Effect of the urgency and landing zone on rates of in-hospital death, stroke, and paraplegia after thoracic endovascular aortic repair in Japan.

OBJECTIVE: The present study used data from the Japanese Committee for Stentgraft Management's national registry, which contains unique surgical data, including surgical timing, anatomic factors, and pathologic factors, to determine the generalized community experience with thoracic endovascular abdominal aortic repair (TEVAR). METHODS: The medical background and short-term outcomes were reviewed for patients who had undergone TEVAR for a thoracic aortic aneurysm (TAA; 14,235 cases) or aortic dissection (AD; 990 type A and 4259 type B) from 2008 to 2015. TEVAR for AD was separated from that for TAAs; only the background and short-term outcomes were evaluated. The technical outcomes of TEVAR for TAA were also evaluated. All the cases were categorized as follows: elective, urgent (within 24 hours after admission), or emergent (immediately after admission). The outcomes included in-hospital mortality and persistent stroke and paraplegia diagnosed at discharge. The number of debranching bypasses, proximal landing zone (0, 1, 2, ≥3), and zone length were included in the logistic regression analysis. RESULTS: The mortality, stroke, and paraplegia rates in the TAA and AD groups were 4.4%, 4.6%, and 3.7% and 4.0%, 2.9%, and 2.8%, respectively. After analyzing the TAA cohort, we found that urgent and emergent cases were associated with all adverse outcomes. The rate of paraplegia increased drastically in the patients with stent graft coverage that extended for six or more zones. Massive atheroma was associated with stroke and paraplegia. The cumulative survival rate of the TAA group was stratified by the urgency (ie, elective, urgent, emergent; P < .001). We found that the more proximal (0, 1, and 2) the landing zone, the greater the risk of stroke. Likewise, the longer (six or more zones) the coverage, the greater the risk of paraplegia. CONCLUSIONS: Urgency was strongly associated with mortality, stroke, and paraplegia, and the classification of urgent and emergent, according to the surgical timing after admission, successfully stratified the population in the long-term overall survival analysis. A proximal landing zone involving the aortic arch and debranching bypasses were associated with the occurrence of stroke, and the length of stent graft coverage for six or more zones was associated with paraplegia. Identifying these risk factors will help operators of TEVAR develop appropriate operative strategies to mitigate patient risk.

Excess burden of a chronic disabling condition: life lost due to traumatic spinal cord injury in a Swiss population-based cohort study.

OBJECTIVES: To estimate excess mortality and life years lost in a Swiss cohort of individuals with traumatic spinal cord injury (TSCI). METHODS: This study uses population-based data collected in the Swiss Spinal Cord Injury Cohort (SwiSCI) study, which covers all specialized rehabilitation centres. Flexible parametric survival models were used to model life years remaining (LYR), potential years life lost (PYLL), relative survival and excess hazard ratios. RESULTS: Men and women with TSCI and an attained age of 30 were estimated to have 42 LYR (95% CI = 37.9-45.5) and 43 LYR (95% CI = 40.1-45.5), respectively; this equates to a life expectancy (LE) of 80.6 and 76.9% of that of the Swiss general population. With respect to lesion level and completeness, persons with incomplete paraplegia had 45.1 LYR at an attained age of 30, whereas individuals with complete tetraplegia only had 28.7 LYR. This pattern was similar for PYLL. CONCLUSIONS: The extended LE following TSCI, even for the most severe lesions, underscores the need for sustained follow-up to support functioning and health for individuals ageing with SCI.

Differential survival after traumatic spinal cord injury: evidence from a multi-center longitudinal cohort study in Switzerland.

