Kopp R, Puippe G, Rancic Z, Hofmann M, Pecoraro F, Pfammatter T, Lachat M.. University Hospital Zurich, Switzerland
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1 Low risk of spinal cord ischemia after endovascular repair for suprarenal and thoracoabdominal aortic aneurysms using parallel stent graft implantation. Kopp R, Puippe G, Rancic Z, Hofmann M, Pecoraro F, Pfammatter T, Lachat M.. University Hospital Zurich, Switzerland
2 no disclosures
3 Thoracoabdominal aortic aneurysms (TAAA) risk of spinal cord ischemia 5-20 % Strategies for prevention of SCI 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: normotension MAP > 80 mm Hg - hemoglobin > 90 mg/dl - CSFD < 12 mm Hg - early iliac reperfusion - staged procedures
4 Extended endovascular aortic repair Spinal cord ischemia during bevar for TAAA - direct occlusion of intercostal + lumbar arteries - secondary reduction of spinal cord perfusion by aneurysm sac thrombosis spinal collateral network staged procedures temporary aneurysm sac perfusion (TASP) segmental artery coil embolisation Etz CD et al. J Thorac Cardiovasc Surg. 2011, 141(4): Moritz S et al. Persp Vasc Surg Endovasc Ther 2011; 23(3)
5 Parallel stent grafts for juxtarenal AA and TAAA repair gutter endoleak %
6 Prevention of spinal cord ischemia during TAAA repair Aim of the study analyze the risk of SCI after endovascular suprarenal and thoracoabdominal aortic repair using the Chimney/Periscope technique Chimney/Periscope technique + SCI prevention strategy n = 125 juxta/pararenal AA 81 TAAA 44
7 concept of SCI USZ PG-EVAR awake patient local anesthesia staged procedures normotension, normal hemoglobin levels no CSF drainage early iliac reperfusion Asutoregulation Autoregulation of spinal perfusion Neuromonitoring
8 Chimney / Periscope grafts for suprarenal AA and TAAA repair Adjuncts for SCI prevention normotension MAP > 80 mm Hg hemoglobin > 90 mg/dl supraa./iliac revascularization early iliac reperfusion no CSFD (option: secondary) staged procedures local anesthesia post op: steroids; option: mannitol n = 56 n = 100 perioperative mortality 2 / % reinterventions 22 / % EL rate: gutter - 23; 15 treated, 4 low flow) 23 / % persistent gutter EL 4 / % type II 4
9 Chimney / Periscope grafts for TAAA repair Adjuncts for SCI prevention normotension MAP > 80 mm Hg hemoglobin > 90 mg/dl supraa./iliac revascularization early iliac reperfusion no CSFD (option: secondary) staged procedures local anesthesia post op: steroids; option: mannitol n = 125 perioperative mortality 2 / % SCI: SCI: modified Tarlov score 0-2 n = 72 reinterventions 29 / % SCI temporary 4 / %* permanent 2 / %* overall permanent 2 / % EL rate (gutter 26; 18 treated, 5 low flow) 26 / % type II 6 * delayed/late SCI
10 TAAA repair with parallelgraft technique Temporary permissive endoleak perfusion SMA chimney -> spinal perfusion TASP open/perfusion branch gutter endoleak permissive endoleak (gutter) lumbar/ spinal segmental artery
11 TAAA repair using Parallelgrafts lumbar/ spinal artery lumbar/ spinal artery Temporary gutter endoleak - > spinal perfusion (TGSP) pararenal/taaa n = 72 gutter EL 26 gutter EL spinal perf. (TGSP) 14
12 Prevention of spinal cord ischemia during TAAA repair Strategies for SCI prevention Single step procedures, ITN + adjuncts, CSFD, normotension, n/hemoglobin, SCI % staged procedures, ITN, + adjuncts, CSFD, MEPs, TASP normotension, n/hemoglobin, iliac perfusion SCI 4-6 % Parallel stent graft, local anesthesia, staged temp. gutter spinal perfusion (TGSP) + few adjuncts normotension, n/hemoglobin iliac perfusion, CSFD, MEPs SCI 2-4 % immediate delayed late SCI
13 Prevention of spinal cord ischemia during TAAA repair Conclusions low rates of SCI after PG EVAR with center specific strategies for SCI prevention awake patients allow best neurological monitoring to document spinal cord integrity with preserved autoregulation of spinal cord perfusion temporary gutter spinal perfusion (TGSP) might contribute to prevention of SCI
14 Low risk of spinal cord ischemia after endovascular repair for suprarenal and thoracoabdominal aortic aneurysms using parallel stent graft implantation. Kopp R, Puippe G, Rancic Z, Hofmann M, Pecoraro F, Pfammatter T, Lachat M.. University Hospital Zurich, Switzerland
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