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.

OBJECTIVE: The aim of this study was to analyze the outcomes of a standardized protocol using routine CSFD, neuromonitoring, LL reperfusion, and selective TASP to prevent SCI during F-BEVAR. BACKGROUND: SCI is to be the most devastating complication for the patient, family, and surgeon, with impact on patient's quality of life and long-term prognosis. An optimal standardized protocol may be used to improve outcomes. METHODS: Patients enrolled in a prospective, nonrandomized single-center study between 2013 and 2018. A SCI prevention protocol was used for TAAAS or complex abdominal aneurysms with ≥5-cm supraceliac coverage including CSFD, neuromonitoring, LL reperfusion, and selective TASP. Endpoints included mortality and rates of SCI. RESULTS: SCI prevention protocol was used in 170 of 232 patients (73%) treated by F-BEVAR. Ninety-one patients (55%) had changes in neuromonitoring, which improved with maneuvers in all except for 9 patients (10%) who had TASP. There was one 30-day or in-hospital mortality (0.4%). Ten patients (4%) developed SCIs including in 1% (1/79) of patients with normal neuromonitoring and 10% (9/91) of those who had decline in neuromonitoring ( P = 0.02). Permanent paraplegia occurred in 2 patients (1%). Factors associated with SCI included total operating time (odds ratio 1.5, 95% confidence interval 1.1-2.2, P = 0.02) and persistent changes in neuromonitoring requiring TASP (odds ratio 15.7, 95% confidence interval 2.9-86.2, P = 0.001). CONCLUSION: This prospective nonrandomized study using a standardized strategy to prevent SCI was associated with low incidence of the SCI during F-BEVAR. Permanent paraplegia occurred in 1%.

Neuromonitoring, Cerebrospinal Fluid Drainage, and Selective Use of Iliofemoral Conduits to Minimize Risk of Spinal Cord Injury During Complex Endovascular Aortic Repair.

PURPOSE: To review outcomes of continuous motor/somatosensory-evoked potential (MEP/SSEP) monitoring, cerebrospinal fluid drainage, and selective use of iliofemoral conduits in patients undergoing endovascular repair of descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysms (TAAAs). METHODS: The clinical data of 49 patients (mean age 75±8 years; 38 men) who underwent endovascular repair of DTA and TAAAs (2011-2014) were reviewed. All patients had cerebrospinal fluid drainage, permissive hypertension (mean arterial pressure ≥80 mm Hg), and MEP/SSEP monitoring. There were 44 (90%) patients with TAAAs and 5 (10%) with DTA. Types I and II TAAAs were repaired in staged procedures. Iliofemoral conduits were used for small iliac arteries and to minimize time of lower extremity ischemia in patients with difficult anatomy. In patients with changes in MEP/SSEPs, a standardized protocol was employed to optimize spinal cord perfusion and restore lower extremity blood flow. Endpoints were mortality, spinal cord injury (SCI), and lower extremity ischemic complications. RESULTS: Sixteen (33%) patients had staged TAAA repair. A total of 163 visceral arteries were targeted by fenestrations and branches (mean 3.7±1.0 vessels/patient). Temporary iliofemoral conduits were used in 16 limbs/14 patients. A stable MEP/SSEP was achieved in all patients. Thirty-one (63%) patients had a ≥75% decrease in MEP/SSEP amplitude in 50 limbs starting on average 75±28 minutes after obtaining vascular access. MEP/SSEP amplitude improved with maneuvers in 12 (39%) patients and returned to baseline with restoration of lower extremity flow in all except 1 patient who developed immediate SCI. Thirty-day mortality was 4%. Three (6%) patients had SCI, 2 permanent and 1 temporary at 14 days. There were no lower extremity ischemic complications. CONCLUSION: Neuromonitoring predicted immediate SCI and allowed use of a protocol to optimize spinal cord and lower extremity perfusion during complex endovascular aortic repair. Larger clinical experience is needed to evaluate the efficacy of neuromonitoring to prevent SCI.

Outcomes of total percutaneous endovascular aortic repair for thoracic, fenestrated, and branched endografts.

OBJECTIVE: Percutaneous endovascular aortic repair (PEVAR) has been increasingly used to treat infrarenal abdominal aortic aneurysms, but few studies have evaluated the results in complex aortic aneurysms. We reviewed the technical success and clinical outcomes of PEVAR using large-diameter sheaths for the treatment of complex aortic aneurysms with thoracic, fenestrated, and branched stent grafts. METHODS: The clinical data of patients who underwent total PEVAR for descending thoracic aneurysm, thoracoabdominal aortic aneurysm, pararenal, and aortoiliac aneurysms using thoracic, fenestrated, and branched stent grafts between 2009 and 2014 were reviewed. Repairs with fenestrated-branched stent grafts were performed using commercially available or investigational devices under a physician-sponsored investigational device protocols. Percutaneous closure was performed using ultrasound guidance and two Perclose devices (Abbott Vascular, Santa Clara Calif) per femoral puncture site. End points were technical success, access-related complications, morbidity, and mortality. RESULTS: There were 102 patients, 77 male and 25 female, with a mean age of 75 ± 8 years. Aneurysm extent was pararenal in 48 patients (47%), thoracoabdominal aortic aneurysm in 27 (26%), descending thoracic aneurysm in 19 (19%), and aortoiliac in 8 (8%). Fenestrated or branched endografts, or both, were placed in 72 patients (71%). Total percutaneous closure was performed in 170 femoral arteries using ≥20F-diameter sheaths in 163 (96%). Technical success was obtained in 161 femoral arteries (95%). There were no factors associated with technical failure. Access-related complications occurred in five patients (5%), including femoral artery thrombosis in three (3%), and retroperitoneal hematoma or pseudoaneurysm in one patient each (1%). There were no 30-day deaths. Freedom from access-related complications was 97% ± 1% at 30 days and 1 year. No access-related complications occurred >30 days. CONCLUSIONS: Total percutaneous technique can be safely performed with a high technical success rate and low rate of access complications in patients with thoracic and complex aortic disease requiring large-diameter sheaths. The rate of access-related complications (5%) is similar to that reported for PEVAR of infrarenal abdominal aortic aneurysms using smaller-profile devices.