Institutional Protocol for Prevention of TEVAR-related Spinal Cord Ischemia - The First 9 Cases.

ABSTRACT

INTRODUCTION: Spinal cord ischemia (SCI) is a feared complication after endovascular correction of thoracic aortic diseases (TEVAR). The guidelines of the European Society for Vascular Surgery recommend prophylactic lumbar drainage (LD) of cerebrospinal fluid in high-risk patients undergoing TEVAR. Our institutional protocol considers as high-risk patients as coverage of the origin of the Adamkiewicz artery (T9-T12), aortic coverage >15 cm, involvement of collaterals (treated or untreated abdominal aortic aneurysm, left subclavian artery revascularization or bilateral occlusion of the internal iliac arteries) and symptomatic SCI. The objective of the study was to demonstrate the efficacy and safety of LD in preventing or treating SCI after TEVAR. METHODS: Patients submitted to LD in the perioperative period of TEVAR under the institutional protocol, between May 2015 and April 2017, were prospectively included. PRIMARY OUTCOME: prevention and/or reversal of neurological symptoms (efficacy). Secondary Outcome: complications related to the technique (safety). RESULTS: We included 8 patients with thoracoabdominal aneurysms and 1 patient with type B aortic dissection, aged 63- 75 years. Eight interventions were elective and one was urgent. The LD catheter was placed before surgery in 8 cases and in the postoperative period in 1 case due to symptomatology of SCI that reverted after liquor drainage. Of those placed pre-operatively, 2 had symptoms of SCI in the postoperative period, which alleviated with increased drainage and hemodynamic and hemoglobin optimization. The patient undergoing urgent TEVAR for ruptured thoracoabdominal aneurysm evolved with multiorgan dysfunction and death 24 hours after surgery. There were no other complications. CONCLUSION: In this initial experience, the institutional protocol with LD placement proved to be safe and effective in preventing and treating SCI after TEVAR.