spinal cord ischaemia following tevaroliverzuzan.net/documents/presentation.pdf · high-risk...
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Spinal cord ischaemia following TEVAR Prediction, Prevention & Management
Oliver Zuzan, MD MPhil FRCA Consultant in Anaesthesia and Critical Care Royal Liverpool University Hospital
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Risk factors
n Length of aorta covered n Hypotension n Previous or concomitant abdominal repair n +/- Occlusion of left subclavian artery
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Prophylactic CSF drainage
n Previous aortic surgery n Combined procedures (e.g. open AAA
repair + TEVAR) n Long graft needed (20cm and above) n High-risk vascular anatomy on pre-op
angiogram
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Prophylactic CSF drainage in open thoracic aneurysm repair
Khan SN, Stansby G. Cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery. Cochrane database of systematic reviews. [Review]. 2004(1):CD003635.
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Ann Thorac Surg 2009 Jul;88(1):9-15
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Complications of CSF drainage
n 24 of out 486 patients (5%) had bloody spinal fluid: ¨ No evidence of intracranial hemorrhage: 7 (1.4%) ¨ Intracranial blood without neurologic deficit: 14 (2.9%) ¨ Intracranial bleeding with neurologic deficits: 3 (0.6%)
Wynn MM, Mell MW, Tefera G, Hoch JR, Acher CW. Complications of spinal fluid drainage in thoracoabdominal aortic aneurysm repair: a report of 486 patients treated from 1987 to 2008. J Vasc Surgery 2009 Jan;49(1):29-34.
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Prophylactic versus therapeutic CSF drainage for thoracic endografts Prophylaxis n No therapeutic interval,
better chance of complete recovery
n Higher numbers = safer system
n Better awareness of problem
n Strong evidence base in open surgery
Treatment n Less patients exposed to
procedural risk of CSF drainage
n Cheaper n Quicker mobilisation n Prophylaxis may not
prevent delayed onset SCI
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Signs and Symptoms
n Sensory deficits (not necessarily typical “level” distribution, can be unilateral)
n Back pain n Loss of deep tendon reflexes n Heavy legs n Decreased muscle power n Paraplegia
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Management
n EMERGENCY! n Blood pressure augmentation (MAP
>90mmHg) n CSF drainage (CSF pressure <10mmHg)
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Induced endoleak n Branched EVAR for TAAA n Early post-op leg weakness n CSF drainage plus BP-augmentation: resolution
of symptoms but further episodes of paraplegia n Stent between distal end of infra-renal graft and
aortic wall (distal endoleak): complete resolution n Stent closed/occluded 3.5 months later n No recurrence of spinal cord ischaemia
Reilly LM, Chuter TA. Reversal of fortune: induced endoleak to resolve neurological deficit after endovascular repair of thoracoabdominal aortic aneurysm. J Endovasc Ther. 2010 Feb;17(1):21-9.
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n We retrieved data from 99 studies incorporating 4906 patients. n Incidences of left-arm ischaemia (0.0% vs 9.2%, p = 0.002) and stroke
(4.7% vs 7.2%, p < 0.001) were significantly less following revascularisation, although mortality (10.5% vs 3.4%, p = 0.032) and endoleak incidence (25.8% vs 12.6%, p = 0.008) were increased.
n No significant differences in spinal-cord ischaemia were seen. n Revascularisation may reduce downstream ischaemic complications but
can cause significant risk. Indications must be carefully considered on an individual patient basis.