Rescue therapy for symptomatic spinal cord ischemia after thoracic endovascular aortic repair

John R Spratt; Kristen L Walker; Dan Neal; George J Arnaoutakis; Tomas D Martin; Martin R Back; Yury Zasimovich; Michael Franklin; Zain Shahid; Gilbert R Upchurch Jr; Salvatore T Scali; Thomas M Beaver

doi:10.1016/j.jtcvs.2022.10.045

Rescue therapy for symptomatic spinal cord ischemia after thoracic endovascular aortic repair

J Thorac Cardiovasc Surg. 2022 Nov 5:S0022-5223(22)01168-0. doi: 10.1016/j.jtcvs.2022.10.045. Online ahead of print.

Affiliations

¹ Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla. Electronic address: john.spratt@surgery.ufl.edu.
² Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla.
³ Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla.
⁴ Acute and Perioperative Pain Medicine Division, Department of Anesthesia, University of Florida, Gainesville, Fla.

PMID: 36509568
DOI: 10.1016/j.jtcvs.2022.10.045

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.

Keywords: aortic aneurysm; aortic dissection; cerebrospinal fluid drain; perioperative management; spinal cord ischemia; thoracic aortic aneurysm; thoracic endovascular aortic repair; thoracoabdominal aortic aneurysm.