Results of a multidisciplinary spinal cord ischemia prevention protocol in elective repair of Crawford’s extent I-III thoracoabdominal aneurysms by fenestrated and branched endografts

Abstract

Aim: Fenestrated/branched endografting (F/B-EVAR) is an established technique to treat thoracoabdominal aortic aneurysms (TAAAs) in high-risk patients. Spinal cord ischemia/infarction (SCI) is a possible postoperative complication leading to deterioration in quality of life and decreased survival. Several strategies have been suggested in order to minimize its occurrence. The aim of this study was to report the outcomes of a dedicated multidisciplinary SCI prevention protocol for elective F/B-EVAR in Crawford’s extent I-III TAAAs.

Methods: All consecutive Crawford’s I-III TAAAs undergoing elective F/B-EVAR from 2010 to 2022 (March) in a single center were prospectively collected and retrospectively analyzed. A dedicated SCI prevention protocol was always adopted. The protocol included several surgical precautions, such as the collateral arterial network optimization, the adoption of a staged repair, and the early limbs reperfusion. Routine use of cerebral spinal fluid drainage (CSFD) was embraced. More anesthesiological measures were the maintenance of perioperative mean arterial pressure > 80 mm Hg, and blood hemoglobin levels > 10 mg/dL. Neurological measures were constituted by intraoperative monitoring with motor-evoked (MEPs) and somatosensory-evoked potentials (SSEPs) plus hourly bedside neurological evaluation during ICU stay. Preoperative comorbidity and postoperative complications were classified according to the Society of Vascular Surgery Reporting Standards. SCI, cardiac/pulmonary morbidities, postoperative hemodialysis, and 30-day/in-hospital mortality were assessed as early outcomes. Survival was evaluated during follow-up.

Results: Out of 104 patients, there were 6 (6%), 51 (49%), and 47 (45%) Crawford’s extent I, II, and III TAAAs, respectively. A staged TAAA repair, according to endograft design, anatomical and clinical characteristics, was performed in 83 (80%) cases. The mean hospital stay was 25 ± 22 days. Eight (8%) patients developed SCI, 2 (2%) transitory, and 6 (6%) permanent. Among those with permanent deficits, only 3 (3%) patients had permanent paraplegia with inability to walk. Out of 104 patients, 5 (5%) had cerebral hemorrhage, two among SCI patients. Postoperative cardiac and pulmonary morbidity was reported in 6 (6%) and 6 (6%) cases, respectively. Hemodialysis was necessary in 3 (3%) patients. Three patients died within 30 postoperative days and other 4 during a prolonged/complicated hospitalization, for an overall in-hospital mortality of 7%. The mean follow-up was 30 ± 18 months. The overall estimated 3-year survival was 62%, with a significant difference in survival at 2 years between patients with and without postoperative SCI (SCI: 18% vs. no-SCI: 69%; P < 0.001).

Conclusions: A dedicated multidisciplinary SCI prevention protocol in elective F/B-EVAR for Crawford’s I-III TAAAs is feasible and safe, with encouraging rates of SCI (8% overall SCI, 6% permanent impairment, and 3% paraplegia). The 30-day mortality (3%), cardiopulmonary morbidities (6%), and dialysis rate (3%) were satisfactory, as well as the estimated survival at 3 years (62%). Patients with SCI had a significantly lower survival (18% vs. 69%) at 2 years.

Keywords

Thoracoabdominal aortic aneurysm / endovascular repair / spinal cord ischemia / paraplegia / prevention protocol / cerebrospinal fluid drainage / motor-evoked potentials / somatosensory-evoked potentials

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