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Advances in complex endovascular aortic surgeryDijkstra, Martijn Leander
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chapter 8Spinal cord ischemia in endovascular thoracic and
thoraco-abdominal aortic repair: review of preventive strategies
M.L. DIJKSTRA,1 T. VAINAS,2 C.J. ZEEBREGTS,1 I. L. HOOFT,3
M.J. VAN DER LAAN. 1
1 Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of
Groningen, Groningen, Th e Netherlands2 Department of Vascular Surgery, Glenfi eld Hospital, University Hospitals of Leicester, Leicester, UK
3 Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center
Utrecht, Utrecht, Th e Netherlands
SUBMITTED FOR PUBLICATION
122
Chapter 8
absTracT
Introduction: The incidence of Spinal cord ischemia (SCI) and subsequent paraple-
gia after thoracic (TEVAR) and thoraco-abdominal endovascular aneurysm repair
is estimated between 2.5 % and 8 %. The aim of this review was to provide an
overview of SCI preventive strategies in TEVAR and thoraco-abdominal repair
and recommend an optimal strategy.
Methods: Pubmed, Embase and the Cochrane Library were searched for studies
on TEVAR, thoraco-abdominal endovascular repair and the use of SCI preventive
measures. The review was reported according to the PRISMA statement.
Results: The final analysis included 43 studies (7168 patients). All studies are
cohort studies (non-comparative cohorts n = 37, comparative cohorts n = 6)
and largely performed retrospectively (n = 27). The included studies had an
average MINORS score of 9 (range 6 - 13) for non-comparative studies and
15.5 (range 12 - 18) for comparative studies. Transient SCI occurred in 5.7 %
(450/7168, 95 % CI 4.5- 6.9 %, range 0.3 - 30.6 %), permanent SCI in 2.2 %
(232/7168, 95 % CI 1.6 - 2.8 %, range 0.3 - 20.8 %). There was a trend towards
increased SCI incidence for more ‘high risk’ cohorts. Avoidance of hypotension
resulted in a slightly lower permanent SCI rate 1.8 % (102/4216, 95 % CI 1.2-
2.3 %) compared to the overall cohort. A very low SCI estimate (transient and
permanent) was found in the subgroup of studies (2 studies, n = 248) using
(mild) peri-operative hypothermia (transient SCI 0.8 %, permanent SCI 0.4 %).
In the subgroup using temporary permissive endoleak, there was a transient
SCI estimate (15.4 %), with a permanent SCI estimate of 4.8 %. The remaining
preventive measures did not significantly impact transient and permanent SCI
estimates.
Conclusion: Low overall transient and permanent SCI rates are achieved during
endovascular thoracic and thoraco-abdominal aortic repair. Permanent SCI rates
up to 21 % are reported in high risk cohorts. The current SCI prevention proto-
cols vary widely. Based on this review, selective spinal fluid drainage, avoidance
of hypotension and mild hypothermia seems justified.
Spinal cord ischemia preventive strategies
123
8
inTroducTion
Since its introduction endovascular aneurysm repair (EVAR) has evolved and is
currently the predominant treatment modality for aortic aneurysms.1 Improved
operating techniques and devices allow for treatment of the majority of aortic
lesions including thoracic aortic pathology by endovascular means and has
become a preferred alternative to open repair with low overall mortality and
morbidity.2–4 Spinal cord ischemia (SCI) and concomitant paraplegia are among
the most dreaded complications of thoracic endovascular aneurysm repair (TE-
VAR) and endovascular thoraco-abdominal aortic repair.5 Although the incidence
of paraplegia is estimated between 2.5 % and 8 % and is lower compared to the
paraplegia rate after open surgical repair, SCI remains a significant problem.6
Lower SCI incidences are achieved in high volume centers, and paraplegia rates
seem to be declining in recent years.7 This decline has been attributed to the use
of rigorous multi-modality SCI prevention strategies.
The identification of risk factors for SCI, the categorization of specific high risk
groups and the development of preventive measures for SCI have been subject
of an extensive body of research. Suggested risk factors for SCI are aneurysm ex-
tent, open surgical repair, prior distal aortic operations, and peri-operative hypo-
tension. Furthermore, loss of intercostal arteries and collateral vasculature (e.g.
subclavian, hypogastric) and duration of the procedure have been suggested as
potential contributing factors.8 For most of the suggested risk factors however,
conflicting results have been reported. Similarly it remains unclear which specific
patients are at risk for development of SCI and ultimately the development of a
uniform multimodal preventive treatment protocol remains elusive.
With regard to the preventive measures for SCI after TEVAR and thoraco-
abdominal repair, most of these strategies have proven their effectiveness in
preventing SCI during open repair. Obviously, not all of the preventive measures
used during open surgery are applicable, given the minimally invasive nature of
these procedures. Currently used measures to prevent SCI after TEVAR and tho-
raco-abdominal repair include spinal fluid drainage, avoidance of peri-operative
hypotension (both aim to maintain adequate spinal cord perfusion), staging the
repair and creating a permissive (temporary) endoleak to allow for temporary
aneurysm (and spinal cord) perfusion. Additionally, peri-operative hypothermia
and intra-thecal medication have been described as adjunct protective mea-
sures.9 Although not necessarily a preventive measure in itself, intra-operative
neuro-monitoring has also been described as a strategy to reduce SCI rates by
early identification of spinal cord mal-perfusion allowing for prompt initiation of
measure to improve cord perfusion resulting in lower post-operative SCI rates.
124
Chapter 8
Tab
le 1
. Gui
delin
e re
com
men
datio
ns, i
nclu
ding
cur
rent
inte
rnat
iona
l rec
omm
enda
tions
on
the
prev
entio
n of
SC
I aft
er th
orac
ic a
nd th
orac
o-ab
dom
inal
end
ovas
cula
r ao
rtic
rep
air
Gu
idel
ine
Spin
al fl
uid
d
rain
Avo
idan
ce
of
hyp
ote
nsi
on
Hyp
oth
erm
iaSt
aged
p
roce
du
res
LSA
re
vasc
ula
riza
tio
nPe
rmis
sive
en
do
leak
Peri
-op
erat
ive
neu
rom
on
ito
rin
g
Man
agem
ent
of D
esce
ndin
g Th
orac
ic A
orta
Dis
ease
s -
ESV
S 20
171
Sele
ctiv
eaYe
sN
RN
RN
RN
RD
epen
ding
on
inst
itutio
nal
expe
rienc
e
Gui
delin
es o
n th
e di
agno
sis
and
man
agem
ent
of a
ortic
di
seas
es -
ESC
201
42
Sele
ctiv
eaYe
sN
RN
RN
RN
RN
R
Endo
vasc
ular
rep
air
of t
raum
atic
tho
raci
c ao
rtic
inju
ry -
SV
S 20
113
Ther
apeu
ticN
RN
RN
RSe
lect
ive
NR
NR
Gui
delin
es f
or t
he d
iagn
osis
and
man
agem
ent
of p
atie
nts
with
tho
raci
c ao
rtic
dis
ease
- A
HA
201
04
Sele
ctiv
eaYe
sO
pen
surg
ery
only
NR
NR
NR
Dep
endi
ng o
n in
stitu
tiona
l ex
perie
nce
Man
agem
ent
of t
he le
ft s
ubcl
avia
n ar
tery
with
tho
raci
c en
dova
scul
ar a
ortic
rep
air
- SV
S 20
095
NR
NR
NR
NR
Yes
NR
NR
a Lon
g se
gmen
t co
vera
ge (>
200
mm
), pr
evio
us A
AA
rep
air
Abb
revi
atio
ns: E
SVS,
Eur
opea
n so
ciet
y fo
r Va
scul
ar S
urge
ry; E
SC, E
urop
ean
soci
ety
for
Car
diol
ogie
; SV
S; S
ocie
ty f
or V
ascu
lar
Suge
ry; A
HA
, Am
eric
an H
eart
Ass
ocia
-tio
n; A
AA
, Abd
omin
al A
ortic
Ane
urys
m; N
R, N
ot r
epor
ted;
LSA
, Lef
t su
bcla
vian
art
ery.
