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PVSS6. Strategies To Improve Spinal Cord Ischemia In Endovascular Thoracic Aortic Repair: Outcomes Of A Prospective Cerebrospinal Fluid Drainage Protocol

Jeffrey Hnath, Manish Mehta, Sean P. Roddy, R. Clement Darling III, Yaron Sternbach, Kathleen J. Ozsvath, Philip S. K. Paty, Paul B. Kreienberg, Benjamin B. Chang, Dhiraj M. Shah.
Albany Medical College, Albany, N.Y.  

OBJECTIVES: Although endovascular repair of thoracic aortic pathology has been shown to reduce the morbidity and mortality rates, spinal cord ischemia remains a persistent problem. We evaluated our experience with spinal cord protective measures using a standardized cerebrospinal fluid (CSF) drainage protocol in patients undergoing endovascular thoracic aortic repair.

METHODS:  From 2004 to 2006, 121 patients underwent elective (n=52, 43%) and emergent (n=69, 57%) endovascular thoracic aortic stentgraft placement for TAA (n=94, 78%), symptomatic ulceration (n=11, 9%), pseudoaneurysms (n=5, 4%) and traumatic aortic transactions (n=11, 9%).  In 2005, a CSF drainage protocol was established to minimize the risks of spinal cord ischemia in all patients; the CSF pressures were maintained at 10-15 mmHg, and the mean arterial blood pressures was maintained at ≥90 mmHg.  Data was prospectively collected in our vascular registry for elective and emergent endovascular thoracic aortic repair and the patients were divided into 2 groups (+CSF drainage protocol, -CSF drainage protocol). Chi square statistical analysis was performed and significance was assumed for p<0.05.

RESULTS: Of the 121 patients with thoracic stentgraft placement the mean age was 72 years, 51% were male, and 46% (n=56) underwent preoperative placement of a CSF drain, while 54% (n=65) did not.  Both groups had similar comorbidities of CAD (43% vs. 41%), HTN (79% vs. 77%), COPD (32% vs. 34%), and CRI (17% vs. 18%).  None of the patients with CSF drainage developed spinal cord ischemia, and 5 (8%) of the patients without CSF drainage developed spinal cord ischemia within 24 hours of endovascular repair (P<0.05).  Only 1 of these 5 patients had a prior infrarenal aortic repair.  All patients with clinical symptoms of spinal cord ischemia had CSF drain placement and augmentation of systemic blood pressures to ≥ 90 mmHg, and 60% (3 of 5 patients) demonstrated marked clinical improvement.

CONCLUSIONS: Perioperative CSF drainage with augmentation of systemic blood pressures may have a beneficial role in reducing the risk of paraplegia in patients undergoing endovascular thoracic aortic stentgraft placement. A future randomized study is warranted.