STUDY DESIGN: Observational cohort study. OBJECTIVES: To understand differentials in the force of mortality with increasing time since injury according to key spinal cord injury (SCI) characteristics. SETTING: Specialized rehabilitation centers within Switzerland. METHODS: Data from the Swiss Spinal Cord Injury (SwiSCI) cohort study were used to model mortality in relation to age, sex, and lesion characteristics. Hazard ratios (HRs) and adjusted survival curves were estimated using flexible parametric survival models of time since discharge from first rehabilitation to death or 30 September 2011, whichever came first. RESULTS: 2 421 persons were included that incurred a new TSCI between 1990 and 2011, contributing a total time-at-risk of 19,604 person-years and 376 deaths. Controlling for attained age, sex, decade, and etiology, there was more than a four-fold higher risk of mortality for complete tetraplegia compared to incomplete paraplegia (HR = 4.27; 95% CI 2.72 to 6.69). Survival estimates differed according to SCI characteristics, with differentials steadily increasing with time since injury. CONCLUSION: This study provides evidence of disparities in mortality and survival outcomes according to SCI characteristics that increases with increasing time since injury. These results lend support to the hypothesis of a progressive and disproportionate accumulation of allostatic load according to SCI characteristics. Future research should investigate cause-specific mortality for insight into potentially modifiable secondary health conditions contributing to these disparities.

Fluctuations in Spinal Cord Perfusion Pressure: A Harbinger of Delayed Paraplegia After Thoracoabdominal Aortic Repair.

Delayed paraplegia (DP) following thoracoabdominal or descending thoracic aortic (TAA/DTA) repair is a dreaded complication. We reviewed our experience with the management of DP using our previously described COPS protocol (blood-pressure stabilization, cerebrospinal-fluid (CSP) draining and O2-delivery). Complete documentation of hourly CSP pressures and detailed hemodynamic variables were available since 2000. A case-control design was used to analyze the extensive hourly data in the perioperative period. Data were analyzed by contingency-tables, t test, and regression analysis, as appropriate. Between 2000 and 2011, we performed 1059 TAA/DTA repairs. Of these, 47 (4.4%) had DP and 31 (2.9%) had immediate neurologic deficit. Postoperatively, renal replacement therapy and drain complications were significantly associated with DP. Variation in systolic blood pressure (SBP) was also highly predictive. Similarly, spinal-cord perfusion pressure (SCPP = SBP ? SP) showed increased risk with greater variability closer to event day (OR 1.3, P = 0.009). Fluctuation of more than 15 mmHg in SBP in a 24-hour period was associated with 3.2-fold increased odds of DP (P = 0.004). In all, 8/47 (17%) made a full recovery, whereas 19 (40%) had partial recovery by discharge. The 30-day mortality was 18/47 (38%) in DP and 7/55 (13%) in controls (P < 0.001). Long-term survival was significantly lower among DP cases (5-year survival of 28% vs. 75%, P < 0.001). DP occurs infrequently and is predictably associated with intraoperative loss of MEP, postoperative renal replacement therapy, drain complications and unstable systolic and spinal-cord perfusion pressures. Increased vigilance is recommended for patients who experience any of these events.

Clinical and pathologic features of Aicardi-Goutières syndrome due to an IFIH1 mutation: A pediatric case report.

We describe the case of a young patient with calcifying encephalopathy, born to asymptomatic parents. An extensive hypothesis-driven etiological assessment was performed and failed to detect the precise etiology during many years. We therefore decided to perform whole exome sequencing of the child-unaffected parents trio. A de novo pathogenic variant in the IFIH1 gene which has recently been shown to cause autosomal dominant forms of Aicardi-Goutières syndrome was identified. This child presented with a severe form with neonatal thrombocytopenia and hepatomegaly, the latter having been detected during late gestation. Although first milestones were uneventful, he progressively lost motor skills from the age of 12 months and developed severe spastic paraplegia. Brain imaging revealed white matter abnormalities and extensive calcifications. He also presented atypical skin lesions, different from chilblains. His medical history was marked by two episodes of acute pancreatitis. We provide herein the results of pathological examination including detailed description of the neuropathological hallmarks. To our knowledge, this the first detailed clinico-pathological description of a patient with an IFIH1 pathogenic variant.

Community-based InterVentions to prevent serIous Complications (CIVIC) following spinal cord injury in Bangladesh: protocol of a randomised controlled trial.