1 Ria
mba
u V
et
al. -
Man
agem
ent
of D
esce
ndin
g Th
orac
ic A
orta
Dis
ease
s: C
linic
al P
ract
ice
Gui
delin
es o
f th
e Eu
rope
an S
ocie
ty f
or V
ascu
lar
Surg
ery
(ESV
S). E
ur J
Vas
c En
dova
sc S
urg.
201
7;53
(1):4
–52.
2 Erb
el R
et
al. 2
014
ESC
gui
delin
es o
n th
e di
agno
sis
and
trea
tmen
t of
aor
tic d
isea
ses.
Eur
opea
n H
eart
Jou
rnal
. 201
4;35
(41)
:287
3–92
6.3 L
ee W
A e
t al.
Endo
vasc
ular
repa
ir of
trau
mat
ic th
orac
ic a
ortic
inju
ry: c
linic
al p
ract
ice
guid
elin
es o
f the
Soc
iety
for V
ascu
lar S
urge
ry. J
Vas
c Su
rg. 2
011;
53(1
):187
–92.
4 Hira
tzka
LF
et a
l. 20
10 A
CC
F/A
HA
/AA
TS/A
CR/
ASA
/SC
A/S
CA
I/SIR
/STS
/SV
M g
uide
lines
for
the
dia
gnos
is a
nd m
anag
emen
t of
pat
ient
s w
ith T
hora
cic
Aor
tic D
isea
se.
Circ
ulat
ion.
201
0;12
1(13
):e26
6–36
9.5 M
atsu
mur
a JS
et
al. T
he S
ocie
ty f
or V
ascu
lar
Surg
ery
Prac
tice
Gui
delin
es: m
anag
emen
t of
the
left
sub
clav
ian
arte
ry w
ith t
hora
cic
endo
vasc
ular
aor
tic r
epai
r. J
Vasc
Su
rg. 2
009;
50(5
):115
5–8.
Spinal cord ischemia preventive strategies
125
8
Current international guidelines mention a number of preventive strategies but
there is some variation in the recommendations (Table 1). For TEVAR, the major-
ity do recommend the avoidance of hypotension and the use of selective cere-
brospinal fluid drainage during endovascular thoracic aortic repair for patients at
high risk (long segment coverage (> 200mm), previous AAA repair10–12) of spinal
cord ischemic injury. The level of evidence for these recommendations is low
(class IIA, level C, European Society of Cardiology grading system). For thoraco-
abdominal endovascular aortic repair, no clear recommendations are made.
The aim of this review was to provide an overview of the current evidence on
the effectiveness of peri-operative strategies to prevent spinal cord ischemia in
TEVAR and thoraco-abdominal endovascular aortic repair and recommend an
optimal preventive strategy based on the available data.
MeThods
The review was reported according to the Preferred Reporting Items for System-
atic reviews and Meta-Analyses (PRISMA) statement.
search and selection
Pubmed, Embase and the Cochrane Library were searched for studies on both
TEVAR and thoraco-abdominal endovascular aortic repair, and the use of spinal
cord ischemia preventive measures (date of electronic search, July 13th 2016).
The full search strategy is shown in appendix I. The reference lists of selected
articles were screened for other relevant publications. Screening of title and
abstract was conducted by two reviewers (MD and ML).
Given the paucity of randomized trials addressing our review question, a broader
range of study designs were considered eligible for review, including compara-
tive and non-comparative cohort studies. Case reports, small sample (n ≤ 10)
cohort studies, studies on open surgical repair, animal studies and non-English
publications were excluded. Furthermore, studies were only included when
the incidence of spinal cord ischemia and the use of one or more preventive
measures during the procedures (elective or acute) were specified, specifically
the use of spinal fluid drain, avoidance of hypotension, hypothermia, staged
procedures, intra-thecal medication, left subclavian artery (LSA) revascularization
or permissive (temporary) endoleak.
126
Chapter 8
data collection and analysis
Study and patient characteristics were collected using standardized forms. The follow-
ing data were extracted: authors, year of publication, number of patients included,
inclusion period, disease type, type of SCI protocol, general patient characteristics
and co-morbidities, incidence of SCI (permanent, transient), preventive measures,
data necessary to calculate the Methodological Index for Non-Randomized Studies
(MINORS) score and characteristics known to influence the incidence of SCI.
The methodological quality of the included studies was assessed using the
MINORS score.13 This instrument is specifically developed and validated to assess
surgical studies, either comparative or non-comparative, and consists of 12 items
(the separate items are scored 0 (not reported), 1 (reported but inadequate) or
2 (reported and adequate). The ideal global scores for non-comparative studies
and for comparative studies are 16 and 24, respectively.13
Indirect comparisons were attempted to compare the effectiveness of preventive
measures. In order to correct for possible patient selection bias, all cohorts were evalu-
ated for high risk demographics and each cohort was given the highest percentage
reported (including: urgent procedures, previous aortic surgery, long segment cover-
age > 200mm). Continuous variables are described as mean and standard deviation,
or median and inter-quartile range (IQR) in case of skewed data. To test for normality
a Kolmogorov-Smirnov test was performed. Differences between continuous variables
were tested using a paired student T-test or Mann-Whitney U test in case of skewed
data. Differences between categorical variables were tested using chi-squared test.
Two-sided P values <.05 were considered significant. Data analysis was performed
using SPSS statistics 20.0 (IBM corporation, Armonk, NY, USA). Meta-analysis was
performed using OpenMeta (open source meta-analysis software, http://www.cebm.
brown.edu/openmeta/). Calculation of 95 % confidence intervals was performed using
logit transformed proportion metric and DerSimonian-Laird random-effects method.
resulTs
identification of studies
In total, 2404 potential relevant references were identified after removal of
duplicates. After detailed assessment, 43 studies and 7168 patients describing 7
preventive measures were included in the final analysis. Insufficient data on the used
preventive measures was the main reason for exclusion during full-text assessment
(Figure 1). The full list of references for the included articles is shown in appendix 2.
Spinal cord ischemia preventive strategies
127
8Characteristics of included studies
There are no randomized controlled trials available to date, all included studies
are cohort studies (non-comparative cohorts n = 37, comparative cohorts n = 6).
The general study characteristics are shown in Table 2. The majority of studies
were performed retrospectively (n = 27, 62.8 %). Nine (20.9 %) studies included
patients with aneurysmal disease only, one (2.3 %) study with dissections only
and the remaining included patients with mixed disease types (aneurysmal, dis-
section, penetrating aortic ulcers, trauma). Overall mean age was 68.6 years and
there was a male predominance (70.7 %).
A specific SCI prevention protocol was described in 33 (76.7 %) of the studies.
With regard to the different preventive measures, a prophylactic spinal fluid drain
was used in 10 studies (23.3 %) versus selective drains in 28 studies (65.1 %). Of
these, selective drains were used in 11 (39.3 %) studies that included thoraco-
Figure 1. PRISMA flow diagram.
128
Chapter 8
Tab
le 2
. Stu
dy a
nd p
atie
nt c
hara
cter
istic
s fo
r th
e in
clud
ed s
tudi
es.
Au
tho
rs
Co
ho
rt t
ype
Dis
ease
ty
pe
SCI
Nr
of
pat
ien
tsA
ge
(mea
n)
Mal
e se
x (%
)H
yper
ten
sio
n
(%)
Dia
bet
es
(%)
Car
dia
c d
isea
se
(%)
Pulm
on
ary
dis
ease
(%
)
Ren
al
dis
ease
(%
)Sm
oki
ng
(%
)
Ach
er, C
. et
al.
