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PVSS5. Expectant Post-Operative Lumbar Spinal Drainage After Thoracic Aortic Endografts

Martin J. Carignan, Marc A. Passman, Mark A. Patterson, Steve M. Taylor, Bart R. Combs, William D. Jordan, Jr.
University of Alabama at Birmingham, Birmingham, Ala.

OBJECTIVES: Although perioperative lumbar spinal drainage has been practiced for open repair of thoraco-abdominal aortic aneurysms, there is no accepted standard for lumbar spinal drainage for thoracic aortic endografting. We sought to evaluate the risk of spinal cord paraplegia in patients undergoing thoracic aortic endografting with lumbar drainage used expectantly in the post-operative period for those developing neurologic symptoms.

METHODS: A prospectively maintained computerized registry was reviewed to identify patients who underwent placement of thoracic aortic endografts. Patient records were analyzed for pre-operative factors (urgency of procedure, aortic pathology), intra-operative details (mean arterial pressure, blood loss, extent of thoracic aortic coverage), and postoperative course (lower extremity neurologic changes, ICU stay, post-operative length of stay, discharge disposition, complications and mortality).

RESULTS: Between January 2000 and December 2006, 96 thoracic aortic endografts were placed in 88 patients (69 elective and 27 urgent procedures). Aortic pathology included 64 aneurysms (66.7%), 20 dissections (20.8%), 11 pseudoaneurysms (11.5%) and 1 post graft stenosis (1.0%). Overall, 6 patients (6.3%) died within 30 days of the procedure 3 (4.3%) after an elective procedure and 3 (11.1%) after an urgent procedure. No patients demonstrated immediate post-operative spinal cord ischemic symptoms, but 6 patients (6.3%) developed delayed neurologic symptoms between 5 and 54 hours after the procedure. Five of these 6 patients had a lumbar drain placed after the presentation of symptoms and 3 improved their neurologic status however, 2 patients (2.1%) remained with severe residual neurologic deficit. All of the 6 patients with spinal ischemia had degenerative aneurysms while none of the 32 patients with non-aneurysm pathology suffered spinal ischemic symptoms (p=0.10). Age, extent of coverage, and prior infrarenal aortic graft did not correlate with spinal ischemic symptoms.

CONCLUSIONS: Expectant post-operative lumbar spinal drainage can be used after thoracic aortic endografting with acceptably low perioperative spinal cord ischemia rates. The benefit of routine lumbar drainage for thoracic aortic endografting has yet to be determined.