INTRODUCTION: In low-income and middle-income countries, people with spinal cord injury (SCI) are vulnerable to life-threatening complications after they are discharged from hospital. The aim of this trial is to determine the effectiveness and cost-effectiveness of an inexpensive and sustainable model of community-based care designed to prevent and manage complications in people with SCI in Bangladesh. METHODS AND ANALYSIS: A pragmatic randomised controlled trial will be undertaken. 410 wheelchair-dependent people with recent SCI will be randomised to Intervention and Control groups shortly after discharge from hospital. Participants in the Intervention group will receive regular telephone-based care and three home visits from a health professional over the 2 years after discharge. Participants in the Control group will receive standard care, which does not involve regular contact with health professionals. The primary outcome is all-cause mortality at 2 years. Recruitment started on 12 July 2015 and the trial is expected to take 5 years to complete. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Institutional Ethics Committee at the site in Bangladesh and from the University of Sydney, Australia. The study will be conducted in compliance with all stipulations of its protocol, the conditions of ethics committee approval, the NHMRC National Statement on Ethical Conduct in Human Research (2007), the Note for Guidance on Good Clinical Practice (CPMP/ICH-135/95) and the Bangladesh Guidance on Clinical Trial Inspection (2011). The results of the trial will be disseminated through publications in peer-reviewed scientific journals and presentations at scientific conferences. TRIAL REGISTRATION NUMBERS: ACTRN12615000630516, U1111-1171-1876.

Mean platelet volume to platelet count ratio predicts in-hospital complications and long-term mortality in type A acute aortic dissection.

Type A acute aortic dissection is a life-threatening vascular emergency because of its high morbidity and mortality. Platelet is a pivotal ingredient involved in the development of acute aortic dissection. In this study, we aimed to investigate whether mean platelet volume (MPV)/platelet count ratio predicts in-hospital complications and long-term mortality in type A acute aortic dissection. In this single-center and prospective cohort study, 106 consecutive patients with Stanford type A acute aortic dissection admitted to the hospital within 12 h after onset were recruited. The best cut-off value of MPV/platelet count ratio predicting all-cause mortality was determined by the receiver operator characteristic analysis. Patients were divided into high (H-MPV/platelet count) and low (L-MPV/platelet count) groups based on the cut-off value of 7.49 (10 fl/10/l). Patients were followed up for 3.5 years. Of the 106 acute aortic dissection patients, 71 (67.0%) died during the study period, with a median follow-up duration of 570 days. Compared to the L-MPV/platelet count group, patients with H-MPV/platelet count had a higher risk of in-hospital complications including hypotension, hypoxemia, myocardial ischemia/infarction, conscious disturbance, pericardial tamponade, paraplegia, and poor survival (all P < 0.05). In multivariable Cox regression models adjusted for potential confounders, MPV/platelet count ratio was positively associated with the hazard of all-cause mortality, irrespective of interventions either with medication only or urgent surgery, and the hazard ratios were 2.81 (95% confidence interval 1.28-4.48) for the H-MPV/platelet count group when taking L-MPV/platelet count group as the reference (P = 0.005). The MPV/platelet count ratio was a strong independent predictor for in-hospital complications and long-term mortality in patients with type A acute aortic dissection.

Endemic Burkitt Lymphoma: Long-term Outcome in 87 Patients Who Presented With Paraplegia in Cameroon.

The reported long-term outcome of endemic Burkitt lymphoma (eBL) patients who present with paraplegia is largely unknown. Records of BL patients treated with comparable short-interval cyclophosphamide chemotherapy schedules between 2004 and 2014 at three Baptist mission hospitals in Cameroon were reviewed. Survivors were followed up and examined at home or in hospital. Eighty-seven of 948 (9.2%) patients had paraplegia at diagnosis. The survival rate in eBL patients with paraplegia at diagnosis was 33% (n = 29) after follow-up of between 2 and 96 (median 40) months. Seven patients (24%) had neurological sequelae and needed rehabilitation. There was no relationship between the duration of symptoms (<2, 2-4, >4 weeks) and the survival rate or the risk to have neurological sequelae. The survival rate and risk for sequelae were similar in patients with confirmed St. Jude stage III and IV diseases.

