Current strategies to prevent spinal cord ischemia in TAAA repair
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1 Current strategies to prevent spinal cord ischemia in TAAA repair Geert Willem Schurink Barend Mees Noud Peppelenbosch Michiel de Haan Michael Jacobs Maastricht University Medical Center, the Netherlands European Vascular Center Aachen-Maastricht, Germany and the Netherlands
2 Proctor for COOK Medical Disclosures
3 Blood supply spinal cord Adamkiewicz artery mm T5 - T8 25% T9 - L2 75% Left side 75%
4 Collateral Network Theory
5 Strategies to prevent SCI Selection of Patients Aneurysm Spinal cord circulation Operative Strategies Postoperative Strategies
6 Cleveland Clinic Experience ER: sicker, older, more prior Ao repair Greenberg et al.circulation. 2008;118:808-81
7 Post-dissection vs Degenerative TAAA No collaterals (n=24) Collaterals (n=31) SCI in 12% SCI in 0% Backes WH, et. JVS. 2008;48(2):
8 Strategies to prevent SCI Selection of Patients Aneurysm Spinal cord circulation Operative Strategies Postoperative Strategies
9 asa L1 asa aka L1
10 Results Inclusion X-clamping SA-AKA Decline of MEPs 14 patients (32%) 60 patients (100%) YES 44 patients (73%) YES 30 patients (68%) NO 0 patients (0%) YES 16 patients (27%) NO 16 patients (100%) NO
11 Strategies to prevent SCI Selection of Patients Operative Strategies CSF drainage Cooling SA artery reattachment/distal aortic perfusion Spinal cord function monitoring Staged repair Postoperative Strategies
12 Strategies to prevent SCI Selection of Patients Operative Strategies CSF drainage Cooling SA artery reattachment/distal aortic perfusion Spinal cord function monitoring Staged repair Postoperative Strategies
13 Strategies to prevent SCI Selection of Patients Operative Strategies CSF drainage Cooling SA artery reattachment/distal aortic perfusion Spinal cord function monitoring Staged repair Postoperative Strategies
14
15
16 MEP amplitudes [mv] 3 2,5 cross-clamping entire aorta right ant.tib.m. left ant.tib.m. right abd.poll.br. left abd.poll.br. 2 1,5 1 0,5 0 time
17 MEP amplitudes [mv] 3 2,5 cross-clamping entire aorta cross-clamping entire aorta right ant.tib.m. left ant.tib.m. right abd.poll.br. left abd.poll.br. 2 1,5 1 0,5 0 time
18 MEP amplitudes [mv] 3 2,5 Perfusion of reimplantated segmental arteries cross-clamping entire aorta right ant.tib.m. left ant.tib.m. right abd.poll.br. left abd.poll.br. 2 1,5 1 0,5 0 time
19 Strategies to prevent SCI Selection of Patients Operative Strategies CSF drainage Cooling SA artery reattachment/distal aortic perfusion Spinal cord function monitoring Staged repair Postoperative Strategies
20 Staged repair in Open TAAA Δt 5 years
21 Staged repair in EndoTAAA Staging TEVAR implantation Creating type III endoleak Sac perfusion branch Leaving branch open Stent between SG components Don t connect iliac limb
22 Staged repair in EndoTAAA
23 Staged repair in EndoTAAA Staging TEVAR implantation Creating type III endoleak Sac perfusion branch Leaving branch open Stent between SG components Don t connect iliac limb
24 Staged repair in EndoTAAA Sac perfusion (n=40) No Sac Perfusion (n=43) Temp. paraparesis 13% 2% Paraplegia 5% 21% Kasprzak P et al. EJVES. 2014;48(3):
25 Staged repair in EndoTAAA General: CSF drainage BP management Preserve LSA and HA perfusion Limit limb ischemia Since June 2012 Staging by only TEVAR first (type II TAAA) B/FEVAR: Spinal cord function monitoring (MEP) Last branch: 15 min balloon occlusion Decision to leave branch open (MEP >50% )
26 electrical stimulation 500 V; ~1.2 A, 5 serial stimuli SCI ischemia MEP response abd. poll. brevis muscle Peripheral ischemia MEP response tibialis anterior muscle
![MEP amplitude [mv] MEPS @ Crawford extent 2 endo TAAA repair with multivessel BEVAR Peripheral ischemia 1500 Right 1400 1300 1200 1100 1000 900 800 700 600 500](/docs-images/87/96812762/images/27-1.jpg "400 300 200 100 0 Leg Spinal Cord Ischemia tib.ant.re tib.ant.li abd.poll.br.re abd.poll.br.li rect.fem.r rect.fem.l T1% 110 100 90 80 70 60 50 40 30 20 10 0 time")
27 MEP amplitude [mv] Crawford extent 2 endo TAAA repair with multivessel BEVAR Peripheral ischemia 1500 Right Leg Spinal Cord Ischemia tib.ant.re tib.ant.li abd.poll.br.re abd.poll.br.li rect.fem.r rect.fem.l T1% time
28 Peripheral ischemia Pitfall time tib.ant.re tib.ant.li MEPs branch test 4 branches connected Completion angio: endoleak Delayed paraparese Cta: thrombosis endoleak
29 Staged repair in EndoTAAA General: CSF drainage BP management Preserve LSA and HA perfusion Since June 2012 Staging by only TEVAR first (type II TAAA) B/FEVAR: Spinal cord function monitoring (MEP) Last branch: 15 min balloon occlusion Decision to leave branch open MEP >50% Endoleak on angiography Aneurysms Sac Pressure SINCE 2 YEARS
30 Results 28 patients 30-day mort: 3,5% Revised Protocol 35,0% SCI: 7% (partial;reversible): both walking again 64% (18 pts) NO open branch staging: * 5% (1 pt) SCI 40,0% 30,0% 25,0% 20,0% 15,0% 10,0% 5,0% 0,0% extent 1 extent 2 extent 3 extent 4 Crawford TAAA Classification 36% (10 pts) open branch staging: * 10% (1pt) SCI
31 Strategies to prevent SCI Selection of Patients Operative Strategies Postoperative Strategies Hemodynamic situation (BP; Hb; CVP) CSF drainage
32 Conclusions Paraplegia is still the most disabeling complication in treatment of TAAA Several pre - intra postoperative strategies are available to decrease SCI Staging is the most promising both in open and endo repair MEPs are important for decision making in open repair MEPs in combination with sac pressurements and angiography help to select patients how need staging in endo repair.
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