2016
Pros
pect
ive
Mix
edYe
s15
574
.056
.1N
RN
RN
RN
RN
RN
R
Am
abile
, P. e
t al
.20
08Re
tros
pect
ive
Mix
edYe
s67
66.0
80.6
53.7
3.0
20.9
19.4
17.9
49.3
Arn
aout
akis
, D. J
. et
al.
2014
Retr
ospe
ctiv
eM
ixed
Yes
9067
.353
.080
.016
.030
.026
.023
.054
.0
Bang
a, P
. V. e
t al
.20
16Re
tros
pect
ive
Mix
edYe
s49
75.0
78.0
88.0
18.0
65.0
43.0
37.0
86.0
Bisd
as, T
. et
al.
2015
Retr
ospe
ctiv
eM
ixed
Yes
142
79.0
78.9
94.0
12.0
44.0
28.0
6.0
59.0
Boba
dilla
, J. L
. et
al.
2013
Pros
pect
ive
Mix
edYe
s94
54.0
60.0
80.0
2.0
32.0
21.0
NR
NR
Chi
esa,
R. e
t al
.20
05Pr
ospe
ctiv
eM
ixed
Yes
103
70.1
83.5
70.0
9.7
45.6
48.5
13.6
64.1
Clo
ugh,
R. E
. et
al.
2014
Pros
pect
ive
Mix
edYe
s30
972
.067
.6N
RN
RN
RN
RN
RN
R
Des
art,
K. e
t al
.20
13Re
tros
pect
ive
Mix
edYe
s60
764
.568
.032
.84.
89.
48.
29.
116
.3
Dia
s, N
. V. e
t al
.20
15Re
tros
pect
ive
Ane
urys
mal
Yes
7268
.073
.684
.718
.133
.343
.141
.744
.4
Drin
kwat
er, S
. L. e
t al
.20
10Re
tros
pect
ive
Mix
edN
o23
565
.964
.3N
RN
RN
RN
RN
RN
R
Gui
llou,
M. e
t al
.20
12Pr
ospe
ctiv
eA
neur
ysm
alYe
s89
69.0
93.3
80.0
18.0
39.0
19.1
27.0
79.0
Han
na, J
. M. e
t al
.20
13Re
tros
pect
ive
Ane
urys
mal
Yes
381
63.6
58.5
87.7
13.1
31.0
30.7
27.8
62.5
Har
rison
, S. C
. et
al.
2012
Pros
pect
ive
Mix
edYe
s10
73.8
60.0
80.0
NR
30.0
NR
100.
070
.0
Hna
th, J
. C. e
t al
.20
08Re
tros
pect
ive
Mix
edYe
s12
151
.072
.0N
RN
R42
.033
.018
.0N
R
Jayi
a, P
. et
al.
2015
Retr
ospe
ctiv
eA
neur
ysm
alYe
s47
72.1
68.0
48.0
6.0
21.0
NR
11.0
14.0
Jonk
er, F
. H. W
. et
al.
2010
Retr
ospe
ctiv
eM
ixed
No
8769
.869
.051
.710
.342
.525
.313
.8N
R
Kam
ada,
T. e
t al
.20
15Re
tros
pect
ive
Mix
edN
o51
72.0
74.5
86.3
11.8
NR
NR
NR
NR
Kas
prza
k, P
. M. e
t al
.20
14Pr
ospe
ctiv
eA
neur
ysm
alYe
s40
72.8
72.5
95.0
NR
52.5
27.5
37.5
60.0
Kat
o, M
. et
al.
2015
Retr
ospe
ctiv
eM
ixed
Yes
5474
.078
.096
.013
.041
.043
.09.
082
.0
Kei
th J
r, C
. J. e
t al
.20
12Pr
ospe
ctiv
eM
ixed
Yes
266
64.1
62.8
84.6
21.4
42.1
29.7
21.4
71.4
Kho
ynez
had,
A. e
t al
.20
07Pr
ospe
ctiv
eM
ixed
No
153
71.0
61.4
73.2
11.1
32.0
20.9
14.4
52.3
Spinal cord ischemia preventive strategies
129
8
Tab
le 2
. Stu
dy a
nd p
atie
nt c
hara
cter
istic
s fo
r th
e in
clud
ed s
tudi
es. (
cont
inue
d)
Au
tho
rs
Co
ho
rt t
ype
Dis
ease
ty
pe
SCI
Nr
of
pat
ien
tsA
ge
(mea
n)
Mal
e se
x (%
)H
yper
ten
sio
n
(%)
Dia
bet
es
(%)
Car
dia
c d
isea
se
(%)
Pulm
on
ary
dis
ease
(%
)
Ren
al
dis
ease
(%
)Sm
oki
ng
(%
)
Kita
gaw
a, A
. et
al.
2013
Pros
pect
ive
Dis
sect
ion
Yes
3066
.086
.750
.013
.343
.36.
716
.766
.7
Kno
wle
s, M
. et
al.
2011
Retr
ospe
ctiv
eM
ixed
Yes
9666
.457
.369
.814
.636
.520
.816
.766
.7
Lee,
M. e
t al
.20
13Re
tros
pect
ive
Mix
edYe
s14
562
.063
.083
.015
.027
.037
.022
.0N
R
Mal
dona
do, T
. S. e
t al
.20
13Re
tros
pect
ive
Mix
edN
o11
8967
.859
.184
.917
.342
.730
.913
.653
.8
Mas
tror
ober
to, P
. et
al.
2013
Retr
ospe
ctiv
eM
ixed
Yes
2171
.666
.776
.214
.39.
561
.9N
RN
R
Mat
suda
, H. e
t al
.20
10Re
tros
pect
ive
Mix
edYe
s60
77.0
81.7
NR
NR
NR
NR
NR
NR
Mau
rel,
B. e
t al
.20
15Re
tros
pect
ive
Ane
urys
mal
Yes
204
71.0
92.6
79.9
18.1
45.1
37.3
24.5
13.7
Pate
l, H
. J. e
t al
.20
06Re
tros
pect
ive
Mix
edYe
s73
67.4
60.3
63.0
10.9
42.5
28.7
NR
NR
Piff
aret
ti, G
. et
al.
2014
Retr
ospe
ctiv
eM
ixed
Yes
7772
.091
.092
.016
.035
.049
.07.
0N
R
Prev
entz
a, O
. et
al.
2009
Retr
ospe
ctiv
eM
ixed
Yes
346
68.0
60.1
90.8
NR
7.8
23.7
19.1
NR
Ross
i, S.
H. e
t al
.20
15Re
tros
pect
ive
Mix
edYe
s69
73.0
75.4
NR
19.8
50.0
30.0
NR
NR
Ryls
ki, B
. et
al.
2013
Pros
pect
ive
Ane
urys
mal
No
105
69.0
68.0
NR
NR
NR
NR
NR
NR
Schl
össe
r, F.
J. V
. et
al.
2009
Retr
ospe
ctiv
eA
neur
ysm
alN
o72
73.0
86.0
NR
NR
NR
NR
14.0
NR
Shah
, T. R
. et
al.
2010
Pros
pect
ive
Mix
edYe
s59
69.2
51.0
67.8
23.7
25.4
27.1
15.3
62.7
Sobe
l, J.
D. e
t al
.20
15Pr
ospe
ctiv
eA
neur
ysm
alYe
s11
672
.074
.094
.013
.056
.049
.021
.093
.0
Tana
ka, K
. et
al.
2015
Retr
ospe
ctiv
eM
ixed
Yes
148
72.8
67.6
81.1
16.9
18.9
10.1
4.1
NR
Ulle
ry, B
. W. e
t al
.20
11Re
tros
pect
ive
Mix
edYe
s41
270
.452
.092
.08.