Predictors of outcome in patients with spinal cord ischemia after open aortic repair.

INTRODUCTION: Spinal cord ischemia is a potentially devastating complication of thoracic aortic surgery. However, predictors of outcome have not been well characterized. The study objective was to generate a prognostic score that accurately stratifies patient outcomes, aiding in future management and planning. METHODS: A retrospective review of 224 consecutive open thoracic aortic surgeries identified patients with spinal cord ischemia, defined as changes on intraoperative somatosensory evoked potentials (SSEP) and/or paraparesis/paraplegia postoperatively. The outcome of interest was poor outcome, defined as death or discharge with a lower extremity motor score ≤40, indicating impaired ambulation. Demographic and clinical characteristics were tested in univariate analyses and significant factors were incorporated in multivariate modeling to determine independent predictors of poor outcome. RESULTS: Seventy-five patients were identified with spinal cord ischemia, of which 43(57 %) had poor outcomes including 28(37 %) that died prior to discharge. Factors associated with poor outcome in univariate analysis included absent lumbar CSF drain (p = 0.03), surgical repair that crossed the diaphragm (p = 0.002), permanent intraoperative SSEP change (p = 0.02), postoperative renal failure (p = 0.004), paraplegia (p = 0.001), and concomitant stroke (p = 0.04). In multivariable analysis, surgical repair crossing the diaphragm (OR 4.8, CI 1.4-16.7, p = 0.02), paraplegia (OR 4.5, CI 1.4-14.0, p = 0.01), and renal failure (OR 6.1, CI 1.7-21.2, p = 0.005) were independently associated with poor outcome. Patients with transient intraoperative neurophysiologic changes were least likely to have poor outcome when compared to patients with no or permanent SSEP changes, and those not monitored (p = 0.03). CONCLUSION: Development of spinal cord ischemia with thoracic aortic repair often leads to death or disability. Characteristics known at the time of event can accurately predict the likelihood of poor outcome.

Pressure sores significantly increase the risk of developing a Fournier's gangrene in patients with spinal cord injury.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: The aim of our study was to evaluate the mortality rate and further specific risk factors for Fournier's gangrene in patients with spinal cord injury (SCI). SETTING: Division of Spinal Cord Injury, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Germany. METHODS: All patients with a SCI and a Fournier's gangrene treated in our hospital were enrolled in this study. Following parameters were taken form patients medical records: age, type of SCI, cause of Fournier's gangrene, number of surgical debridements, length of hospital and intensive care unit stay, co morbidity factors and mortality rate. In addition, laboratory parameter including the laboratory risk indicator for necrotizing fasciitis (LRINEC) score and microbiological findings were analyzed. Clinical diagnosis was made via histological examination. RESULTS: A total of 16 male patients (15 paraplegic and one tetraplegic) were included in the study. In 81% of all cases, the origin of Fournier's gangrene was a pressure sore. The median LRINEC score on admission was 6.5. In the vast majority of cases, a polybacterial infection was found. No patient died during the hospital stay. The mean number of surgical debridements before soft tissue closure was 1.9 and after a mean time interval of 39.1 days wound closure was performed in all patients. CONCLUSIONS: Pressure sores significantly increase the risk of developing Fournier's gangrene in patients with SCI. We reported the results of our patients to increase awareness among physicians and training staff working with patients with a SCI in order to expedite the diagnosis.

[What are the causes of death in patients with spinal cord injury today?--a descriptive analysis of 102 cases]. / Woran sterben Querschnittgelähmte heute?--Eine Nachuntersuchung von 102 Fällen.

