Prophylactic cerebrospinal fluid drainage for thoracic endovascular aortic repair (TEVAR)

Mazzeffi M, et al. Contemporary Single-Center Experience With Prophylactic Cerebrospinal Fluid Drainage for Thoracic Endovascular Aortic Repair in Patients at High Risk for Ischemic Spinal Cord Injury. J Cardiothorac Vasc Anesth. 2018 Apr;32(2): 883-889.

Full-text for Emory users.

Flowchart TEVAR high risk ISCI outcomes_complications

Fig 2. Flowchart showing patient outcomes and complications in the cohort. SCI, spinal cord injury; SCPP, spinal cord perfusion pressure; TEVAR, thoracic endovascular aortic repair.

In summary, in a contemporary cohort of 102 patients undergoing TEVAR with a high risk for ischemic SCI, prophylactic CSF drainage was associated with a 2% paraplegia rate and 3.9% rate of drain-related complications. No patient with a drain-related complication had permanent injury, and only 1 patient required surgical intervention for spinal cord compression from epidural hematoma. Three patients with new paraplegia after surgery improved with targeted MAP increases and CSF drainage aimed to increase SCPP by 25%, whereas 1 patient’s symptoms never improved. These data further support the safety of prophylactic lumbar CSF drainage in patients undergoing TEVAR with a high risk for ischemic SCI.”

Song S, et al. Effects of preemptive cerebrospinal fluid drainage on spinal cord protection during thoracic endovascular aortic repair. J Thorac Dis. 2017 Aug;9(8):2404-2412.

Free full-text.

“The benefit of prophylactic CSFD in open aortic surgery has been established by 2 meta-analyses (9,11). In TEVAR, the risk of SCI has not been completely established, with reported incidence rates ranging from 3% to 12% (2,12), and spinal cord-protective protocols are less defined than open aortic surgeries. Many studies have reported the incidence of SCI after TEVAR with CSFD, but no randomized trials have examined this issue. In the literature, risk factors that have been associated with SCI after TEVAR include emergency surgery, treatment of a long portion of the aortic segment, dissection, rupture, advanced age, and prior abdominal aortic operation or stent graft (7). The exclusion of intercostal arteries (T7-L1) supplying the anterior spinal artery is associated with neurological events, and long coverage of the thoracic aorta is a significant risk factor of SCI (13). With the increasing application of TEVAR for various thoracic aortic pathologies, the use of CSFD is becoming more important for minimizing neurological deficits. However, no consensus has been reached among vascular surgeons about the best strategy for CSFD.”

Wortmann M, Böckler D, Geisbüsch P. Perioperative cerebrospinal fluid drainage for the prevention of spinal ischemia after endovascular aortic repair. Gefasschirurgie. 2017; 22(Suppl 2):35-40.

Free full-text.

Implementation protocols for cerebrospinal fluid drainage (Wortmann, 2017)

There are three different feasible protocols for the implementation of perioperative CSF drainage:

  1. In the case of routine implementation, all patients undergo preoperative spinal catheter placement prior to the planned endovascular procedure [12].
  2. In a so called selective implementation, only those patients at increased risk for spinal ischemia undergo preoperative spinal catheter placement. This is intended to reduce the incidence of neurological complications in high-risk patients without exposing those patients at low risk to the potential additional complications associated with spinal catheter placement. Selective use currently represents the most widespread implementation protocol for perioperative CSF drainage in endovascular procedures [2, 4, 46, 47]. However, there are no standardized recommendations on patient selection or on the precise conduction of the CSF drainage.
  3. The third possible is to entirely waive a preoperative placement of a spinal catheter. Only those patients who develop spinal ischemia postoperatively undergo emergency spinal catheter placement. In such cases, a consistent reduction in CSF pressure is able to achieve a significant improvement in neurological complications [1]. However, neurological deficits persist in up to 30% of patients despite this intervention.

More PubMed results on prophylactic CSFD for TEVAR.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s