CSF Drainage in TEVARAnesthetic Considerations

Dr. Gregory Hans

CHU of Liege

Disclosure of Interest

None

Plan

• Epidemiology of SCI in TEVAR

• Pathophysiology of SCI and CSF drainage

• Evidence and Guidelines

• Risks of CSF drainage

• Tips and tricks

Epidemiology

Etz CD et al. Eur J Cardiothorac Surg 2015;47:943-957.

Epidemiology

• Risk factors for SCI after TEVAR

– Extent of the repair

– PAD or previous aortic surgery

– Preoperative CKD

Consequences

Conrad MF et al. J Vasc Surg 2008;48:47-53.

Can CSF drainage help ?

SCPP = MAP – (CSFP or CVP)

Etz CD et al. Eur J Cardiothorac Surg 2015;47:943-957.

1. No proximal cross clamp

2. Permanent sacrifice of segmental arteries

Isaak, R. S. J Cardiothorac Vasc Anesth. 2015.

Bajwa, A. Eur J Vasc Endovasc Surg.

2008

Azevedo Mendes, M., J Cardiothorac Vasc Anesth.

2015

Xue, L., et al. Chin Med J (Engl). 2013.

Etz, C. D. J Thorac Cardiovasc Surg. 2011.

Wong CS et al., J Vasc Surg, 2012

Hnath JC et al., J Vasc Surg, 2008

0 % 8 %

Guidelines

Erbel, R., Eur Heart J. 2014.

Risks of CSF drainage

1-3 %

• Intracranial hemorrhage

• “Spinal” hematoma

• Meningitis

5-10 %

• Post-puncture headache

• Skin infection

• Catheter fracture

• Cranial nerve palsy

Wynn MM et al., J Vasc Surg, 2009

Leyvi G et al., J Cardiothorac Vasc Anesth,

2005

Conclusions• When ?

– Therapeutically: all episodes of SCI following TEVAR

– Prophylactically in high risk patients ?

• How ?

– Guidelines for regional anesthesia in anticoagulated patients

– Pressure transducers at the level of the RA

– Continuous reading, drain for CSF≤15 mmHg

– MAP and CVP reading and optimization

• How long ?

– 48-72 hours

– 24 hours of close monitoring following drain removal