As there are only few reliable data concerning mortality of SCI patients, this retrospective monocentric cohort study was carried out. Despite essential improvements in intensive medical care from the accident scene to clinic life, comprehensive rehabilitation, and implementation of a lifelong aftercare system, the life expectancy of SCI patients is still reduced. Especially patients with high tetraplegia die significantly earlier from pulmonary complications. The longer the onset of SCI is survived, the more patients die from age-related diseases. In old paraplegic patients, pressure sores are the only major SCI-related complication. Successful social reintegration and professional care are the most important factors for an expanded lifespan after occurrence of a SCI. Hence, the special impact of lifelong treatment of SCI patients ("comprehensive care") is confirmed.

Metastatic paraplegia and vital prognosis: perspectives and limitations for rehabilitation care. Part 1.

OBJECTIVE: To evaluate the vital prognosis of patients with metastatic epidural spinal cord compression (MESCC) to determine the relevance and duration of physical medicine and rehabilitation (PM&R) admission. DATA SOURCES: Publications from 1980 to January 2010 selected from 3 databases. STUDY SELECTION: Publications reporting data correlated with survival and prognosis factors, highlighting publications with level A scientific evidence (prospective randomized controlled studies with significant casuistry and relevant judgment criteria). The work focused on patients with MESCC below T1. DATA EXTRACTION: Standardized reading grid. DATA SYNTHESIS: Thirty-eight studies met the inclusion criteria. Most were retrospective. For survival rate at 1 year, they reported data ranging from 12% to 58%. The 12-month and median survival rates were the data reported most often in the articles. The median survival rate ranged from 2.4 to 30 months, and 12-month survival rates ranged from 12% to 58%. Of publications that chose this parameter, 95% reported 12-month survival rates less than 55.2% (95th percentile) regardless of patients' functional status and associated risk factors (eg, location of primary cancer, metastases spreading, pretreatment ambulatory status). CONCLUSIONS: Despite major progress in cancer care, patients with MESCC still have a limited vital prognosis. The relevance and duration of PM&R care must be evaluated against the patient's functional need for rehabilitation while making time for family. The hypothesis of a 1-month stay extended only once appears reasonable for patients to adapt to their new functional status without taking precious time away from their loved ones.

Metastatic paraplegia and functional outcomes: perspectives and limitations for rehabilitation care. Part 2.

OBJECTIVE: To identify functional outcomes that could justify the need for a rehabilitation care program for patients with metastatic epidural spinal cord compression (MESCC) and paraplegia. DATA SOURCES: Publications from 1950 to January 2010 selected from 3 databases. STUDY SELECTION: Original articles dealing with outcome data for functional status, pain, and bladder dysfunction. DATA EXTRACTION: Standardized reading grid. DATA SYNTHESIS: The data are dominated by retrospective studies for even functional-related data, and studies from rehabilitation teams are rare. They report a functional evolution similar to a population with traumatic spinal cord injury for the first 3 months. Patients who were ambulatory before treatment retained their ability to walk, and patients who were nonambulatory before treatment could regain gait abilities. Data also showed a positive impact on pain and bladder and/or bowel dysfunction. CONCLUSIONS: By restricting physical medicine and rehabilitation therapeutic care to a short time (1-2mo), the progression margin is possible in the short term and implies a voluntary and active therapeutic care approach for patients with paraplegia after MESCC on the basis of a codified and standardized program with clinical indicators, as well as patients' comfort indicators.

Metastatic paraplegia: care management characteristics within a rehabilitation center.

