protection protocols in F/BEVAR.

Keywords: Aortic aneurysm; Dissection; Endovascular technique; Health services research; Outcomes assessment; Spinal cord ischemia.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Administrative Claims, Healthcare*
  • Aged
  • Aged, 80 and over
  • Aortic Aneurysm, Abdominal / mortality
  • Aortic Aneurysm, Abdominal / surgery*
  • Aortic Aneurysm, Thoracic / mortality
  • Aortic Aneurysm, Thoracic / surgery*
  • Aortic Dissection / mortality
  • Aortic Dissection / surgery*
  • Arrhythmias, Cardiac / epidemiology
  • Blood Vessel Prosthesis Implantation / adverse effects*
  • Blood Vessel Prosthesis Implantation / mortality
  • Databases, Factual
  • Elective Surgical Procedures
  • Endovascular Procedures / adverse effects*
  • Endovascular Procedures / mortality
  • Female
  • Germany / epidemiology
  • Humans
  • Incidence
  • Male
  • Middle Aged
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Sex Factors
  • Spinal Cord Ischemia / epidemiology*
  • Spinal Cord Ischemia / mortality
  • Spinal Cord Ischemia / therapy
  • Time Factors
  • Treatment Outcome