Paraplegia in endovascular repair of TAA and in TEVAR: Incidence,

prevention and therapy

Johannes Lammer

Medical University Vienna, Austria

Conflict of interests:none

68y, male, PAU in coral reef aorta, distal embolization; paraplegia 24h after intervention

Spinal Cord Ischaemia in Endovascular Thoracicand Thoraco-abdominal Aortic Repair: Review ofPreventive Strategies. Dijkstra ML, Vainas T, Zeebregts CJ, Hooft L,

van der Laan MJ. Eur J Vasc Endovasc Surg. 2018 Mar 7.

43 studies (7168 patients).

Transient SCI in 5.7% (450/7,168)Permanent SCI in 2.2% (232/7,168)

Incidence of Spinal Cord Ischemia (SCI) after TEVAR of TAA, TAAA, and Acute Dissection

TEVAR OSRN % N % pAll paraplegia, paraparesis46/1,389 3.4 123/1,474 8.2 0.0001**Permanent paraplegia9/710 1.4 31/625 4.9 0.001**

*Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery†. Etz CD, et al. Eur J Cardiothorac Surg. 2015 Jun;47(6):943-57. **Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease a systematic review and meta-analysis of comparative studies. Cheng D, et al.J Am Coll Cardiol. 2010 Mar 9;55(10):986-1001.

Anatomy of spinal cord arterial supply

4 levels of supply:

• Subclavian arteries

• Intercostal arteries

• Lumbo-sacral arteries

• Hypogastric arteries

Imaging of anterior spinal artery (ASA)

ASA detectability was at 80-83% using CTA and 90-93% with time resolved MRA. Use of both CTA and MRA provided detection rates of 97%.MR angiography and CT angiography of the artery of Adamkiewicz: state of the art. Yoshioka K, et al. Radiographics. 2006 Oct;26 Suppl 1:S63-73.Identifying the Adamkiewicz artery using 3-T time-resolved magnetic resonance angiography: its role in addition tomultidetector computed tomography angiography. Takagi H, et al. Jpn J Radiol. 2015 Dec;33(12):749-56.

Risk factors for SCIafter TEVAR of TAA, TAAA, and Acute B-Dissection

• Previous aortic surgery (destruction of collateral arterial network).

• Length of covering the aorta.• Occlusion of > 1 level of arterial supply: i.e. additional

occlusion of left subclavian occlusion of hypogastric arteries.

• Post-OP hypotension (mean arterial pressure < 80mmHg).• High cerebro-spinal fluid (CSF) pressure (>10mmHg).• Patient age.• Renal insufficiency.

Strategies to prevent spinal cord ischemia

Arterial procedures:

• Imaging of arteria Adamkiewicz and spinal arterial supply.• In case of subclavian artery coverage, revascularization by

bypass, transposition, or stentgraft with side branch.• In case of bilateral hypogastric artery occlusion, use of distally

branched stentgraft.• Early removal of iliac artery flow blocking sheath.• Staged stenting: delayed connection of one side branch to

maintain sack perfusion for collateral artery development.• MISACE - minimal invasive spinal artery coil embolization before

stentgraft procedure to induce collateral artery development.

Strategies to prevent spinal cord ischemia

Medical precautions

• Cerebro-spinal fluid (CSF) drain 24 hours before endovascular procedure to enable heparinization without risk for epidural hematoma

• IMC/ICU stay for min. 48 hours (SCI detection after 0-72 hours, mean 10 h).

• Post-OP mean arterial pressure >80mmHg, to prevent spinal hypoperfusion.

• Cerebro-spinal fluid (CSF) pressure ≤ 10mmHg (spinal cord ischemia may cause oedematous swelling and CSF hypersecretion).

• Neurologic monitoring for min. 48 hours.

Strategies to treat spinal cord ischemia

• CSF drainage – pressure initially < 7mmHg, output not > 20ml/h.

• Systolic arterial pressure 120-130mmHg, mean arterial pressure > 80mmHg.

• Dexametasone, Mannitol 20%• Systemic hypothermia (35°C)

Conclusion

Incidence: • 3.4% - 5.7%Prevention: • preoperative protection of collateral flow• CSF catheter• ICU monitoring (RR, neurology, CSF pressure)Treatment:• CSF drainage• RR increase• Dexametasone, Mannitol 20%