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CC BY 4.0 · Aorta (Stamford) 2022; 10(06): 290-297
DOI: 10.1055/s-0042-1757792
Special Feature Article

Cerebrospinal Fluid Drainage for Prevention of Spinal Cord Ischemia in Thoracic Endovascular Aortic Surgery—Pros and Cons

Hesham Ellauzi 
1   Aortic Institute at Yale New-Haven, Department of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
2   Department of Surgery, Istishari Hospital, Amman, Jordan
,
Harendra Arora
3   Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
,
John A. Elefteriades
1   Aortic Institute at Yale New-Haven, Department of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
,
Mohammad A. Zaffar
1   Aortic Institute at Yale New-Haven, Department of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
,
Rama Ellauzi
2   Department of Surgery, Istishari Hospital, Amman, Jordan
4   Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan.
,
Wanda M. Popescu
5   Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
› Author Affiliations Funding None.
› Further Information
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Abstract

Thoracic endovascular aortic repair (TEVAR) carries a risk of spinal cord ischemia (SCI) which exerts a devastating impact on patient's quality of life and life expectancy. Although routine prophylactic cerebrospinal fluid (CSF) drainage is not unequivocally supported by current data, several studies have demonstrated favorable outcomes. Patients at high risk for SCI following TEVAR likely will benefit from prophylactic CSF drains. However, the intervention is not risk free, and thorough risk/benefit analysis should be individualized to each patient.

Keywords

TEVAR - CSF drainage - spinal cord ischemia - spinal drain - cerebrospinal fluid


Publication History

Received: 07 September 2021

Accepted: 14 April 2022

Article published online:
20 December 2022

© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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  • References

