Neurological Complications of TEVAR. Frank J Criado, MD. Union Memorial-MedStar Health Baltimore, MD USA

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1

2 ISES Online

3 Neurological Complications of Frank J Criado, MD TEVAR Union Memorial-MedStar Health Baltimore, MD USA frank.criado@medstar.net

4 Paraplegia Incidence is 0-4% after surgical Rx of TAAs confined to the DTA but >5% for TAAA Many techniques have been developed and proposed to prevent it: clamp-and-sew, distal aortic and visceral perfusion, complete CP bypass, profound hypothermia and circulatory arrest, direct spinal cord cooling, CSF drainage, and pharmacologic adjuncts Cross-clamping of thoracic aorta causes decreased spinal perfusion pressure and increased CSF pressure, resulting in decreased perfusion pressure

5 Paraplegia Incidence is 0-4% after surgical Rx of TAAs confined to the DTA Many techniques have been developed and proposed to prevent it: clamp-and-sew, distal aortic and visceral perfusion, complete CP bypass, profound hypothermia and circulatory arrest, direct spinal cord cooling, CSF drainage, and pharmacologic adjuncts Cross-clamping of thoracic aorta causes decreased spinal perfusion pressure and increased CSF pressure, resulting in decreased perfusion pressure

6 Paraplegia Incidence is 0-4% after surgical Rx of TAAs confined to the DTA Myriad of techniques have been developed and proposed to prevent it: clamp-and-sew, distal aortic and visceral perfusion, complete CP bypass, profound hypothermia and circulatory arrest, direct spinal cord cooling, CSF drainage, and pharmacologic adjuncts Cross-clamping of thoracic aorta causes decreased spinal perfusion pressure and increased CSF pressure, resulting in decreased perfusion pressure

7 TAG Device Surgical Control Operative Mortality 2% 11.7% p=0.003 Paraplegia/Paraparesis 3% 14% p < Stroke 4% 4%

8 Thoracic Endovascular Experience UMH Baltimore (4/1/97-12/31/04) n=215 patients 245 procedures TAA degenerative, saccular, post traumatic, post-surgical, pseudo, penetrating ulcers Aortic dissection 80 - acute, chronic, dissecting aneurysms, intramural hematoma

9 Thoracic Endovascular Experience UMH Baltimore (4/1/97-12/31/04) n=215 patients 245 procedures TAA 135 Mortality 4.6% - degenerative, saccular, post traumatic, Stroke post-surgical, 2.0% pseudo, penetrating ulcers SCI 3.0% Aortic dissection 80 - acute, chronic, dissecting aneurysms, intramural hematoma

10 2005 1,895 TEVAR patients SCI 2.7% (0-12.5) Stroke 2.2% (0-18.6) Mortality 6.7% (0-19) Sullivan TM, Sundt TM III J Vasc Surg 2006;43 Suppl A:85A-88A

11 TEVAR-related Stroke Stroke has only recently been recognized as an important complication of TEVAR with an incidence that may be equal to or even higher than that of SCI

12 Coverage/Exclusion of LSA Massive fatal cerebellar stroke 1/56 1.8% - endograft coverage of aorta from left CCA to distal DTA for ruptured acute dissection - absent right vertebral artery

13 TEVAR-Related Stroke About equal # of carotid and v-b territory distribution Most thought to be embolic Catheter and wire manipulations in the aortic arch Arch disease Exclusion of arch branches Non-conformity of devices to arch knuckle

14 Conformity *

15

16 Risk Factors of Neurologic Complications Khoynezhad A, Donayre CE, Bui H et al. Ann Thorac Surg 2007;83:S pts had 184 TEVAR procedures Oct 98-Sept 05 Descending TAA 91, acute type B AD 25, chronic type B AD 42, transection 12, penetrating AU 14 Stroke 8 procedure-related rate 4.3% SCI 8 procedure-related rate 4.3%

17 Risk Factors of Neurologic Complications Khoynezhad A, Donayre CE, Bui H et al. Ann Thorac Surg 2007;83:S882-9 Stroke 8 TAA 5, AD 3 2/8 pts recovered completely, 6/8 left with permanent deficits No correlation between proximal landing zone and stroke type (posterior 3, diffuse 2, frontal 1, mid 1) Univariate analysis of associated risk factors: obesity, significant intraoperative blood loss, peripheral vascular embolization or thrombosis