711
.016
.510
.139
.3
Yin
gbin
, J. e
t al
.20
13Re
tros
pect
ive
Mix
edN
o21
765
.065
.971
.09.
769
.1N
RN
RN
R
Zam
or, K
. C. e
t al
.20
15Pr
ospe
ctiv
eM
ixed
No
8059
.979
.078
.516
.230
.011
.326
.358
.9
Zeng
, Q. e
t al
.20
16Pr
ospe
ctiv
eM
ixed
Yes
2165
.095
.290
.59.
523
.8N
R14
.342
.9
Zipf
el, B
. et
al.
2013
Pros
pect
ive
Mix
edYe
s40
663
.074
.0N
RN
RN
RN
RN
RN
R
Tota
l71
6868
.670
.777
.413
.335
.129
.221
.156
.8
Abb
revi
atio
ns: N
R, N
ot r
epor
ted
130
Chapter 8
Tab
le 3
. Ris
k of
bia
s an
alys
is f
or t
he in
clud
ed s
tudi
es.
Au
tho
rsM
INO
Rs
sco
re
(max
sco
re)
Ris
k fa
cto
rs
rep
ort
edH
igh
ris
k SC
I co
ho
rt (
%)
Prev
iou
s ao
rtic
su
rger
y (%
)Le
ng
th o
f ao
rtic
co
vera
ge
rep
ort
ed
Pate
nt
colla
tera
l va
scu
lar
bed
sIn
tra-
op
erat
ive
hyp
ote
nsi
on
Op
erat
ive
tim
e (m
in)
Ach
er, C
. et
al.
8 (1
6)Ye
s49
.046
.5Ye
sN
RN
oN
R
Am
abile
, P. e
t al
.8
(16)
Yes
16.4
16.4
Yes
NR
No
NR
Arn
aout
akis
, D. J
. et
al.
11 (1
6)Ye
s22
.022
.0N
oN
RN
oN
R
Bang
a, P
. V. e
t al
.8
(16)
Yes
49.0
22.0
Yes
NR
No
290
Bisd
as, T
. et
al.
10 (1
6)Ye
s91
.047
.0Ye
sN
RYe
s27
2
Boba
dilla
, J. L
. et
al.
11 (1
6)Ye
s16
.0N
RYe
sN
oYe
sN
R
Chi
esa,
R. e
t al
.12
(16)
Yes
12.6
12.6
Yes
Yes
Yes
NR
Clo
ugh,
R. E
. et
al.
11 (1
6)Ye
s32
.0N
RN
oYe
sN
RN
R
Des
art,
K. e
t al
.8
(16)
Yes
18.6
18.6
Yes
Yes
No
NR
Dia
s, N
. V. e
t al
.10
(16)
Yes
76.0
56.9
No
Yes
No
412
Drin
kwat
er, S
. L. e
t al
.9
(16)
Yes
NR
NR
Yes
Yes
No
257
Gui
llou,
M. e
t al
.13
(16)
Yes
75.0
30.0
No
NR
Yes
221
Han
na, J
. M. e
t al
.8
(16)
Yes
17.8
17.8
Yes
Yes
Yes
NR
Har
rison
, S. C
. et
al.
8 (1
6)Ye
s10
0.0
20.0
Yes
No
Yes
557
Hna
th, J
. C. e
t al
.18
(24)
Yes
33.9
33.9
Yes
No
Yes
NR
Jayi
a, P
. et
al.
6 (1
6)Ye
s10
0.0
21.0
No
No
Yes
NR
Jonk
er, F
. H. W
. et
al.
7 (1
6)Ye
s10
0.0
12.6
Yes
No
Yes
NR
Kam
ada,
T. e
t al
.6
(16)
Yes
7.8
7.8
No
Yes
No
NR
Kas
prza
k, P
. M. e
t al
.18
(24)
Yes
100.
032
.5N
oN
oYe
sN
R
Kat
o, M
. et
al.
9 (1
6)Ye
s50
.022
.0Ye
sYe
sYe
s20
0
Kei
th J
r, C
. J. e
t al
.10
(16)
Yes
70.0
NR
Yes
Yes
Yes
NR
Kho
ynez
had,
A. e
t al
.8
(16)
Yes
45.8
45.8
Yes
Yes
Yes
NR
Spinal cord ischemia preventive strategies
131
8
Tab
le 3
. Ris
k of
bia
s an
alys
is f
or t
he in
clud
ed s
tudi
es. (
cont
inue
d)
Au
tho
rsM
INO
Rs
sco
re
(max
sco
re)
Ris
k fa
cto
rs
rep
ort
edH
igh
ris
k SC
I co
ho
rt (
%)
Prev
iou
s ao
rtic
su
rger
y (%
)Le
ng
th o
f ao
rtic
co
vera
ge
rep
ort
ed
Pate
nt
colla
tera
l va
scu
lar
bed
sIn
tra-
op
erat
ive
hyp
ote
nsi
on
Op
erat
ive
tim
e (m
in)
Kita
gaw
a, A
. et
al.
10 (1
6)Ye
s33
.333
.3N
oN
oYe
sN
R
Kno
wle
s, M
. et
al.
7 (1
6)Ye
s32
.332
.3Ye
sN
oN
oN
R
Lee,
M. e
t al
.9
(16)
Yes
31.0
31.0
Yes
Yes
No
NR
Mal
dona
do, T
. S. e
t al
.9
(16)
Yes
27.1
27.1
Yes
No
No
NR
Mas
tror
ober
to, P
. et
al.
10 (1
6)Ye
s30
.09.
5N
oN
oYe
s11
5
Mat
suda
, H. e
t al
.8
(16)
Yes
40.0
40.0
Yes
Yes
Yes
NR
Mau
rel,
B. e
t al
.16
(24)
Yes
50.0
29.4
Yes
Yes
Yes
182
Pate
l, H
. J. e
t al
.9
(16)
Yes
22.0
17.8
Yes
Yes
Yes
NR
Piff
aret
ti, G
. et
al.
10 (1
6)Ye
s66
.066
.0Ye
sN
oN
oN
R
Prev
entz
a, O
. et
al.
7 (1
6)Ye
s23
.713
.3Ye
sN
oN
RN
R
Ross
i, S.
H. e
t al
.15
(24)
Yes
36.2
36.2
Yes
Yes
Yes
NR
Ryls
ki, B
. et
al.
12 (1
6)N
o33
.0N
RN
oN
oN
oN
R
Schl
össe
r, F.
J. V
. et
al.
9 (1
6)Ye
s10
0.0
100.
0Ye
sYe
sYe
sN
R
Shah
, T. R
. et
al.
14 (2
4)Ye
s5.
15.
1Ye
sYe
sN
oN
R
Sobe
l, J.
D. e
t al
.10
(16)
Yes
44.0
44.0
Yes
No
Yes
499
Tana
ka, K
. et
al.
11 (1
6)Ye
s38
.412
.2Ye
sN
RYe
sN
R
Ulle
ry, B
. W. e
t al
.10
(16)
Yes
28.8
28.8
No
Yes
Yes
NR
Yin
gbin
, J. e
t al
.6
(16)
No
9.2
NR
No
No
Yes
NR
Zam
or, K
. C. e
t al
.12
(24)
No
25.0
NR
No
No
No
NR
Zeng
, Q. e
t al
.8
(16)
Yes
100.
0N
RYe
sN
oYe
s15
7
Zipf
el, B
. et
al.