  • 1 Volodos' NL, Karpovich IP, Shekhanin VE, Troian VI, Iakovenko LF. [A case of distant transfemoral endoprosthesis of the thoracic artery using a self-fixing synthetic prosthesis in traumatic aneurysm]. Grudn Khir 1988; (06) 84-86
    PubMedGoogle Scholar
  • 2 Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994; 331 (26) 1729-1734
    CrossrefPubMedGoogle Scholar
  • 3 Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg 1993; 17 (02) 357-368 , discussion 368–370
    CrossrefPubMedGoogle Scholar
  • 4 Harky A, Kai Chan JS, Ming Wong CH, Bashir M. Open versus endovascular repair of descending thoracic aortic aneurysm disease: a systematic review and meta-analysis. Ann Vasc Surg 2019; 54: 304-315.e5
    CrossrefPubMedGoogle Scholar
  • 5 DeSart K, Scali ST, Feezor RJ. et al. Fate of patients with spinal cord ischemia complicating thoracic endovascular aortic repair. J Vasc Surg 2013; 58 (03) 635-42.e2
    CrossrefPubMedGoogle Scholar
  • 6 Conrad MF, Ye JY, Chung TK, Davison JK, Cambria RP. Spinal cord complications after thoracic aortic surgery: long-term survival and functional status varies with deficit severity. J Vasc Surg 2008; 48 (01) 47-53
    CrossrefPubMedGoogle Scholar
  • 7 Ali F, Reddy V, Dublin AB. Anatomy, Back, Anterior Spinal Artery. Treasure Island, FL: StatPearls; 2021
    Google Scholar
  • 8 Gofur EM, Singh P. Anatomy, Back, Vertebral Canal Blood Supply. Treasure Island, FL: StatPearls; 2021
    Google Scholar
  • 9 Uchida N. How to prevent spinal cord injury during endovascular repair of thoracic aortic disease. Gen Thorac Cardiovasc Surg 2014; 62 (07) 391-397
    CrossrefPubMedGoogle Scholar
  • 10 Walters BC, Hadley MN, Hurlbert RJ. et al; American Association of Neurological Surgeons, Congress of Neurological Surgeons. Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery 2013; 60 (CN_suppl_1): 82-91
    CrossrefPubMedGoogle Scholar
  • 11 Hawryluk G, Whetstone W, Saigal R. et al. Mean arterial blood pressure correlates with neurological recovery after human spinal cord injury: analysis of high frequency physiologic data. J Neurotrauma 2015; 32 (24) 1958-1967
    CrossrefPubMedGoogle Scholar
  • 12 Menacho ST, Floyd C. Current practices and goals for mean arterial pressure and spinal cord perfusion pressure in acute traumatic spinal cord injury: defining the gaps in knowledge. J Spinal Cord Med 2021; 44 (03) 350-356
    CrossrefPubMedGoogle Scholar
  • 13 Khan NR, Smalley Z, Nesvick CL, Lee SL, Michael II LM. The use of lumbar drains in preventing spinal cord injury following thoracoabdominal aortic aneurysm repair: an updated systematic review and meta-analysis. J Neurosurg Spine 2016; 25 (03) 383-393
    CrossrefPubMedGoogle Scholar
  • 14 Hnath JC, Mehta M, Taggert JB. et al. Strategies to improve spinal cord ischemia in endovascular thoracic aortic repair: Outcomes of a prospective cerebrospinal fluid drainage protocol. J Vasc Surg 2008; 48 (04) 836-840
    CrossrefPubMedGoogle Scholar
  • 15 Cinà CS, Abouzahr L, Arena GO, Laganà A, Devereaux PJ, Farrokhyar F. Cerebrospinal fluid drainage to prevent paraplegia during thoracic and thoracoabdominal aortic aneurysm surgery: a systematic review and meta-analysis. J Vasc Surg 2004; 40 (01) 36-44
    CrossrefPubMedGoogle Scholar
  • 16 Suarez-Pierre A, Zhou X, Gonzalez JE. et al. Association of preoperative spinal drain placement with spinal cord ischemia among patients undergoing thoracic and thoracoabdominal endovascular aortic repair. J Vasc Surg 2019; 70 (02) 393-403
    CrossrefPubMedGoogle Scholar
  • 17 Bobadilla JL, Wynn M, Tefera G, Acher CW. Low incidence of paraplegia after thoracic endovascular aneurysm repair with proactive spinal cord protective protocols. J Vasc Surg 2013; 57 (06) 1537-1542
    CrossrefPubMedGoogle Scholar
  • 18 Bower TC, Murray MJ, Gloviczki P, Yaksh TL, Hollier LH, Pairolero PC. Effects of thoracic aortic occlusion and cerebrospinal fluid drainage on regional spinal cord blood flow in dogs: correlation with neurologic outcome. J Vasc Surg 1989; 9 (01) 135-144
    CrossrefPubMedGoogle Scholar
  • 19 Dasmahapatra HK, Coles JG, Wilson GJ. et al. Relationship between cerebrospinal fluid dynamics and reversible spinal cord ischemia during experimental thoracic aortic occlusion. J Thorac Cardiovasc Surg 1988; 95 (05) 920-923
    CrossrefPubMedGoogle Scholar
  • 20 Etz CD, Homann TM, Plestis KA. et al. Spinal cord perfusion after extensive segmental artery sacrifice: can paraplegia be prevented?. Eur J Cardiothorac Surg 2007; 31 (04) 643-648
    CrossrefPubMedGoogle Scholar
  • 21 Strauch JT, Lauten A, Spielvogel D. et al. Mild hypothermia protects the spinal cord from ischemic injury in a chronic porcine model. Eur J Cardiothorac Surg 2004; 25 (05) 708-715
    CrossrefPubMedGoogle Scholar
  • 22 Strauch JT, Spielvogel D, Lauten A. et al. Importance of extrasegmental vessels for spinal cord blood supply in a chronic porcine model. Eur J Cardiothorac Surg 2003; 24 (05) 817-824
    CrossrefPubMedGoogle Scholar
  • 23 Etz CD, Kari FA, Mueller CS, Brenner RM, Lin HM, Griepp RB. The collateral network concept: remodeling of the arterial collateral network after experimental segmental artery sacrifice. J Thorac Cardiovasc Surg 2011; 141 (04) 1029-1036
    CrossrefPubMedGoogle Scholar
  • 24 Hiratzka LF, Bakris GL, Beckman JA. et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, Society for Vascular Medicine. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. J Am Coll Cardiol 2010; 55 (14) e27-e129
    CrossrefPubMedGoogle Scholar
