SPINAL CORD ISCHEMIA AFTER THORACIC ANEURYSM REPAIR: RISK STRATIFICATION & PREVENTION DISCLOSURES. INDIVIDUAL None

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1 DISCLOSURES AFTER THORACIC ANEURYSM REPAIR: INDIVIDUAL None RISK STRATIFICATION & PREVENTION INSTITUTIONAL Cook, Inc W. L. Gore, Inc Conrad, J Vasc Surg,

2 Intraoperative Adjuncts Oversew intercostals immediately Reimplant intercostals Hypogastric preservation Left subclavian artery preservation Shorten aortic crossclamp time Sew fast Crawford reimplantation technique Left heart bypass / distal aortic perfusion Epidural cooling (4 C) CSF drainage Hemodynamic stability / permissive hypertension Neuromonitoring O/E ratio of SCI has declined from 1 to 0.25 or less (range ) over last decade O/E ratio of SCI has declined from 1 to 0.25 or less (range ) over last decade O/E ratio of SCI has declined from 1 to 0.25 or less (range ) over last decade Spinal fluid drainage Hypothermia Induced / permissive hypertension Neuroprotection Steroids Naloxone Barbiturates Dedicated / experienced team Protocol for patient management Spinal fluid drainage Hypothermia Induced / permissive hypertension Neuroprotection Steroids Naloxone Barbiturates Dedicated / experienced team Protocol for patient management 2

3 Most important factors for SCI Not important factors for SCI Age Renal function Aortic occlusion time Core temperature Intercostal reimplantation? Crawford type II and dissection Data Limitations Reports mix acuity Reports mix pathology TAAA results often included Outcomes for TAA alone not always presented DTAA YEAR TEVAR/ OPEN PATHOLOGY TEVAR SCI OPEN SCI P COMMENT Buth DTAA 4.1% EUROSTAR Ullery DTAA 2.8% Single center DISSECTION Buth dissection 1.5% EUROSTAR Nienaber INSTEAD dissection 2.8% Prospective, Randomized, best med rx Ullery dissection 5.0% Single center Luebke dissection acute 4.9% OR 0.26 Meta-analysis Thrumurthy dissection 0.4% review 3

4 BAI YEAR TEVAR/OP EN PATHOLOGY TEVAR SCI OPEN SCI P COMMENT Tang / 329 BAI 0% 5.6% <0.001 Meta-analysis Xenos / 875 BAI 3.3% 1.6% Meta-analysis Xenos / 333 Trauma rupture 0.5% 6.6% 0.37 Meta-snalysis RUPTURE Xenos / 501 All TA rupture % ND / OR 0.27 Meta-analysis Gopaldas / 559 All TA rupture 6.9% 7.5% NIS DB Jonker / 81 DTAA rupture 5.5% 3.1% Meta-analysis Cambria AAS 1.7% 5.5% 0.36 Multiinstitutional prospective Naughton AAS 8.0% 13% NSS Important factors for SCI Length of aorta excluded Exclusion of distal thoracic aorta > 20 cm > 25 cm > 30 cm 3-4 stant grafts Coverage of two collateral routes L subclavian coverage Hypogastric coverage Infrarenal aortic replacement 0.04 History of prior aortic surgery Important factors for SCI Adjuncts Female Hypotension Perioperative Prolonged intraoperative 0.04 Renal failure 0.02 DTAA pathology 0.07 Iliac conduit Blood transfusion Reoperation for bleeding Increased contrast volume Oversew intercostals immediately Reimplant intercostals Hypogastric preservation Left subclavian artery preservation Shorten aortic crossclamp time Sew fast Crawford reimplantation technique Left heart bypass / distal aortic perfusion Epidural cooling (4 C) CSF drainage Hemodynamic stability / permissive hypertension Neuromonitoring 4

5 Adjuncts Preserve collateral spinal cord perfusion Carotid subclavian bypass Hypogastric artery bypass (? Left more important) Hemodynamic stability / permissive hypertension Reduce or stop antihypertensive medications preop Stage procedures to avoid hypotension Use pressors Gradual reintroduction of antihypertensives over several weeks CSF drainage to effect, not to a specific pressure Routine lumbar drain insertion OPEN TAA REPAIR Early onset More profound deficit paraplegia Less likely to resolve TEVAR Delayed onset Less profound deficit paraparesis More likely to resolve OPEN TAA REPAIR Raise the blood pressure Volume Pressors Steroids Bolus Continuous infusion naloxone TEVAR Raise the blood pressure Volume Pressors Steroids Bolus Continuous infusion Induce endoleak A B C 5

6 A B C A B A B C Harrison, J Vasc Surg,

7 7

8 We must beware of needless innovation, especially when guided by logic. Winston Churchill 8

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