12 (1
6)Ye
s55
.711
.3Ye
sN
oYe
sN
R
Abb
revi
atio
ns: S
CI,
Spin
al c
ord
isch
emia
; NR,
Not
rep
orte
d
132
Chapter 8
abdominal repairs. In three studies (7.0 %) no spinal fluid drainage was used
and in the remaining two (4.7 %) a preventive protocol on the use of a drain
was not specified. The use of an ‘emergent’ drain (e.g. in case of symptoms
peri-operatively) was not included in this review, as this is a therapeutic and not
a preventive measure. As for the other modalities, avoidance of hypotension was
used in 32 (74.4 %), hypothermia in 2 (4.7 %), staged procedures in 7 (16.3 %),
prophylactic LSA revascularization in 29 (67.4 %), permissive endoleaks in 6
(14.0 %) and peri-operative monitoring in 5 (11.6 %) of the preventive protocols.
Intra-thecal medication was not described in any of the included papers. Four
studies (9.3 %) used only one preventive measure. In 25 (58.1 %) studies more
than two preventive measures were used, in 12 (27.9 %) more than three. Data
was subsequently pooled and sub-analysis for each of the different preventive
measures was performed. Analysis was performed for both transient and per-
manent SCI.
Quality of included studies
Overall the included studies had an average MINORS score of 10.0 (range 6
– 18). For non-comparative studies this was 9.0 (range 6 – 13) and for compara-
tive studies this was 15.5 (range 12 – 18). The majority of included studies did
clearly state the aim of the study and there was no frequent loss to follow up.
However, consecutive patients were not always included and data was collected
retrospectively in the majority of the included studies, which mainly resulted in
lower MINORS scores. Table 3 shows the MINORS score per study.
spinal cord ischemia
Overall, transient SCI occurred in 5.7 % (450/7168, 95 % CI 4.5– 6.9 %) and
permanent SCI in 2.2 % (232/7168, 95 % CI 1.6 – 2.8 %, Figure 2 and Table 4).
The highest transient SCI estimate was 30.6 % (Dias 2015), the lowest estimate
was 0.3 % (Lee 2013). Estimates for permanent SCI ranged from 0.3 % (Archer
2016 and Lee 2013) to 20.8 % (Dias 2015). There was no time trend over the last
decades for the incidence of SCI.
The studies were then grouped by preventive measure and the overall incidences
of both transient and permanent SCI per preventive measure used are shown
in Table 4. Avoidance of hypotension resulted in a slightly lower permanent SCI
rate 1.8 % (102/4216, 95 % CI 1.2–2.3 %) compared to the overall cohort. A
very low SCI estimate (both transient and permanent) was found in the small
subgroup of studies (2 studies, n = 248) using (mild) peri-operative hypothermia
(transient SCI 0.8 % and permanent SCI 0.4 %). Interestingly, in the subgroup us-
Spinal cord ischemia preventive strategies
133
8
Fig
ure
2. F
ores
t pl
ot s
how
ing
the
tran
sien
t SC
I (le
ft) a
nd p
erm
anen
t SC
I (rig
ht) e
stim
ates
for
the
incl
uded
stu
dies
. For
eac
h st
udy
the
estim
ate
and
95 %
CI i
s gi
ven
(sec
ond
colu
mn)
. The
abs
olut
e nu
mbe
r of
eve
nts
and
tota
l num
ber
of p
atie
nts
are
show
n in
the
thi
rd c
olum
n an
d th
e fo
rest
plo
t ch
arts
in t
he la
st c
olum
n.
134
Chapter 8
ing temporary permissive endoleak, there was a transient SCI estimate of 15.4 %
with a permanent SCI estimate of 4.8 %. The remaining preventive measures
(selective spinal fluid drain, avoidance of hypotension, staged procedures, selec-
tive revascularization, monitoring or the use of > 2 preventive measures) did not
have a significant impact on transient and permanent SCI estimates. Notably,
there was a large overlap of the used preventive measures since the majority of
the studies employed multiple preventive measures, and marked heterogene-
ity of the cohorts, therefore no indirect comparisons were made and the data
presented is solely descriptive.
When the individual cohorts were divided by a-priori SCI risk, there was a trend
towards increased SCI incidence for more ‘high risk’ cohorts. Interestingly, this
trend was more evident for prophylactic, compared to selective spinal fluid
drainage (Figure 3).
Table 4. Pooled analyses per preventive measure used. The references correspond with the included study reference list, appendix 2.
Preventive measure - Pooled analysis Transient SCI estimate Permanent SCI estimate
Profylactic spinal fluid drain2,3,8,12,14,17,25,32,35 11.1 %(76/644, 0.060 – 0.162)
3.7 %(34/644, 0.014 – 0.059)
Selective spinal fluid drain4–7, 9–11, 13, 15, 18–24, 26–31, 33, 34, 36, 37, 41, 42
5.3 %(360/6088, 0.040 – 0.066)
2.3 %(194/6088, 0.016 – 0.030)
No spinal fluid drain1, 16, 40 5.8 %(9/139, 0.019 – 0.097)
1.8 %(3/139, -0.004 – 0.040)
Avoidance of hypotension1, 3, 4, 8, 10–14, 17–21, 23, 25–31, 33–38, 40–43
5.5 %(248/4216, 0.042 – 0.068)
1.8 %(102/4216, 0.012–0.023)
Hypothermia42, 43 0.8 %(2/249, -0.003 – 0.018)
0.4 %(0/249, -0.004 – 0.011)
Staged procedures3, 6, 10, 17, 27, 29, 31 7.1 %(60/837, 0.045 – 0.096)
3.2 %(28/837, 0.020 – 0.043)
Selective LSA revascularization1–3, 6–8, 10, 11, 18, 19, 21–24, 26–31, 34–37, 39–43
5.2 %(344/5764, 0.039 – 0.066)
2.3 %(193/5764, 0.015 – 0.030)
Permissive temporary endoleak3, 12, 14, 17, 31, 35
15.4 %(56/331, 0.095 – 0.214)
4.8 %(19/331, 0.025 – 0.071)
Neuromonitoring3, 8, 26, 31, 37 11.6 %(53/662, 0.038 – 0.194)
4.7 %(25/662, 0.007 – 0.087)
> 2 preventive measures3, 6, 8, 10–12, 14, 17–19, 21, 23, 26–31, 34–37, 41–43
5.2 %(211/3711, 0.038–0.067)
1.8 %(91/3711, 0.012–0.024)
≤ 2 preventive measures1, 2, 4, 5, 7, 9, 13, 15, 16, 20, 22, 24, 25, 32, 33, 38–40
6.2 %(239/3457, 0.044–0.081)
2.6 %(141/3457, 0.014–0.037)
Overall 5.7 %(450/7168, 0.045 – 0.069)
2.2 %(232/7168, 0.016 – 0.028)
Abbreviations: LSA, Left subclavian artery; SCI, Spinal cord ischemia.
Spinal cord ischemia preventive strategies
135
8
discussion
Based on the available data no definitive recommendations can be made with
regard to the optimal preventive strategies for SCI in endovascular thoraco-
abdominal aortic repair. Current knowledge is mainly based on non-comparative
cohorts, there are no randomized controlled trials evaluating any of the preven-
tive measures for SCI, let alone multiple intervention strategies. Therefore, one
must conclude that the currently employed (multi-modality) protocols used are
extrapolated from those used routinely in open surgical repair and based on the
theoretical models of SCI pathophysiology.
As shown by Table 2, the data available are highly heterogeneous and largely
retrospectively obtained. In addition, the majority of the included studies had a
mixed population of aneurysmal disease, dissections, PAU and in some studies
traumatic injury, further complicating the assessment. Patient characteristics in
terms of co-morbidities were similar for the included studies (Table 2).
