Strategies for prevention of spinal cord ischemia in the management of thoracic and thoracoabdominal aneurysms

Abstract

Spinal cord ischemia (SCI) is undoubtedly the most devastating adverse event that occurs after either a thoracic aortic aneurysm (TAA) or thoracoabdominal aortic aneurysm (TAAA) repair. While open surgery techniques and minimally invasive endovascular options are now available for treating complex anatomy aortic aneurysms, spinal cord ischemia still occurs to a greater extent than desirable. Multiple risk factors have been associated with this adverse event, such as advanced age, perioperative hypotension, extent of the repair, and ligation of multiple intercostal and lumbar arteries during the surgical repair. The present literature review aims to analyze the contributing risk factors for SCI in the context of aortic surgery, explore the most relevant strategies for preventing postoperative SCI, and discuss the current management strategy when this complication occurs.

Keywords

Spinal cord ischemia / thoracic aneurysm / thoracoabdominal aneurysm / TEVAR / F/BEVAR / hypogastric artery patency / subclavian artery patency / lumbar drain / staged repair

References

[1] Ince H.Etiology, pathogenesis and management of thoracic aortic aneurysm.Nat Clin Pract Cardiovasc Med2007;4:418-27

[2] Isselbacher EM.Thoracic and abdominal aortic aneurysms.Circulation2005;111:816-28

[3] Bickerstaff LK,Hollier LH.Thoracic aortic aneurysms: a population-based study.Surgery1982;92:1103-8

[4] Stoecker JB.Epidemiology of thoracoabdominal aortic aneurysms.Semin Vasc Surg2021;34:18-28

[5] Coselli JS,Price MD.Spinal cord deficit after 1114 extent II open thoracoabdominal aortic aneurysm repairs.J Thorac Cardiovasc Surg2020;159:1-13

[6] Spanos K,Kubitz JC.Risk of spinal cord ischemia after fenestrated or branched endovascular repair of complex aortic aneurysms.J Vasc Surg2019;69:357-66

[7] De Bakey ME, Cooley DA. Successful resection of aneurysm of thoracic aorta and replacement by graft.J Am Med Assoc1953;152:673-6

[8] De Bakey ME, Cooley DA. Surgical treatment of aneurysm of abdominal aorta by resection and restoration of continuity with homograft.Surg Gynecol Obstet1953;97:257-66

[9] Etheredge SN,Smith JV,Goldman MJ.Successful resection of a large aneurysm of the upper abdominal aorta and replacement with homograft.Surgery1955;38:1071-81

[10] Nishi H,Tanaka H,Fukui S.Spinal cord injury in patients undergoing total arch replacement: a cautionary note for use of the long elephant technique.J Thorac Cardiovasc Surg2011;142:1084-9

[11] Chiesa R,Civilini E.Open repair of descending thoracic aneurysms.HSR Proc Intensive Care Cardiovasc Anesth2010;2:177-90 PMCID:PMC3484579

[12] Coselli JS,Preventza O.Outcomes of 3309 thoracoabdominal aortic aneurysm repairs.J Thorac Cardiovasc Surg2016;151:1323-38

[13] Liang NL,Fischbein MP.Midterm outcomes of endovascular repair of aortic arch aneurysms with the gore thoracic branch endoprosthesis.Eur J Vasc Endovasc Surg2022;64:639-45

[14] Matsumura JS,Dake MD,Svensson LG.International controlled clinical trial of thoracic endovascular aneurysm repair with the Zenith TX2 endovascular graft: 1-year results.J Vasc Surg2008;47:247-57; discussion 257

[15] Motta F,Kalbaugh CA.Outcomes and complications after fenestrated-branched endovascular aortic repair.J Vasc Surg2019;70:15-22

[16] Aucoin VJ,Novak Z.Predictors and outcomes of spinal cord injury following complex branched/fenestrated endovascular aortic repair in the US aortic research consortium.J Vasc Surg2023;77:1578-87

[17] Tenorio ER,Lima GBB,Oderich GS.Lessons learned over 2 decades of fenestrated-branched endovascular aortic repair.Semin Vasc Surg2022;35:236-44

[18] Wanhainen A,Van Herzeele I.Editor's choice - european society for vascular surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.Eur J Vasc Endovasc Surg2019;57:8-93

[19] Biglioli P,Cannata A.Upper and lower spinal cord blood supply: the continuity of the anterior spinal artery and the relevance of the lumbar arteries.J Thorac Cardiovasc Surg2004;127:1188-92

[20] Rojas S,RodríGuez-Baeza A.Variable anatomic configuration of the posterior spinal arteries in humans.Clin Anat2018;31:1137-43

[21] Colman MW,Schwab JH.Spinal cord blood supply and its surgical implications.J Am Acad Orthop Surg2015;23:581-91

[22] Hasan S. Neuroanatomy, spinal cord arteries. Treasure Island, FL: StatPearls Publishing; 2023.

