Article of interest: Resuscitative Endovascular Balloon Occlusion of Aaorta Use in Nontrauma Emergency General Surgery: A Multi-institutional Experience.

Hatchimonji JS, Chipman AM, McGreevy DT, et al. Resuscitative Endovascular Balloon Occlusion of Aaorta Use in Nontrauma Emergency General Surgery: A Multi-institutional Experience. J Surg Res. 2020 Dec;256:149-155.

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Background: The aim of this study was to determine the current utilization patterns of resuscitative endovascular balloon occlusion of aorta (REBOA) for hemorrhage control in nontrauma patients.

Methods: Data on REBOA use in nontrauma emergency general surgery patients from six centers, 2014-2019, was pooled for analysis. We performed descriptive analyses using Fisher’s exact, Student’s t, chi-squared, or Mann-Whitney U tests as appropriate.

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Article of interest: Spinal cord protection practices used during endovascular repair of complex aortic aneurysms by the U.S. Aortic Research Consortium.

Aucoin VJ, Eagleton MJ, Farber MA, et al. Spinal cord protection practices used during endovascular repair of complex aortic aneurysms by the U.S. Aortic Research Consortium. J Vasc Surg. 2021 Jan;73(1):323-330. doi: 10.1016/j.jvs.2020.07.107.

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Results: The most common practices routinely included blood pressure elevation (7 of 8; 87.5%), with most having a mean arterial pressure goal of not less than 90 mm Hg in the perioperative period (5 of 7; 71%), a hemoglobin goal intra- and postoperatively of not less than 10 mg/dL (6 of 8; 75%), and the use of prophylactic spinal drains in high-risk patients (6 of 8; 75%). Significant variation was found among the group for the timing of the resumption of antihypertensive medications, duration of hemoglobin goals after the procedure, and management of spinal drains. Many methods described in reported studies were not routinely used by most of the group, including a perioperative steroid bolus (1 of 8; 12.5%), mannitol (2 of 8; 25%), and naloxone infusion (1 of 8; 12.5%). Rescue maneuvers included placement of a cerebrospinal fluid (CSF) drain if not already present (8 of 8; 100%), decreasing the target CSF drain pop-off pressure (6 of 8; 75%), increasing the CSF drainage volume (5 of 8; 62.5%), increasing the mean arterial pressure goal (8 of 8; 100%), increasing the hemoglobin goal (8 of 8; 100%), and imaging the spine using computed tomography or magnetic resonance imaging (7 of 8; 87.5).

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Surgical management of ruptured abdominal aortic aneurysms

Powell JT, Wanhainen A. Analysis of the Differences Between the ESVS 2019 and NICE 2020 Guidelines for Abdominal Aortic Aneurysm. Eur J Vasc Endovasc Surg. 2020 Jul;60(1):7-15.

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See also: Surgical Grand Rounds: EVAR, FEVAR, and Open Repair: What to make of alphabet soup

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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.

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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.”

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