With the current treatment protocols, low overall rates of SCI are achieved
(permanent SCI estimate 2.2 % (232/7168, 0.016 – 0.028), Figure 2), which is
comparable to earlier reports of SCI rates being estimated at 2 – 6 %.6 There is
however a large variation for the individual cohorts, with the highest reported
transient and permanent SCI rates being 30.6 % and 20.8 % respectively. These
incidences were reported in the study by Dias et. al.14. In a sub-analysis per-
formed by the authors, the only factors independently associated with SCI were
Crawford type II TAAA and a higher contrast volume. The authors do state that
Figure 3. Scatter plot showing the permanent SCI estimate (y-axis) versus the percentage of ‘high risk’ patients included in the the study cohort (x-axis).
136
Chapter 8
the implementation of a more standardized SCI protocol led to a reduction in SCI
rate, but a residual SCI rate of 13.2 % at discharge is still considerably high. The
relatively ‘high risk’ population may have attributed to this. Also, in this study
SCI was the primary outcome measure and rigorous post-operative protocols for
the detection of SCI were implemented, possibly adding to the high incidence
of SCI.
In open thoracic and thoraco-abdominal aneurysm repair the use of spinal drains
has been well established. The use of a spinal fluid drain reduces the intra-thecal
pressure and is thus believed to improve spinal cord perfusion pressure.15 During
endovascular repair the potential gain is arguably lower due to less hemody-
namic disturbances peri-operatively. Given the invasive nature of spinal drain
insertion and the potential associated complications, consensus amongst experts
is that the routine use of spinal fluid drains is not mandated but should be
used selectively in high risk patients.6, 16, 17 High risk patients generally include
patients with previous aortic surgery and/or expected long segment coverage of
the aorta (> 200mm). Other reported risk factors include advanced age, renal
insufficiency and emergency procedures. More recently, compromised collateral
vascular beds (e.g. occluded/stenosed subclavian and hypogastric arteries) have
been associated with an increased risk of SCI.7 There is however no generally
accepted uniform algorithm to determine when a patient is ‘high risk’. Since the
routine use of spinal drains does seem to have slightly less favorable outcomes,
especially in ‘high risk’ cohorts (Figure 3) and given the invasive nature of this
preventive measure, it could be argued a selective drainage protocol should be
used in these categories of patients.
The use of vasopressive agents and intra-venous fluid administration to increase
the mean arterial pressure as a treatment modality in case of spinal cord isch-
emia or paraplegia have been described and proved to be successful in selected
cohorts.18, 19 The risk of developing spinal cord ischemia during a hypotensive pe-
riod has also been described. A peri-operative period of hypotension (MAP < 70
mmHg) was found to be a significant predictor or SCI and a MAP of at least 90
mmHg post-operatively is advised in order to prevent SCI.18 The current data
shows an overall SCI estimate for permanent SCI of 1.8 % (n = 4216, 95 % CI 1.2
– 2.3 %) for studies using avoidance of hypotension, which is lower compared to
the whole cohort (2.2 %, 95 % CI 1.6 – 2.8 %, Table 4). The routine implementa-
tion of this relatively easy and non-invasive measure therefore seems reasonable.
Hypothermia was only used in two studies, including a total of 249 patients.20, 21
Both studies used a multi-modality (> 3) preventive protocol. In the study by
Acher et. al. patients were operated on moderate systemic hypothermia (34°C).
Spinal cord ischemia preventive strategies
137
8
In addition, selective spinal fluid drainage, avoidance of hypotension and selec-
tive LSA revascularization were included in the study protocol. The group led by
Bobadilla also used a multi modality ‘proactive’ preventive protocol with moder-
ate hypothermia (< 35°C), prophylactic spinal fluid drainage, avoidance of hy-
potension and selective LSA revascularization. No permanent SCI was observed
in either cohort (permanent SCI estimate 0.3 % and 0.5 %, respectively) and
only two cases of transient SCI (one in each study) were witnessed. Interestingly,
patients in the study by Acher et. al. had an average length of aortic coverage of
250mm and 46.5 % had undergone previous aortic surgery, making the very low
SCI rate even more impressive. This would suggest that a multimodal approach
including hypothermia had a significant effect in the prevention of the develop-
ment of both transient and permanent SCI (Table 4). Therefore operating under
moderate hypothermia may be considered beneficial. However, the sample size is
small. Furthermore, several other preventive measures were used simultaneously,
which makes is difficult to attribute the difference solely to the hypothermia.
The concept of permissive or induced endoleak was first described in 2010 by
Reilly and Chuter. The authors seemingly reversed symptoms of spinal cord isch-
emia after endovascular repair of a type II TAAA by creating a temporary type Ib
endoleak.22 Subsequently, the use of paraplegia preventing branches (PPBs), for
the creation of controlled type III endoleaks, has been described by Lioupis et al.
in 2011.23 The current review showed that the use of permissive endoleak was
associated with a fairly high transient SCI estimate (Table 4), but no increased
permanent SCI estimate. This seems counter-intuitive, as one would suggest
that persistent perfusion of the aneurysm sac protect against SCI development.
Six studies used this technique, including 331 patients.24–29 The majority of the
included patients were deemed at (very) high risk for the development of SCI,
leading to possible bias. Patients treated in these studies were all deemed to be
at high risk for developing SCI, although specific risk factors were not mentioned
in either study.
With regard to staged procedures, evidence shows that in open thoracic pro-
cedures a previous abdominal repair generates an increased risk for spinal cord
ischemia if a supplementary thoracic repair is carried out.17 The pathophyiologi-
cal mechanism is most likely multifactorial. Recent clinical studies show that the
perfusion of the spinal cord is regulated by an extensive collateral network. The
collateral network consist of paraspinous arterial collaterals, segmental spinal
arteries, and intercostal and lumbar arteries.30 Taking the previous considerations
into account staged interventions may show a lower rate of SCI, potentially
through provoked expansion of the collateral network or the formation of new
vessel leading to sufficient perfusion of the spinal cord.31, 32 The data in the
138
Chapter 8
current review failed to show a beneficial effect for staged endovascular repair
of extensive (thoraco)abdominal aneurysms (Table 4). Recently, sequential coil
embolization of intercostal arteries has been suggested as a method to protect
the spinal cord after TEVAR through stimulation of collateral flow of the spinal
cord. No results of this technique in men have been published.33
There are numerous publications on collateral re-vascularization and SCI preven-
tion, largely focused on LSA revascularization (since endovascular repair does not
allow for re-implantation of intercostal arteries). A systematic review and meta-
analysis by Rizvi et al. showed that coverage of the LSA without revascularization
was associated with a trend towards an increased risk of paraplegia (odds ratio
[OR] = 2.69, [CI] 0.75–9.68) when compared with patients who underwent LSA
revascularization.34 A review by Weigang et al. in 2011 concluded that patients
should undergo prophylactic LSA transposition or carotid-LSA bypass if coverage
of the LSA origin is anticipated, to prevent neurological complications including
paraplegia.35 The current data does not corroborate these statements, since
there is no difference in either transient or permanent SCI with or without selec-
tive LSA revascularization. A possible association between LSA occlusion and SCI
was not part of this review.
Finally, if the pathophysiological mechanism occurring in SCI is multi-factorial,
using multiple preventive measures in unison could result in lower SCI rates. The
presented meta-analysis however did not show a significant difference in SCI
rates if a SCI preventive protocol including multiple preventive strategies was
used.
The current meta-analysis has several caveats and possible sources of bias. First,
the data is very heterogeneous. Given the heterogeneity of the data, no direct or
indirect comparisons between the different preventive measures could be made.