STUDY DESIGN: Retrospective study. OBJECTIVES: To determine the potential impact of rehabilitation care on associated symptoms and functional improvements of paraplegic patients with metastatic spinal cord compression. SETTING: CMN Propara, Montpellier (France). MEASURES: Demographics, Functional Independence Measure (FIM), Frankel Modified Score and Visual Analog Scale (VAS) for pain, intercurrent adverse medical events and neurological outcome, duration of stay, survival time, rehospitalization in a non-Spinal Cord Injury unit, number of contracts defining the patients rehabilitation goals, number of contracts defining the patients duration of stay within the rehabilitation center. RESULTS: We reviewed the charts of 26 patients. The initial neurological profile was paraplegia or paraparesis for 24 patients and quadriparesis for 2 patients. Regarding functional improvements: four patients demonstrated a poor functional evolution, five patients showed no functional improvements or very slight improvements and all the other patients showed an increase in their overall functional aptitudes. At the end of the stay, 14 patients were urinary independent. Our study reports 52 rehospitalizations in an another unit and 101 outpatient visits during their rehabilitation stay in a physical medicine and rehabilitation (PM&R) center. For the 14 patients who were deceased at the time of data collection, the median survival rate post-paraplegia was 12.7 months. A total of 12 of the 14 patients spent more than a third of their remaining survival time in a rehabilitation center. DISCUSSION: Compared to the patients' life expectancy, their stay in a rehabilitation center is too long and prevents them from spending time with family and loved ones. The occurrence rate of the associated symptoms is high because of both cancer-related disorders and neurological disorders caused by the spinal cord lesion. PM&R professionals are faced with patients affected by chronic pain and fatigue as well as frequent rehospitalizations, short stays and outpatient stays, in the primary oncology unit. This study focuses on the need to privilege the patients' comfort over their functional rehabilitation.

Tokuhashi prognosis score: an important tool in prediction of the neurological outcome in metastatic spinal cord compression: a retrospective clinical study.

STUDY DESIGN: Retrospective clinical study. OBJECTIVE: The aim of this study was to examine whether the Tokuhashi score correlates with the neurologic outcome in early surgical treatment in metastatic spinal cord compression (MSCC). A retrospective analysis of 35 consecutive incomplete tetraplegic and paraplegic patients with vertebral metastases (VM) and spinal cord compression (SCC) was performed. SUMMARY OF BACKGROUND DATA: MSCC is a challenging problem in VM and constitutes an oncologic emergency. The Tokuhashi score has been modified recently and seems to constitute the best method of prediction for real survival in patients with VM. Until now the influence of the neurologic status as a prognostic factor has been discussed controversially. METHODS: Data of 35 patients with VM and incomplete tetraplegia or paraplegia, who underwent surgical treatment, were reviewed retrospectively from 2005 to 2006 at our hospital. All patients were classified among the American Spinal Injury Association (ASIA) Impairment Scale (AIS) before and after surgery and at the follow-up. Data were analyzed with SPSS 15.0 and correlation coefficients (Spearman rho) were computed. RESULTS: Analysis showed that 19 patients (54.3%) with an average Tokuhashi score of 9 showed an improvement in the AIS, whereas 12 (34.3%) patients with an average score of 8 had no change and 4 (11.4%) patients with a score of 7 had deterioration. AIS changes showed a positive correlation with Tokuhashi score (r = 0.33; P = 0.048). CONCLUSION: Our clinical observation suggests that patients with spinal metastases and a high Tokuhashi score benefit from surgical treatment with moderate improvement in sensomotoric function even in a heterogenic collective.

Dalteparin vs low-dose unfractionated heparin for prophylaxis against clinically evident venous thromboembolism in acute traumatic spinal cord injury: a retrospective cohort study.

BACKGROUND: When venous thromboembolism (VTE) includes deep-vein thrombosis (DVT) and pulmonary embolism (PE), patients with acute traumatic spinal cord injury (SCI) have the highest incidence of VTE among all hospitalized groups, with PE the third most common cause of death. Although low-molecular-weight heparin (LMWH) outperforms low-dose unfractionated heparin (LDUH) in other patient populations, the evidence in SCI remains less robust. OBJECTIVE: To determine whether the efficacy for LMWH shown in previous SCI surveillance studies (eg, routine Doppler ultrasound) would translate into real-world effectiveness in which only clinically evident VTE is investigated (ie, after symptoms or signs present). METHODS: A retrospective cohort study was conducted of 90 patients receiving LMWH dalteparin (5,000 U daily) or LDUH (5,000 U twice daily) for VTE prophylaxis after acute traumatic SCI. The incidence of radiographically confirmed VTE was primarily analyzed, and secondary outcomes included complications of bleeding and heparin-induced thrombocytopenia. RESULTS: There was no statistically significant association (p = 0.7054) between the incidence of VTE (7.78% overall) and the type of prophylaxis received (LDUH 3/47 vs dalteparin 4/43). There was no significant differences in complications, location of VTE, and incidence of fatal PE. Paraplegia (as opposed to tetraplegia) was the only risk factor identified for VTE. CONCLUSIONS: There continues to be an absence of definitive evidence for dalteparin (or other LMWH) over LDUH as the choice for VTE prophylaxis in patients with SCI. Novel approaches to VTE prophylaxis are urgently required for this population, whose risk of fatal PE has not decreased over the last 25 years.

