Reinhard Kopp, Karin Pfister, Beatrix Cucuruz, Konstantinos Gallis, Piotr M Kasprzak
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1 Immediate, delayed and late spinal cord ischemia after extended endovascular thoracoabdominal aortic repair Reinhard Kopp, Karin Pfister, Beatrix Cucuruz, Konstantinos Gallis, Piotr M Kasprzak
2 Disclosure Speaker name: Reinhard Kopp I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) X I do not have any potential conflict of interest
3 Thoracoabdominal aortic aneurysms (TAAA) Treatment options Open surgery Hybrid procedure BEVAR
4 Thoracoabdominal aortic aneurysms (TAAA) risk of spinal cord ischemia 5-20 % O Callaghan A et al., J Vasc Surg 2015; 61: Dias NV et al. Eur J Vasc Endovac Surg 2015; 49: Kasprzak PM et al. Eur J Vsc Endovasc Surg 2014: 48: Verhoeven ELG et al. Eur J Vasc Endovasc Surg 2015; 49: Bisdas T et al. J Vasc Surg 2015; 61: adjuncts - normotension, hemoglobin - CSFD - early iliac reperfusion - open branch concept / TASP
5 Treatment of TAAA with branched EVAR - risk of spinal cord ischemia open branch concept with TASP (temporary aneurysm sac perfusion) 09/ /2017 n = 156 neurological outcome - spinal cord ischemia (SCI) 08/ /2017 single step n = 69 staged TASP n = 87 P staged TASP completed n = 75 stroke paresthesia postop SCI SCI d30 16 (23.2 %) 4 (4.6 %) (5.3 %) P TASP TASP: temporary aneurysm sac perfusion Perfusion SCI: Tarlov 0-2 score
6 spinal cord ischemia (%) BEVAR for TAAA: open branch + TASP concept + other adjuncts earlysci delayedsci early SCI (< 48 h) delayed / late SCI Tarlov / / / / / / / /2016
7 Spinal cord ischemia (SCI) during complex and extended endovascular aortic repair BEVAR (n = 156; 08/ /2017) delayed and late SCI (temporary and permanent) after BEVAR: 13/146 (8.9 %, permanent 3.4 %) H.F. 60y delayed temporary 4 d no CSFD/nonfunct 52 cm staged/ TASP K.H. 83y late permanent 18 d RR hypotension 24 cm single step F.M. 61y delayed temporary 4 d no CSFD/nonfunct 43 cm single step H.G. 69y late permanent 36 mo hypotension, periop. anemia 51 cm staged/ TASP S.P. 81y delayed temporary 3 d hypotension 25 cm single step S.W. 83y delayed temorary 5 d hypotension 30 cm single step W.F. 76y delayed permanent 4 d CPR, hypotension, LSA occluded 42 cm staged/ TASP M.B. 74y delayed temporary 10 d hypotension, COPD, anemia 46 cm staged/ TASP A.N. 78y delayed permanent 7 d hyper/hypotens, cerebral bleeding 39 cm staged/ TASP R.S. 64y delayed permanent 4 d endoleak type III, hypotension 35 cm single step B.I. 56y delayed temporary 3 d hypotension 41 cm single step R.L 75y delayed temporary 4d TASP nonfunct., hypotension 33 cm non-intend. sing.st. H.S. 75y delayed temporary 3d hypotension? 38 cm staged/ TASP A.S. 69y FEVAR/late temporary 7 mo antihypertensive treatment, 32 cm single step hypotension, anemia, diarrhea
8 Spinal cord ischemia (SCI) during complex and extended endovascular aortic repair BEVAR (n = 156; 09/ /2017) delayed and late SCI (temporary and permanent) after BEVAR: 13/146 (8.9 %, permanent 4.1 %) Pat. H.G. 69y late SCI after 36 mo, permanent Crawford II infrarenal bifurcated graft 4 branched EVAR (51 cm stent graft length) staged procedure/ TASP - step 1: temp. SCI - step 2: temp. SCI 36 months later femoral artery TEA periop. hypotension, anemia (> 6 h) -> paraplegia -> volume, EC, no CSFD, -> no improvement
9 Spinal cord ischemia (SCI) during complex and extended endovascular aortic repair Late SCI after FEVAR Pat. A.W. late temporary SCI 42 d antihypertensive treatment, hypotension, anemia, type B aortic dissection chronic aortic expansion 4 fenestrated EVAR (FEVAR) 42 days later volume loss anemia,diarrhea antihypertensive therapy -> paraparesis -> therapy initiated (< 6h) volume, EC, CSFD -> neurologic symptoms disappeared
10 Delayed/late SCI after endovascular thoracoabdominal aneurysm repair SCI after extended endovascular aortic repair immediate postop awake with SCI (< 48 h) early delayed postop normal, awake -> secondary SCI (2-14 days) late postop normal, awake -> secondary SCI (>14 days)
11 Delayed or late SCI after endovascular thoracoabdominal aneurysm repair Risk factors for delayed or late SCI (n = 13/146; temporary/permanent: 4.8 vs 4.1 %) BEVAR for TAAA periop mortality: 7.7 % OR p ASA 3/ (4.2 vs % length covered aorta (4.9 vs 16 %) aneurysm type (I/II: 19.5 %, III: 5.0 %; IV: 4.5 %)
12 open branch with TASP (temporary aneurysm sac perfusion) various causes of delayed and late spinal cord ischemia (SCI) coverage of intercostal/lumbar arteries hypotension - volume loss - bleeding (periop, gastrointestinal) - diarrhea, vomiting - antihypertensive treatment individual variability of spinal cord perfusion
13 Various causes of delayed and late SCI hypotension antihypertensive treatment
14 Spinal cord ischemia (SCI) during complex and extended endovascular aortic repair BEVAR (n = 156; 08/ /2017) delayed and late SCI (temporary and permanent) after BEVAR: 13/146 (8.9 %, permanent 3.4 %) Treatment initiated within 6 h later than 6 h - normotension (volume, EC, vasopressor) - spinal drainage - treat cause of hypotension SCI permanent 0 / 7 ( 0 %) 5 / 6 ( 83.3 %) p = 0.005
15 open branch with TASP (temporary aneurysm sac perfusion) Conclusions Delayed and late SCI have to be considered as a life long risk after extended TAAA repair and prevention of hypotension, perioperative anemia and consideration of moderate antihypertensive therapy is important Patients and medical professionals have to be aware of the risk of delayed and late SCI after endovascular TAAA repair. Immediate treatment can frequently restore neuromuscular function and prevent paraplegia
16
17 Delayed SCI and thoracoabdominal aneurysm repair SCI SCI immediate: postop awake immediate: postop 4.6 % awake with SCI 4.6 % delayed: postop normal, delayed: postop normal, -> secondary SCI (1-14 days) -> secondary 2.7 % SCI (1-14 days) 2.7 %
18 Delayed or late SCI after endovascular thoracoabdominal aneurysm repair delayed SCI: 12/424 (2.8 %) TEVAR - permanent SCI: 0.7 % - periop. mortality: 8.3 %
19 Immediate, delayed and late spinal cord ischemia after extended endovascular thoracoabdominal aortic repair Reinhard Kopp, Karin Pfister, Beatrix Cucuruz, Konstantinos Gallis, Piotr M Kasprzak
Kopp R, Puippe G, Rancic Z, Hofmann M, Pecoraro F, Pfammatter T, Lachat M.. University Hospital Zurich, Switzerland
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Description. Section: Surgery Effective Date: April 15, Subsection: Surgery Original Policy Date: December 6, 2012 Subject:
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