Nonetheless, it was opted to pool these data for a number of reasons; first to
give insight in overall SCI estimates, second to emphasize that current treat-
ment protocols are not always clear and vary widely, and third because given
the available data this was the only viable option. The majority of the included
data was collected retrospectively. Not all studies were conducted with SCI as
the primary outcome measure and there is a large variety in follow up protocols
and post-operative examinations. A number of studies had strict post-operative
protocols, including serial examinations by independent neurologists, which will
undoubtedly lead to a higher incidence of (at least transient) SCI. Also, the length
of aortic coverage was not included in the analysis. This proved to be impossible
based on the available data, where the length of coverage was frequently not
reported or reported in such a way that a comparison could not be made.
Spinal cord ischemia preventive strategies
139
8
In summary, low transient and especially permanent SCI rates are achieved dur-
ing endovascular thoracic and thoraco-abdominal aortic repair. These SCI rates
are achieved using multiple preventive measures, often used in unison. It seems
reasonable to employ several preventive measures, including selective spinal
fluid drainage, avoidance of hypotension and mild hypothermia, However, no
definitive recommendation on spinal cord ischemia preventive measures can be
made based upon the current literature. To acquire sufficient and high quality
data a large international multi-center registry should be instated.
conclusion
Low overall transient and permanent SCI rates are achieved during endovascular
thoracic and thoraco-abdominal aortic repair. However, permanent SCI rates up
to 21 % are reported in high risk cohorts. The current SCI prevention protocols
vary widely. Based on the presented data the employment of selective spinal
fluid drainage in high risk patients, avoidance of hypotension and mild hypother-
mia seems justified. Further high quality data is needed to establish a definitive
preventive strategy.
140
Chapter 8
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tive Strategies Can Prevent Permanent Paraplegia in the Majority of Patients Who
Develop Spinal Cord Ischaemia After Endovascular Repair of Thoracoabdominal
Aortic Aneurysms. Eur J Vasc Endovasc Surg. 2015; 50(5): 599-607.
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Chapter 8
aPPendix
appendix 1
Search
The following searches were used: 1. Pubmed: “(Aortic OR Aorta OR
Aorta [Mesh]) AND (Endovascular OR TEVAR OR EVAR OR “endovascular
procedures”[MeSH]) AND (“spinal cord ischemia” OR “Spinal cord”[Mesh] OR
“spinal cord ischemia”[Mesh] OR paraplegia OR paraplegia[MeSH] OR paralysis
OR paralysis [MeSH])”, 2. Embase: “(Aortic OR Aorta OR ‘Aorta’/exp OR ‘Aorta
sinus’/exp) AND (Endovascular OR TEVAR OR EVAR OR ‘Endovascular surgery’/exp
OR ‘Angioplasty’/exp OR ‘Atherectomy’/exp OR ‘Angioscopy’/exp OR ‘Catheter-
ization’/exp OR ‘Percutaneous cardiovascular procedure’/exp) AND (‘spinal cord
ischemia’ OR ‘Spinal cord’/exp OR ‘spinal cord ischemia’/exp OR ‘extrapyramidal
system’/exp OR ‘gray matter’/exp OR ‘pyramidal tract’/exp OR ‘spinothalamic
tract’/exp OR ‘white matter’/exp OR ‘posterior horn cell’/exp OR ‘anterior horn
cell’/exp OR paraplegia OR ‘paralysis’/exp)” and 3. Cochrane Library: “Spinal
cord ischemia” AND “Aortic Aneurysm”.
Spinal cord ischemia preventive strategies
145
8
appendix 2
Reference list of included articles.
1. Acher C, Acher CW, Marks E, Wynn M. Intraoperative neuroprotective interven-
tions prevent spinal cord ischemia and injury in thoracic endovascular aortic repair.
J Vasc Surg. 2016; 63(6): 1458-65.
2. Amabile P, Grisoli D, Giorgi R, Bartoli JM, Piquet P. Incidence and determinants of
spinal cord ischaemia in stent-graft repair of the thoracic aorta. Eur J Vasc Endovasc
Surg. 2008; 35(4): 455-61.
3. Arnaoutakis DJ, Arnaoutakis GJ, Beaulieu RJ, Abularrage CJ, Lum YW, Black JH,
3rd. Results of adjunctive spinal drainage and/or left subclavian artery bypass in
thoracic endovascular aortic repair. Ann Vasc Surg. 2014; 28(1): 65-73.
4. Banga PV, Oderich GS, Reis de Souza L, Hofer J, Cazares Gonzalez ML, Pulido JN, et
al. Neuromonitoring, Cerebrospinal Fluid Drainage, and Selective Use of Iliofemoral
Conduits to Minimize Risk of Spinal Cord Injury During Complex Endovascular
Aortic Repair. J Endovasc Ther. 2016; 23(1): 139-49.
5. Bisdas T, Panuccio G, Sugimoto M, Torsello G, Austermann M. Risk factors for spinal
cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms. J
Vasc Surg. 2015; 61(6): 1408-16.
6. Bobadilla JL, Wynn M, Tefera G, Acher CW. Low incidence of paraplegia after tho-
racic endovascular aneurysm repair with proactive spinal cord protective protocols.
J Vasc Surg. 2013; 57(6): 1537-42.
7. Chiesa R, Melissano G, Marrocco-Trischitta MM, Civilini E, Setacci F. Spinal cord
ischemia after elective stent-graft repair of the thoracic aorta. J Vasc Surg. 2005;
42(1): 11-7.
8. Clough RE, Patel AS, Lyons OT, Bell RE, Zayed HA, Carrell TW, et al. Pathology
specific early outcome after thoracic endovascular aortic repair. Eur J Vasc Endovasc
Surg. 2014; 48(3): 268-75.
9. DeSart K, Scali ST, Feezor RJ, Hong M, Hess PJ, Jr., Beaver TM, et al. Fate of patients
with spinal cord ischemia complicating thoracic endovascular aortic repair. J Vasc
Surg. 2013; 58(3): 635-42 e2.
10. Dias NV, Sonesson B, Kristmundsson T, Holm H, Resch T. Short-term outcome of spi-
nal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms.
Eur J Vasc Endovasc Surg. 2015; 49(4): 403-9.
11. Drinkwater SL, Goebells A, Haydar A, Bourke P, Brown L, Hamady M, et al. The
incidence of spinal cord ischaemia following thoracic and thoracoabdominal aortic
endovascular intervention. Eur J Vasc Endovasc Surg. 2010; 40(6): 729-35.
146
Chapter 8
12. Guillou M, Bianchini A, Sobocinski J, Maurel B, D’Elia P, Tyrrell M, et al. Endovascu-
lar treatment of thoracoabdominal aortic aneurysms. Journal of Vascular Surgery.
2012; 56(1): 65-73.
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selective preoperative lumbar drain placement for thoracic endovascular aortic
repair. Ann Thorac Surg. 2013; 95(6): 1968-74; discussion 74-5.
14. Harrison SC, Agu O, Harris PL, Ivancev K. Elective sac perfusion to reduce the risk of
neurologic events following endovascular repair of thoracoabdominal aneurysms. J
Vasc Surg. 2012; 55(4): 1202-5.
15. Hnath JC, Mehta M, Taggert JB, Sternbach Y, Roddy SP, Kreienberg PB, et al.
Strategies to improve spinal cord ischemia in endovascular thoracic aortic repair:
Outcomes of a prospective cerebrospinal fluid drainage protocol. J Vasc Surg. 2008;
48(4): 836-40.
16. Jayia P, Constantinou J, Hamilton H, Ivancev K. Temporary Perfusion Branches to
Decrease Spinal Cord Ischemia in the Endovascular Treatment of Thoraco-Abdom-
inal Aortic Aneurysms: Based on a Presentation at the 2013 VEITH Symposium,
November 19-23, 2013 (New York, NY, USA). Aorta (Stamford, Conn). 2015; 3(2):
56-60.
17. Jonker FH, Verhagen HJ, Lin PH, Heijmen RH, Trimarchi S, Lee WA, et al. Outcomes
of endovascular repair of ruptured descending thoracic aortic aneurysms. Circula-
tion. 2010; 121(25): 2718-23.