  • 25 Bisdas T, Panuccio G, Sugimoto M, Torsello G, Austermann M. Risk factors for spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms. J Vasc Surg 2015; 61 (06) 1408-1416
    CrossrefPubMedGoogle Scholar
  • 26 Hiraoka T, Komiya T, Tsuneyoshi H, Shimamoto T. Risk factors for spinal cord ischaemia after thoracic endovascular aortic repair. Interact Cardiovasc Thorac Surg 2018; 27 (01) 54-59
    CrossrefPubMedGoogle Scholar
  • 27 Ullery BW, Cheung AT, Fairman RM. et al. Risk factors, outcomes, and clinical manifestations of spinal cord ischemia following thoracic endovascular aortic repair. J Vasc Surg 2011; 54 (03) 677-684
    CrossrefPubMedGoogle Scholar
  • 28 Schlösser FJ, Verhagen HJ, Lin PH. et al. TEVAR following prior abdominal aortic aneurysm surgery: increased risk of neurological deficit. J Vasc Surg 2009; 49 (02) 308-314 , discussion 314
    CrossrefPubMedGoogle Scholar
  • 29 Matsumura JS, Lee WA, Mitchell RS. et al; Society for Vascular Surgery. The Society for Vascular Surgery Practice Guidelines: management of the left subclavian artery with thoracic endovascular aortic repair. J Vasc Surg 2009; 50 (05) 1155-1158
    CrossrefPubMedGoogle Scholar
  • 30 Mousa AY, Morcos R, Broce M, Bates MC, AbuRahma AF. New preoperative spinal cord ischemia risk stratification model for patients undergoing thoracic endovascular aortic repair. Vasc Endovascular Surg 2020; 54 (06) 487-496
    CrossrefPubMedGoogle Scholar
  • 31 Coselli JS, LeMaire SA, Köksoy C, Schmittling ZC, Curling PE. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. J Vasc Surg 2002; 35 (04) 631-639
    CrossrefPubMedGoogle Scholar
  • 32 Svensson LG, Hess KR, D'Agostino RS. et al. Reduction of neurologic injury after high-risk thoracoabdominal aortic operation. Ann Thorac Surg 1998; 66 (01) 132-138
    CrossrefPubMedGoogle Scholar
  • 33 Crawford ES, Svensson LG, Hess KR. et al. A prospective randomized study of cerebrospinal fluid drainage to prevent paraplegia after high-risk surgery on the thoracoabdominal aorta. J Vasc Surg 1991; 13 (01) 36-45 , discussion 45–46
    CrossrefPubMedGoogle Scholar
  • 34 Khan SN, Stansby G. Cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery. Cochrane Database Syst Rev 2012; 10 (10) CD003635
    PubMedGoogle Scholar
  • 35 Safi HJ, Miller III CC, Huynh TT. et al. Distal aortic perfusion and cerebrospinal fluid drainage for thoracoabdominal and descending thoracic aortic repair: ten years of organ protection. Ann Surg 2003; 238 (03) 372-380 , discussion 380–381
    CrossrefPubMedGoogle Scholar
  • 36 Böckler D, Kotelis D, Kohlhof P. et al. Spinal cord ischemia after endovascular repair of the descending thoracic aorta in a sheep model. Eur J Vasc Endovasc Surg 2007; 34 (04) 461-469
    CrossrefPubMedGoogle Scholar
  • 37 Hanna JM, Andersen ND, Aziz H, Shah AA, McCann RL, Hughes GC. Results with selective preoperative lumbar drain placement for thoracic endovascular aortic repair. Ann Thorac Surg 2013; 95 (06) 1968-1974 , discussion 1974–1975
    CrossrefPubMedGoogle Scholar
  • 38 Wong CS, Healy D, Canning C, Coffey JC, Boyle JR, Walsh SR. A systematic review of spinal cord injury and cerebrospinal fluid drainage after thoracic aortic endografting. J Vasc Surg 2012; 56 (05) 1438-1447
    CrossrefPubMedGoogle Scholar
  • 39 Chaudhary O, Sharkey A, Schermerhorn M. et al. Protocolized based management of cerebrospinal fluid drains in thoracic endovascular aortic aneurysm repair procedures. Ann Vasc Surg 2021; 72: 409-418
    CrossrefPubMedGoogle Scholar
  • 40 Abdelbaky M, Papanikolaou D, Zafar MA. et al. Safety of perioperative cerebrospinal fluid drain as a protective strategy during descending and thoracoabdominal open aortic repair. JTCVS Tech 2021; 6: 1-8
    CrossrefPubMedGoogle Scholar
  • 41 Rong LQ, Kamel MK, Rahouma M, White RS, Lichtman AD, Pror KO. Cerebrospinal fluid drain-related complications in patients undergoing open and endovascular repairs of thoracic and thoracoabdominal aortic pathologies: a systematic review and meta-analysis. J Vasc Surg 2018; 68 (02) 652
    CrossrefPubMedGoogle Scholar
  • 42 Wynn MM, Sebranek J, Marks E, Engelbert T, Acher CW. Complications of spinal fluid drainage in thoracic and thoracoabdominal aortic aneurysm surgery in 724 patients treated from 1987 to 2013. J Cardiothorac Vasc Anesth 2015; 29 (02) 342-350
    CrossrefPubMedGoogle Scholar
  • 43 Cheung AT, Pochettino A, Guvakov DV, Weiss SJ, Shanmugan S, Bavaria JE. Safety of lumbar drains in thoracic aortic operations performed with extracorporeal circulation. Ann Thorac Surg 2003; 76 (04) 1190-1196 , discussion 1196–1197
    CrossrefPubMedGoogle Scholar
  • 44 Youngblood SC, Tolpin DA, LeMaire SA, Coselli JS, Lee V-V, Cooper Jr JR. Complications of cerebrospinal fluid drainage after thoracic aortic surgery: a review of 504 patients over 5 years. J Thorac Cardiovasc Surg 2013; 146 (01) 166-171
    CrossrefPubMedGoogle Scholar
  • 45 Weigang E, Hartert M, Siegenthaler MP. et al. Perioperative management to improve neurologic outcome in thoracic or thoracoabdominal aortic stent-grafting. Ann Thorac Surg 2006; 82 (05) 1679-1687
    CrossrefPubMedGoogle Scholar
  • 46 Cheung AT, Pochettino A, McGarvey ML. et al. Strategies to manage paraplegia risk after endovascular stent repair of descending thoracic aortic aneurysms. Ann Thorac Surg 2005; 80 (04) 1280-1288 , discussion 1288–1289
    CrossrefPubMedGoogle Scholar
  • 47 Arora H, Ullery BW, Kumar PA, Cheung AT. Pro: patients at risk for spinal cord ischemia after thoracic endovascular aortic repairs should receive prophylactic cerebrospinal fluid drainage. J Cardiothorac Vasc Anesth 2015; 29 (05) 1376-1380
    CrossrefPubMedGoogle Scholar