Thorac Cardiovasc Surg 2012; 60 - PP72
DOI: 10.1055/s-0031-1297719

Spinal cord ischemia after thoracic stent-grafting: Causes apart from intercostal artery coverage

B Zipfel 1, S Buz 1, D Hullmeine 2, V Düsterhöft 1, R Hammerschmidt 1, R Hetzer 1
  • 1Deutsches Herzzentrum Berlin, Herz-, Thorax- und Gefäßchirurgie, Berlin, Germany
  • 2DRK-Kliniken Köpenick, Department of Neurology, Berlin, Germany

Objectives: The incidence of spinal cord ischemia (SCI) in thoracic stent-grafting (TEVAR) is unexpectedly low. Individual analysis may give new insights into the mechanisms.

Methods: In an 11 year period thoracic stent-grafts were implanted in 406 patients for various aortic pathologies. Mean age was 63 (15–91) years and 300 (74%) patients were male; 54 patients underwent staged thoracic stent-graft procedures. The length of aorta covered was between 75 and 584 (mean 204)mm. Thoraco-abdominal branched or fenestrated stent-grafts with were implanted in 11 patients. The left subclavian artery was occluded in 160 patients (39%) in half of those (n=78) after protective revascularization. Prophylactic cerebral spinal fluid (CSF) drainage was used selectively in three cases; no neuromonitoring was employed.

Results: Incidence of SCI was 2.7% (n=11), 6 patients (1.5%) suffered a major permanent deficit. All cases occurred during postoperative hospitalization, two after a secondary procedure. Conditions with a potential influence on spinal cord ischemia were analyzed. Statistical correlation was found for previous conventional or endovascular abdominal aortic aneurysm (AAA) repair (OR 4.8 (1.4–17.1); p=0.026) for coverage of the entire descending thoracic aorta (OR 3.6 (1.1–12.0); p=0.045) and implantation of thoraco-abdominal branched and fenestrated stent-grafts (OR 9.5 (1.2–50.6); p=0.032). Individual analysis revealed other conditions that might have played a role such as: intraluminal thrombus at the landing site causing embolization of thrombus or debris into the segmental arteries by expansion of the stent-graft, severe visceral ischemia, profound hemorrhagic shock, and heparin induced thrombocytopenia.

Conclusions: The incidence of SCI in TEVAR is low. Extended coverage of the thoracic aorta and thoraco-abdominal branched stent grafts seem to have a higher risk, but other factors may contribute to the individual disaster.