[23] Melissano G,Bertoglio L,Campos Moraes Amato A.Angio-CT imaging of the spinal cord vascularisation: a pictorial essay.Eur J Vasc Endovasc Surg2010;39:436-40

[24] Griepp EB.The collateral network concept.Tex Heart Inst J2010;37:672-4 PMCID:PMC3014112

[25] Heidemann F,Rohlffs F.Staged procedures for prevention of spinal cord ischemia in endovascular aortic surgery.Gefasschirurgie2018;23:39-45 PMCID:PMC6096720

[26] Hiratzka LF,Beckman JA.2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine.Circulation2010;121:e266-369

[27] Coselli JS,Miller CC 3rd.Mortality and paraplegia after thoracoabdominal aortic aneurysm repair: a risk factor analysis.Ann Thorac Surg2000;69:409-14

[28] Agee JM,Blackbourne LH,Tribble CG.Reducing postischemic paraplegia using conjugated superoxide dismutase.Ann Thorac Surg1991;51:911-4

[29] Granke K,Zdrahal P.Longitudinal study of cerebral spinal fluid drainage in polyethylene glycol-conjugated superoxide dismutase in paraplegia associated with thoracic aortic cross-clamping.J Vasc Surg1991;13:615-21

[30] Lintott P,Stansby G.Spinal cord complications of thoracoabdominal aneurysm surgery.Br J Surg1998;85:5-15

[31] Fedorow CA,Mutch WA.Lumbar cerebrospinal fluid drainage for thoracoabdominal aortic surgery: rationale and practical considerations for management.Anesth Analg2010;111:46-58

[32] Feezor RJ.Strategies for detection and prevention of spinal cord ischemia during TEVAR.Semin Vasc Surg2009;22:187-92

[33] Xue L,Ding H.Risk of spinal cord ischemia after thoracic endovascular aortic repair.J Thorac Dis2018;10:6088-96 PMCID:PMC6297439

[34] Koo CH,Hwang JY,Shin HJ.Profound hypotension before aortic clamping can exacerbate spinal cord ischemic injury after aortic surgery in rats.J Clin Med2020;9:3395 PMCID:PMC7690663

[35] Conrad MF,Davison JK.Thoracoabdominal aneurysm repair: a 20-year perspective.Ann Thorac Surg2007;83:S856-61

[36] Kemp CM,Aftab M.Preventing spinal cord injury following thoracoabdominal aortic aneurysm repair: the battle to eliminate paraplegia.JTCVS Tech2021;8:11-5 PMCID:PMC8350759

[37] Banno H,Sato T.Low-density vulnerable thrombus/plaque volume on preoperative computed tomography predicts for spinal cord ischemia after endovascular repair for thoracic aortic aneurysm.J Vasc Surg2021;73:1557-65.E1

[38] Tanaka H,Matsuda H.Embolism is emerging as a major cause of spinal cord injury after descending and thoracoabdominal aortic repair with a contemporary approach: magnetic resonance findings of spinal cord injury.Interact Cardiovasc Thorac Surg2014;19:205-10

[39] Isoda S,Kawashima J,Yano Y.De-airing an open stent graft to potentially reduce spinal cord injury.Gen Thorac Cardiovasc Surg2019;67:566-8

[40] Ullery BW,Low D.Neurological complications of thoracic endovascular aortic repair.Semin Cardiothorac Vasc Anesth2011;15:123-40

[41] Alizadegan S.Delayed presentation of spinal cord ischemia after endovascular repair of a thoracoabdominal aneurysm.J Vasc Surg2015;62:835

[42] Furlan JC,Shannon P,Krassioukov AV.Descending vasomotor pathways in humans: correlation between axonal preservation and cardiovascular dysfunction after spinal cord injury.J Neurotrauma2003;20:1351-63

[43] Tsantili AR,Samolis A.Anatomical variations of human vertebral and basilar arteries: a current review of the literature.Morphologie2023;107:169-75

[44] Gomes VC,Queiroz A,Leão PP.Biomechanical analysis of cadaveric thoracic aorta zones: the isthmus is the weakest region.Ann Vasc Surg2021;77:263-73

