Spinal Drain Rescue Therapy for Spinal Cord Ischemia in 936 TEVARs at a Tertiary Aortic Center
John R. Spratt1, Kristen L. Walker1, Dan Neal1, George Arnaoutakis1, Tomas Martin1, Martin R. Back1, Yury Zasimovich2, Salvatore Scali1, Thomas M. Beaver1
1Department of Surgery, University of Florida Health, Gainesville, Florida, United States, 2Department of Anesthesia, University of Florida, Gainesville, Florida, United States
Spinal cord ischemia(SCI) after thoracic endovascular aortic repair(TEVAR) can be associated with permanent neurologic deficits and poor long-term survival. “Rescue therapy”(RT) after SCI onset may improve/resolve neurologic symptoms but few data describe the effect of specific interventions on SCI outcomes. We evaluated the effectiveness of post-TEVAR RT at our tertiary aortic center.
Our TEVAR database was reviewed for SCI incidence and RT details. RT was any intervention treating new post-TEVAR SCI symptoms, including placement of cerebrospinal fluid drains(CSFD), augmentation of existing CSF drainage, medical therapy(naloxone, corticosteroids, mannitol), and optimization of spinal cord oxygen delivery(RBC transfusion, induced/permissive hypertension). Discharge SCI was categorized as paralysis/ paraparesis and temporary (temp)/ permanent (perm).
863 patients underwent 936 TEVARs (2011-2020). Post-TEVAR SCI occurred in 7.7%(n=73) with permanent paraplegia in 1.5%(n=14). SCI patients were more likely to be older(72±10vs.67±14years,OR1.04, 95%CI[1.02-1.06],p<.001), have COPD(OR 1.8,[1.1-2.9],p=.02), and prior abdominal aortic surgery(OR1.9,[1.1-3.3],p=.03). Most postop SCI resulted in either temp paralysis(1.8%,n=17) or paraparesis(1.9%,n=18) while 1.5%(n=14) had perm paralysis and 0.8%(n=8) had perm paraparesis. Initial paralysis that improved to perm paraparesis with RT occurred in 1.7%(n=16).
Among SCI categories, temp deficits had the shortest(0.91±0.95days) postop interval before SCI symptoms, while perm paralysis had the longest(3.5±6.1d). Late-onset symptoms predicted perm deficits(OR1.4/postop day,[1.0-1.9],p=.05).
Preop CSFDs were placed in 43%(n=368) while 2.5%(n=22) received rescue postop CSFDs. Higher ASA class(OR4.1/unit increase,[1.7-9.8],p=.002), lower preop HGB(OR0.98/0.1g/dL increase, [0.97-0.99],p=.02), and elevated preop INR(OR 1.2/0.1unit increase,[1.1-1.4],p=.004) predicted rescue CSFD need.
The most common RTs were: emergent CSFD placement and/or increased drainage from existing CSFD(92%), induced/permissive hypertension(80%), corticosteroid bolus(38%), and naloxone infusion(36%). Neurologic improvement occurred in 70%(n=51/73). No single RT had a significant association with temp(vs. perm) deficits or with improvement of the initial SCI symptoms(vs. perm deficit). However, new/increased CSF drainage trended toward improved SCI outcome(OR0.2,[0.03-1.1],p=.06).
Permanent SCI in contemporary TEVAR is rare(1.5%). Older patients with comorbidities and metabolic derangements are at increased post-TEVAR SCI risk. SCI symptoms completely/partially resolved with CSFD and multimodal RT in 70% of procedures, but no single rescue intervention was independently associated with neurologic improvement. TEVAR centers should have robust processes providing timely/protocolized CSFD placement to augment SCI rescue.
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