[Paraplegia after endovascular repair of the thoracic and thoracoabdominal aorta]. / Paraplegie nach endovaskulärer Therapie der thorakalen und thorakoabdominellen Aorta.

AIM: The aim of this study was to analyse the incidence and aetiology of paraplegia secondary to endovascular repair of the thoracic and thoracoabdominal aorta (TEVAR). METHODS: A retrospective study was conducted in the patients treated at our facility between March 1997 and April 2007. During this interval, 173 patients (163 men; median age: 62 years) underwent endovascular repair of the thoracic aorta. Indications for treatment were thoracic aortic aneurysms in 36 patients, thoracoabdominal aortic aneurysms in 33 patients, type B dissections in 43 patients, type A dissections in 5 patients, penetrating aortic ulcers in 31 patients, traumatic aortic transections in 9 patients, post-traumatic aortic aneurysms in 5 patients, aortobronchial fistulas in 8 patients, aortic patch ruptures in 2 patients, and an anastomotic aortic aneurysm in 1 patient. 101 procedures (58%) were conducted as emergency interventions while 72 were elective. Device design and implant strategy were chosen on the basis of an evaluation of morphology from a computed tomographic scan. Clinical assessment and imaging of the aorta (CT or magnetic resonance imaging) during follow up were performed prior to discharge, at 6 and 12 months, and then annually. RESULTS: A primary technical success was achieved in 170 patients (98%). The overall 30-day mortality rate was 9.2%. Length of follow-up ranged from 1 to 96 months, with a mean of 52 months. Paraplegia or paraparesis developed in 3 patients (1.7%). Two of these patients had a thoracoabdominal aortic aneurysm and the third a chronic expanding type B dissection, being treated with hybrid procedures. CONCLUSIONS: Endovascular repair of the thoracic and thoracoabdominal aorta is associated with a relatively low risk for postoperative paraplegia or paraparesis. Patients requiring long segment aortic coverage, and with prior aortic replacement are especially at risk.

Spinal cord complications after thoracic aortic surgery: long-term survival and functional status varies with deficit severity.

OBJECTIVE: Paraplegia after thoracoabdominal aneurysm (TAA) repair has been associated with poor survival. Little information exists concerning the spectrum of severity that characterizes spinal cord ischemic (SCI) complications. This study stratified SCI by deficit severity to determine its impact on late survival and functional outcomes. METHODS: A review of our prospectively maintained thoracic aortic database was performed from May 1987 through December 2005 to identify patients who experienced SCI of any extent after TAA repair. During this period, 576 patients underwent descending thoracic aortic repair (93 open, 105 endovascular [TEVAR]) or open TAA repair (279 extent I to III; 99 extent IV). To stratify severity of SCI, we created a spinal cord ischemia deficit (SCID) scale, which is defined as: I, flaccid paralysis; II, average neurologic muscle grade indicating <50% function; and III, average neurologic muscle grade indicating >50% function. Long-term outcomes were evaluated in relation to these groups by actuarial methods. RESULTS: During the study period, 64 (11.1%) patients developed SCI of any severity (7 of 105 [6.6%] TEVAR, 57 of 471 [12%] open). These were stratified by SCID level: I, 24 (37.5%); II, 31 (48.4%); and III, 9 (14.1%). SCI was immediate in 33 (54.1%) and delayed in 28 (45.9%). Most SCI (6 of 7) associated with TEVAR was delayed. The 30-day mortality was significantly higher in the SCI group than the overall patient cohort (15 of 64 [23.4%] vs 41 of 512 [8%], P < .001) and varied by SCID level: I, 11 of 24 (45.8%); II, 4 of 31 (12.9%); and III, 0 of 9 (0%; P = .001). The 5-year actuarial survival for all SCI was lower than for non-SCI patients (25% +/- 6% vs 51% +/- 3%, P < .001) and varied linearly with SCID level but was similar between SCID II/III and the non-SCI patients (41% +/- 10% vs 51% +/- 3%, P = .281). No SCID I patients were alive at 5 years. No patients with SCID I recovered the ability to walk, but eight of 11 (73%) with SCID II and the nine (100%) with SCID III could ambulate with or without assistance at last follow-up. CONCLUSION: Survival and functional outcomes correlate with SCI severity. Patients with SCID I have a poor long-term outlook. Survival of SCID II/III patients is similar to non-SCI patients; most recover the ability to ambulate.

