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

• Published in: Journal of endovascular therapy Vol. 23; no. 1; pp. 139 - 149
• Main Authors: Banga, Peter V., Oderich, Gustavo S., Reis de Souza, Leonardo, Hofer, Jan, Cazares Gonzalez, Meaghan L., Pulido, Juan N., Cha, Stephen, Gloviczki, Peter
• Format: Journal Article
• Language: English
• Published: Los Angeles, CA SAGE Publications 01-02-2016
• Subjects: Aged; Aged, 80 and over; Aortic Aneurysm, Thoracic - diagnosis; Aortic Aneurysm, Thoracic - mortality; Aortic Aneurysm, Thoracic - physiopathology; Aortic Aneurysm, Thoracic - surgery; Arterial Pressure; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation - adverse effects; Blood Vessel Prosthesis Implantation - instrumentation; Blood Vessel Prosthesis Implantation - mortality; Cerebrospinal Fluid Leak; Endovascular Procedures - adverse effects; Endovascular Procedures - instrumentation; Endovascular Procedures - mortality; Evoked Potentials, Motor; Evoked Potentials, Somatosensory; Female; Femoral Artery - physiopathology; Femoral Artery - surgery; Humans; Iliac Artery - physiopathology; Iliac Artery - surgery; Intraoperative Neurophysiological Monitoring; Male; Middle Aged; Prospective Studies; Prosthesis Design; Regional Blood Flow; Retrospective Studies; Risk Factors; Spinal Cord Injuries - diagnosis; Spinal Cord Injuries - etiology; Spinal Cord Injuries - mortality; Spinal Cord Injuries - prevention & control; Spinal Cord Ischemia - diagnosis; Spinal Cord Ischemia - etiology; Spinal Cord Ischemia - mortality; Spinal Cord Ischemia - prevention & control; Stents; Time Factors; Treatment Outcome; intraoperative monitoring; endovascular repair; stent-graft; paraplegia; spinal cord ischemia; mortality; collateral circulation; thoracoabdominal aortic aneurysm; iliofemoral conduits; evoked potentials; cerebrospinal fluid drainage
• ISSN: 1526-6028; 1545-1550
• DOI: 10.1177/1526602815620898

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.