[45] Rommens KL.Contemporary management of aortic arch aneurysm.Semin Thorac Cardiovasc Surg2019;31:697-702

[46] Rehman SM,Perera R.How to manage the left subclavian artery during endovascular stenting for thoracic aortic dissection? An assessment of the evidence.Ann Vasc Surg2010;24:956-65

[47] Buth J,Hobo R.Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. a study from the European collaborators on stent/graft techniques for aortic aneurysm repair (EUROSTAR) registry.J Vasc Surg2007;46:1103-11.E2

[48] Choo SJ.Commentary: different routes, same destination?.J Thorac Cardiovasc Surg2020;159:1231-2

[49] Dake MD,Han SM.Outcomes of endovascular repair of aortic aneurysms with the GORE thoracic branch endoprosthesis for left subclavian artery preservation.J Vasc Surg2022;76:1141-9.E3

[50] Maldonado TS,Rockman CB.Left subclavian artery coverage during thoracic endovascular aortic aneurysm repair does not mandate revascularization.J Vasc Surg2013;57:116-24

[51] Riesenman PJ,Mendes RR,Fulton JJ.Coverage of the left subclavian artery during thoracic endovascular aortic repair.J Vasc Surg2007;45:90-4

[52] Matsumura JS.Left subclavian artery revascularization: society for vascular surgery practice guidelines.J Vasc Surg2010;52:65S-70S

[53] Aydin A.Mechanisms and prevention of anterior spinal artery syndrome following abdominal aortic surgery.Angiol Sosud Khir2015;21:155-64

[54] Picone AL,Ricotta JR,Deweese JA.Spinal cord ischemia following operations on the abdominal aorta.J Vasc Surg1986;3:94-103

[55] Eagleton MJ,Petkosevek D,Greenberg RK.Hypogastric and subclavian artery patency affects onset and recovery of spinal cord ischemia associated with aortic endografting.J Vasc Surg2014;59:89-94

[56] Giosdekos A,Sfyroeras GS.The use of iliac branch devices for preservation of flow in internal iliac artery during endovascular aortic aneurysm repair.J Vasc Surg2020;71:2133-44

[57] Simonte G,Farchioni L.Lesson learned with the use of iliac branch devices: single centre 10 year experience in 157 consecutive procedures.Eur J Vasc Endovasc Surg2017;54:95-103

[58] Schneider DB,Lee JT,Chaer RA.Five-year outcomes from a prospective, multicenter study of endovascular repair of iliac artery aneurysms using an iliac branch device.J Vasc Surg2023;77:122-8

[59] Feezor RJ,Hess PJ Jr.Extent of aortic coverage and incidence of spinal cord ischemia after thoracic endovascular aneurysm repair.Ann Thorac Surg2008;86:1809-14; discussion 1814

[60] Flores J,Shiiya N,Matsuzaki K.Extensive deployment of the stented elephant trunk is associated with an increased risk of spinal cord injury.J Thorac Cardiovasc Surg2006;131:336-42

[61] Czerny M,Sodeck G.Mechanisms of symptomatic spinal cord ischemia after TEVAR: insights from the European registry of endovascular aortic repair complications (EuREC).J Endovasc Ther2012;19:37-43

[62] Afifi RO,Zaidi ST.Intercostal artery management in thoracoabdominal aortic surgery: to reattach or not to reattach?.J Thorac Cardiovasc Surg2018;155:1372-8.e1

[63] Jacobs MJ,Elenbaas T.Spinal cord blood supply in patients with thoracoabdominal aortic aneurysms.J Vasc Surg2002;35:30-7

[64] Marturano F,Giustiniano E,Piccioni F.Prevention of spinal cord injury during thoracoabdominal aortic aneurysms repair: what the anaesthesiologist should know.J Pers Med2022;12:1629 PMCID:PMC9605294

[65] Etz CD,Mueller CS.Staged repair significantly reduces paraplegia rate after extensive thoracoabdominal aortic aneurysm repair.J Thorac Cardiovasc Surg2010;139:1464-72

[66] O'Callaghan A,Eagleton MJ.Staged endovascular repair of thoracoabdominal aortic aneurysms limits incidence and severity of spinal cord ischemia.J Vasc Surg2015;61:347-54.E1

[67] Dias-Neto M,Huang Y.Comparison of single- and multistage strategies during fenestrated-branched endovascular aortic repair of thoracoabdominal aortic aneurysms.J Vasc Surg2023;77:1588-97.E4