Economic factors and longevity in spinal cord injury: a reappraisal.

OBJECTIVE: To review and reassess the findings of Krause and colleagues on the effect of economic and other risk factors on life expectancy after spinal cord injury, using an expanded and updated database. DESIGN: Pooled person-year analysis. SETTING: Model Spinal Cord Injury Systems hospitals. PARTICIPANTS: A total of 7331 persons injured since 1973 who were enrolled in the National Spinal Cord Injury Database and received an evaluation between November 1995 and December 2005. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mortality, determined by routine follow-up supplemented by information from the Social Security Death Index. Logistic regression models based on the predictor variables were developed to estimate the chance of dying in a given year. RESULTS: As in the Krause study, life expectancies of persons with the greatest handicap in economic self-sufficiency were substantially shorter than average. However, the positive effect of favorable economics was much less than previously reported, largely because having health insurance coverage through workers' compensation was no longer a powerful (or statistically significant) predictor of survival. CONCLUSIONS: The beneficial effect of favorable economics appears to be much less than previously reported. Further, the interpretation of the effects of modifiable factors (such as economics and social integration) is complicated by questions of cause and effect.

Reduced mortality, paraplegia, and stroke with stent graft repair of blunt aortic transections: a modern meta-analysis.

OBJECTIVE: Stent grafting has become the first-line approach to traumatic thoracic aortic transections (TTAT) in some trauma centers due to a perceived decrease in morbidity and mortality compared with standard open repair. We reviewed contemporary outcomes of patients undergoing endovascular repair of TTAT (endoTTAT) and those undergoing open repair (openTTAT) to determine if current reported results support first-line use of endoTTAT. METHOD: Retrospective, nonrandomized studies published in English (>5 cases/report) involving TTAT listed in PubMed between 2001 and 2006 were systematically reviewed. Periprocedural outcomes between endoTTAT and openTTAT were analyzed. Mean follow-up was 22.9 months for endoTTAT (reported for 22 of 28 studies) and 48.6 months for openTTAT (reported for 5 of 12 studies). For statistical analysis, t tests were used. RESULTS: We analyzed 33 articles reporting 699 procedures in which 370 patients treated with endoTTAT and 329 patients managed with openTTAT. No statistical differences were found between patient groups in mean age (41.3 vs 38.8 years, P < .10), injury severity score (39.8 vs 36.0, P < .10), or technical success rates of the procedure (96.5% vs 98.5%, P = .58). In contrast, mortality was significantly lower in the endoTTAT group (7.6% vs 15.2%, P = .0076) as were rates of paraplegia (0% vs 5.6%, P < .0001) and stroke (0.85% vs 5.3%, P = .0028). The most common procedure-related complications for each technique were iliac artery injury during endoTTAT and recurrent laryngeal nerve injury after openTTAT. CONCLUSIONS: To our knowledge, no large multicenter prospective randomized trial comparing endoTTAT and openTTAT has been published in the literature. This meta-analysis of pooled data serves as a surrogate, demonstrating a significant reduction in mortality, paraplegia, and stroke rates in patients who undergo endoTTAT; however, the long-term durability of endoTTAT remains in question.