18. Kamada T, Yoshioka K, Tanaka R, Makita S, Abiko A, Mukaida M, et al. Strategy for
thoracic endovascular aortic repair based on collateral circulation to the artery of
Adamkiewicz. Surg Today. 2015.
19. Kasprzak PM, Gallis K, Cucuruz B, Pfister K, Janotta M, Kopp R. Editor’s choice—
Temporary aneurysm sac perfusion as an adjunct for prevention of spinal cord
ischemia after branched endovascular repair of thoracoabdominal aneurysms. Eur
J Vasc Endovasc Surg. 2014; 48(3): 258-65.
20. Kato M, Motoki M, Isaji T, Suzuki T, Kawai Y, Ohkubo N. Spinal cord injury after
endovascular treatment for thoracoabdominal aneurysm or dissection. Eur J Car-
diothorac Surg. 2015; 48(4): 571-7.
21. Keith Jr CJ, Passman MA, Carignan MJ, Parmar GM, Nagre SB, Patterson MA, et
al. Protocol implementation of selective postoperative lumbar spinal drainage after
thoracic aortic endograft. Journal of Vascular Surgery. 2012; 55(1): 1-8.
22. Khoynezhad A, Donayre CE, Bui H, Kopchok GE, Walot I, White RA. Risk factors of
neurologic deficit after thoracic aortic endografting. Ann Thorac Surg. 2007; 83(2):
S882-9; discussion S90-2.
23. Kitagawa A, Greenberg RK, Eagleton MJ, Mastracci TM, Roselli EE. Fenestrated
and branched endovascular aortic repair for chronic type B aortic dissection with
thoracoabdominal aneurysms. J Vasc Surg. 2013; 58(3): 625-34.
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147
8
24. Knowles M, Murphy EH, Dimaio JM, Modrall JG, Timaran CH, Jessen ME, et al. The
effects of operative indication and urgency of intervention on patient outcomes
after thoracic aortic endografting. J Vasc Surg. 2011; 53(4): 926-34.
25. Lee M, Lee do Y, Kim MD, Won JY, Yune YN, Lee TY, et al. Selective coverage of
the left subclavian artery without revascularization in patients with bilateral patent
vertebrobasilar junctions during thoracic endovascular aortic repair. J Vasc Surg.
2013; 57(5): 1311-6.
26. Maldonado TS, Dexter D, Rockman CB, Veith FJ, Garg K, Arko F, et al. Left subcla-
vian artery coverage during thoracic endovascular aortic aneurysm repair does not
mandate revascularization. J Vasc Surg. 2013; 57(1): 116-24.
27. Mastroroberto P, Ciranni S, Indolfi C. Extensive endovascular repair of thoracic
aorta: observational analysis of the results and effects on spinal cord perfusion. J
Cardiovasc Surg (Torino). 2013; 54(4): 523-30.
28. Matsuda H, Ogino H, Fukuda T, Iritani O, Sato S, Iba Y, et al. Multidisciplinary
approach to prevent spinal cord ischemia after thoracic endovascular aneurysm
repair for distal descending aorta. Ann Thorac Surg. 2010; 90(2): 561-5.
29. Maurel B, Delclaux N, Sobocinski J, Hertault A, Martin-Gonzalez T, Moussa M, et al.
Editor’s choice - The impact of early pelvic and lower limb reperfusion and attentive
peri-operative management on the incidence of spinal cord ischemia during tho-
racoabdominal aortic aneurysm endovascular repair. European Journal of Vascular
and Endovascular Surgery. 2015; 49(3): 248-54.
30. Patel HJ, Williams DM, Upchurch GR, Jr., Shillingford MS, Dasika NL, Proctor MC,
et al. Long-term results from a 12-year experience with endovascular therapy for
thoracic aortic disease. Ann Thorac Surg. 2006; 82(6): 2147-53.
31. Piffaretti G, Bonardelli S, Bellosta R, Mariscalco G, Lomazzi C, Tolenaar JL, et al.
Spinal cord ischemia after simultaneous and sequential treatment of multilevel
aortic disease. J Thorac Cardiovasc Surg. 2014; 148(4): 1435-42 e1.
32. Preventza O, Wheatley GH, 3rd, Williams J, Ramaiah V, Rodriguez-Lopez J, Di-
ethrich EB. Identifying paraplegia risk associated with thoracic endografting. Asian
cardiovascular & thoracic annals. 2009; 17(6): 568-72.
33. Rossi SH, Patel A, Saha P, Gwozdz A, Salter R, Gkoutzios P, et al. Neuroprotec-
tive Strategies Can Prevent Permanent Paraplegia in the Majority of Patients Who
Develop Spinal Cord Ischaemia After Endovascular Repair of Thoracoabdominal
Aortic Aneurysms. Eur J Vasc Endovasc Surg. 2015; 50(5): 599-607.
34. Rylski B, Blanke P, Siepe M, Kari FA, Euringer W, Sudkamp M, et al. Results of
high-risk endovascular procedures in patients with non-dissected thoracic aortic
pathology: intermediate outcomes. Eur J Cardiothorac Surg. 2013; 44(1): 156-62.
35. Schlosser FJ, Verhagen HJ, Lin PH, Verhoeven EL, van Herwaarden JA, Moll FL,
et al. TEVAR following prior abdominal aortic aneurysm surgery: increased risk of
neurological deficit. J Vasc Surg. 2009; 49(2): 308-14; discussion 14.
148
Chapter 8
36. Shah TR, Maldonado T, Bauer S, Cayne NS, Schwartz CF, Mussa F, et al. Female
patients undergoing TEVAR may have an increased risk of postoperative spinal cord
ischemia. Vasc Endovascular Surg. 2010; 44(5): 350-5.
37. Sobel JD, Vartanian SM, Gasper WJ, Hiramoto JS, Chuter TA, Reilly LM. Lower
extremity weakness after endovascular aneurysm repair with multibranched thora-
coabdominal stent grafts. J Vasc Surg. 2015; 61(3): 623-8.
38. Tanaka K, Yoshitaka H, Chikazawa G, Sakaguchi T, Totsugawa T, Tamura K. Inves-
tigation of the surgical complications during thoracic endovascular aortic repair:
experiences with 148 consecutive cases treated at a single institution in Japan. Surg
Today. 2015; 45(1): 22-8.
39. Ullery BW, Cheung AT, Fairman RM, Jackson BM, Woo EY, Bavaria J, et al. Risk
factors, outcomes, and clinical manifestations of spinal cord ischemia following
thoracic endovascular aortic repair. J Vasc Surg. 2011; 54(3): 677-84.
40. Yingbin J, Jiefei M, Jian L, Yonghui S, Haiyan P, Baimeng Z, et al. Evaluation of
the thoracic aortic dissection treated by endografts covering a longer distance of
aorta according to the location of the Adamkiewicz artery. Thorac Cardiovasc Surg.
2013; 61(7): 569-74.
41. Zamor KC, Eskandari MK, Rodriguez HE, Ho KJ, Morasch MD, Hoel AW. Outcomes
of Thoracic Endovascular Aortic Repair and Subclavian Revascularization Tech-
niques. J Am Coll Surg. 2015; 221(1): 93-100.
42. Zeng Q, Guo X, Huang L, Sun L. Single-center experience with simultaneous
thoracic endovascular aortic repair and abdominal endovascular aneurysm repair.
Vascular. 2016.
43. Zipfel B, Buz S, Redlin M, Hullmeine D, Hammerschmidt R, Hetzer R. Spinal cord
ischemia after thoracic stent-grafting: causes apart from intercostal artery cover-
age. Ann Thorac Surg. 2013; 96(1): 31-8.