[68] Geisbüsch S,Koruth JS.Endovascular coil embolization of segmental arteries prevents paraplegia after subsequent thoracoabdominal aneurysm repair: an experimental model.J Thorac Cardiovasc Surg2014;147:220-6 PMCID:PMC3918675

[69] Etz CD,Mohr FW.First-in-man endovascular preconditioning of the paraspinal collateral network by segmental artery coil embolization to prevent ischemic spinal cord injury.J Thorac Cardiovasc Surg2015;149:1074-9

[70] Branzan D,Moche M.Ischaemic preconditioning of the spinal cord to prevent spinal cord ischaemia during endovascular repair of thoracoabdominal aortic aneurysm: first clinical experience.EuroIntervention2018;14:828-35

[71] Addas JAK,Mahmood DN.Minimally invasive segmental artery coil embolization (MISACE) prior to endovascular thoracoabdominal aortic aneurysm repair.Cardiovasc Intervent Radiol2022;45:1462-9

[72] Petroff D,Kölbel T.Paraplegia prevention in aortic aneurysm repair by thoracoabdominal staging with 'minimally invasive staged segmental artery coil embolisation’ (MIS²ACE): trial protocol for a randomised controlled multicentre trial.BMJ Open2019;9:e025488 PMCID:PMC6429943

[73] Coselli JS,Köksoy C,Curling PE.Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial.J Vasc Surg2002;35:631-9

[74] Suarez-Pierre A,Gonzalez JE.Association of preoperative spinal drain placement with spinal cord ischemia among patients undergoing thoracic and thoracoabdominal endovascular aortic repair.J Vasc Surg2019;70:393-403

[75] Aucoin VJ,Farber MA.Spinal cord protection practices used during endovascular repair of complex aortic aneurysms by the U.S. aortic research consortium.J Vasc Surg2021;73:323-30

[76] Parodi FE,Oderich GS.The development and potential implications of the US Fenestrated and Branched Aortic Research Consortium.Semin Vasc Surg2022;35:380-4

[77] Kärkkäinen JM,Sen I.Cerebrospinal fluid drainage complications during first stage and completion fenestrated-branched endovascular aortic repair.J Vasc Surg2020;71:1109-18.E2

[78] Rong LQ,Rahouma M.Cerebrospinal-fluid drain-related complications in patients undergoing open and endovascular repairs of thoracic and thoraco-abdominal aortic pathologies: a systematic review and meta-analysis.Br J Anaesth2018;120:904-13

[79] Kakinohana M.What should we do against delayed onset paraplegia following TEVAR?.J Anesth2014;28:1-3

[80] Awad H,El Sayed HF,Tili E.Spinal cord injury after thoracic endovascular aortic aneurysm repair.Can J Anaesth2017;64:1218-35 PMCID:PMC5954412

[81] Rinaldi E,Favia N,Chiesa R.Spinal cord ischemia in open and endovascular aortic repair.Aorta2022;10:194-200 PMCID:PMC9754877

[82] Werndle MC,Phang I.Monitoring of spinal cord perfusion pressure in acute spinal cord injury: initial findings of the injured spinal cord pressure evaluation study.Crit Care Med2014;42:646-55

[83] Behzadi F,Zielke TJ.Risk factors associated with spinal cord ischemia during aortic aneurysm repair.Ann Vasc Surg2023;91:36-49

[84] Tenorio ER,Banga PV.Prospective assessment of a protocol using neuromonitoring, early limb reperfusion, and selective temporary aneurysm sac perfusion to prevent spinal cord injury during fenestrated-branched endovascular aortic repair.Ann Surg2022;276:e1028-34

[85] Tabayashi K,Akimoto H.Epidural cooling for regional spinal cord hypothermia during most or all of descending thoracic or thoracoabdominal aneurysm repair.Acta Chir Belg2002;102:224-9

[86] Bobadilla JL,Tefera G.Low incidence of paraplegia after thoracic endovascular aneurysm repair with proactive spinal cord protective protocols.J Vasc Surg2013;57:1537-42

[87] Donato T,Artru A.Effect of mannitol on cerebrospinal fluid dynamics and brain tissue edema.Anesth Analg1994;78:58-66

[88] Pascarella A,Bono F.Effect of mannitol bolus administration on cerebrospinal fluid pressure in patients with idiopathic intracranial hypertension: a pilot study.J Neurol2022;269:6158-64

[89] Kunihara T,Shiiya N,Yasuda K.Naloxone lowers cerebrospinal fluid levels of excitatory amino acids after thoracoabdominal aortic surgery.J Vasc Surg2004;40:681-90