18 Risk Factors of Neurologic Complications Khoynezhad A, Donayre CE, Bui H et al. Ann Thorac Surg 2007;83:S882-9 SCI (paraplegia/paraparesis) 8 TAA in all Immediate 4 (recovered 1), delayed 4 (recovered 1) Both patients who recovered had CSD catheter inserted Access iliac conduit 5/8 Compromised hypogastric artery 2/8 Univariate analysis of associated risk factors: aneurysm pathology, iliac conduit, hypogastric artery exclusion

19 TEVAR and Paraplegia Overall, TEVAR-related paraplegia rates of <5% for TAA and <2% for acute dissection are being reported consistently But there are patients who may be at increased risk

20 NO CLAMP!

21 Guidelines for placement of CSF drainage catheter Anticipated endograft coverage T9-T12 (origin of anterior spinal artery) Coverage of most or all of DTA (left CCA to celiac) Compromised collateral pathways (history of previous AAA repair) Symptomatic SCI post TEVAR Drain must remain in place for hrs Maintain CSF pressure of <10 mmhg Coselli JS et al. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. J Vasc Surg 2002;35:631-9

22 Neurologic Complications Associated with Endovascular Repair of Thoracic Aortic Pathology. Incidence and Risk factors. A Study from the EUROSTAR Registry Jacob Buth, Peter L Harris et al. Presented at the SVS Meeting June 7, 2007, Baltimore, MD

23 Results: Patients were followed for a mean of 14.1 months (range 0 to 72). Fifteen patients (2.5%) developed paraplegia or paraparesis and 19 (3.1%) stroke. Two of these patients had both complications combined. At multivariate regression analysis independent correlation with SCI was observed for five factors: (1) left subclavian artery covering without revascularization (P =.027, Odds Ratio (OR) = 3.9), (2) renal failure (P =.02, OR = 3.6), (3) concommittant open abdominal aorta surgery (P =.037, OR = 5.5) and (4) number of used stent-grafts 3 (P =.043, OR 3.5). In an extended model (5) a diameter of the most distal part of the stentgraft(s) of 40 millimeter or larger confounded with the number of stent-grafts and correlated significantly with SCI (P = 0.009, OR = 5.2). In patients with perioperative stroke two correlating factors were identified: (1) duration of the intervention (P =.0045, OR = 6.4) and (2) female gender (P =.023, OR = 3.3).

24 Left subclavian artery covering and correlation with neurological event Paraplegia N=15, N (%) Other N=591 N (%) P-value With L Subclavian artery covering 6 (40.0) 153 (25.9) NS without transposition/bypass 6 (40.0)* 113 (19.1).0444 with transposition/bypass 0 40 (6.8) NS Stroke N=19, N (%) Other N=587 N (%) P-value With L Subclavian artery covering 5 (26.3) 154 (26.2) NS without transposition/bypass 5 (26.3)* 114 (19.4) NS with transposition/bypass 0 (0) 40 (6.8) NS * one patient with left subclavian artery covering without revascularisation had a paraplegia and stroke combined

25 Conclusion: Perioperative paraplegia or paraparesis was significantly associated with blockage of the left subclavian artery without revascularization. The clinical significance of this source of collateral perfusion of the spinal cord had not been confirmed previously. In addition, extensive covering of intercostal arteries reflected by the use of multiple stent-grafts and a distal size > 40 mm of the stent-graft correlated with SCI. Intracranial stroke was associated with lengthy manipulation of wires, catheters and introducer sheaths within the aortic arch.

26 Left Subclavian Artery: Strategies Indications for preliminary (or concomitant) revascularization: dominant left VA (MRA, duplex ultrasound, angiography) previous LIMA operation planned extensive endograft coverage aberrant right SA

27

28 TEVAR: The Future Traumatic injuries * Focal and degenerative TAAs involving the DTA * Acute aortic syndrome (type B dissections, PU, IMH, ruptured TAA) * Arch lesions distal to the origin of the IA Chronic dissections Total arch involvement Ascending aorta

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