[90] Hiramoto JS,Gasper W,Chuter T.Strict control of blood glucose with an intravenous insulin infusion decreases the risk of post-operative lower extremity weakness after complex endovascular aortic aneurysm repair.Eur J Vasc Endovasc Surg2019;58:848-53

[91] Hall ED.Neuroprotective actions of glucocorticoid and nonglucocorticoid steroids in acute neuronal injury.Cell Mol Neurobiol1993;13:415-32

[92] Laschinger JC,Cooper MM,Nathan IM.Prevention of ischemic spinal cord injury following aortic cross-clamping: use of corticosteroids.Ann Thorac Surg1984;38:500-7

[93] Acher C,Marks E.Intraoperative neuroprotective interventions prevent spinal cord ischemia and injury in thoracic endovascular aortic repair.J Vasc Surg2016;63:1458-65

[94] Pasqualucci A,Vaidyan KPT.Epidural corticosteroids, lumbar spinal drainage, and selective hemodynamic control for the prevention of spinal cord ischemia in thoracoabdominal endovascular aortic repair: a new clinical protocol.Adv Ther2020;37:272-87

[95] Estrera AL,Miller CC 3rd,Safi HJ.Neuromonitor-guided repair of thoracoabdominal aortic aneurysms.J Thorac Cardiovasc Surg2010;140:S131-5

[96] Sloan TB,Koht A.Intraoperative electrophysiologic monitoring in aortic surgery.J Cardiothorac Vasc Anesth2013;27:1364-73

[97] Kolesár D,Pavel J,Marsala J.Region-specific sensitivity of the spinal cord to ischemia/reperfusion: the dynamic of changes in catalytic NOS activity.J Physiol Sci2009;59:97-103

[98] Macdonald DB.Spinal cord monitoring during descending aortic procedures. In: Intraoperative monitoring of neural function. Amsterdam, The Netherlands: Elsevier; 2008. pp. 815-28.

[99] Bianchi F,Caravati H.Intraoperative neurophysiologic monitoring in thoracoabdominal aortic aneurysm surgery can provide real-time feedback for strategic decision making.Neurophysiol Clin2022;52:232-41

[100] Haghighi SS,Johnson JC,Oro JJ.Suppression of spinal and cortical somatosensory evoked potentials by desflurane anesthesia.J Neurosurg Anesthesiol1996;8:148-53

[101] Boezeman RP,Morshuis WJ.Spinal near-infrared spectroscopy measurements during and after thoracoabdominal aortic aneurysm repair: a pilot study.Ann Thorac Surg2015;99:1267-74

[102] Etz CD,Mueller CS.The collateral network concept: a reassessment of the anatomy of spinal cord perfusion.J Thorac Cardiovasc Surg2011;141:1020-8 PMCID:PMC3062787

[103] Vanpeteghem CM,De Hert SG.Assessment of spinal cord ischemia with near-infrared spectroscopy: myth or reality?.J Cardiothorac Vasc Anesth2020;34:791-6

[104] Kasprzak PM,Cucuruz B,Janotta M.Editor’s choice-temporary aneurysm sac perfusion as an adjunct for prevention of spinal cord ischemia after branched endovascular repair of thoracoabdominal aneurysms.Eur J Vasc Endovasc Surg2014;48:258-65

[105] Harrison SC,Harris PL.Elective sac perfusion to reduce the risk of neurologic events following endovascular repair of thoracoabdominal aneurysms.J Vasc Surg2012;55:1202-5

[106] Maurel B,Sobocinski J.The impact of early pelvic and lower limb reperfusion and attentive peri-operative management on the incidence of spinal cord ischemia during thoracoabdominal aortic aneurysm endovascular repair.Eur J Vasc Endovasc Surg2015;49:248-54

[107] Ito A,Ushijima K.Intraoperative spinal cord ischemia during thoracic endovascular aortic repair under epidural anesthesia: 4AP6-9.Eur J Anaesthesiol2014;31:70

[108] Tiesenhausen K,Koch G,Oberwalder P.Cerebrospinal fluid drainage to reverse paraplegia after endovascular thoracic aortic aneurysm repair.J Endovasc Ther2000;7:132-5

[109] Weissler EH,Raman V.Permissive hypertension and collateral revascularization may allow avoidance of cerebrospinal fluid drainage in thoracic endovascular aortic repair.Ann Thorac Surg2020;110:1469-74

[110] Aljarrah Q,Elheis M,Jamal A.Successful reversal of isolated delayed spinal cord ischemia following endovascular abdominal aneurysm repair.Vasc Health Risk Manag2019;15:81-7