Permissive Hypertension and Collateral Revascularization May Allow Avoidance of Cerebrospinal Fluid Drainage in Thoracic Endovascular Aortic Repair.
Aged
Algorithms
Antihypertensive Agents
/ administration & dosage
Aortic Diseases
/ complications
Cerebrospinal Fluid
Drainage
Endovascular Procedures
/ methods
Female
Humans
Hypertension
/ complications
Male
Middle Aged
Postoperative Complications
/ prevention & control
Retrospective Studies
Spinal Cord Ischemia
/ prevention & control
Subclavian Artery
/ surgery
Withholding Treatment
Journal
The Annals of thoracic surgery
ISSN: 1552-6259
Titre abrégé: Ann Thorac Surg
Pays: Netherlands
ID NLM: 15030100R
Informations de publication
Date de publication:
11 2020
11 2020
Historique:
received:
08
11
2019
revised:
04
04
2020
accepted:
17
04
2020
pubmed:
15
6
2020
medline:
15
12
2020
entrez:
15
6
2020
Statut:
ppublish
Résumé
The utility of cerebrospinal fluid drainage (CSFD) for prevention of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) remains unclear. We previously published our institutional algorithm restricting preoperative CSFD to patients deemed high risk for SCI. Since that publication, our algorithm has evolved with preoperative CSFD avoided in all patients undergoing isolated descending TEVAR with or without arch involvement (+/- arch TEVAR). This study evaluated the updated algorithm in a contemporary cohort. Patients who underwent TEVAR for descending aortic +/-arch pathology between February 2012 and September 2018 at a single center were identified from an institutional aortic surgery database. The algorithm includes left subclavian artery (LSA) revascularization in cases of coverage with no preservation of antegrade flow, permissive hypertension, and use of evoked potential monitoring. The primary end points were SCI or postoperative CSFD. During the study interval, 225 patients underwent descending +/- arch TEVAR. CSFD was used before TEVAR in 2 patients (0.9%) in violation of the algorithm, and they were excluded from the study cohort. Endograft coverage below T6 occurred in 81%. The LSA was fully covered in 100 patients (47%), all of whom underwent LSA revascularization. Following the updated algorithm, the incidence of temporary or permanent SCI was 0%. No patient required postoperative CSFD. A restrictive lumbar CSFD algorithm, including permissive hypertension and LSA revascularization in the setting of descending +/- arch TEVAR, appears safe, with a 0% incidence of SCI in 223 consecutive patients treated during a 6.5-year interval. We recommend consideration of further prospective study to evaluate this algorithm.
Sections du résumé
BACKGROUND
The utility of cerebrospinal fluid drainage (CSFD) for prevention of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) remains unclear. We previously published our institutional algorithm restricting preoperative CSFD to patients deemed high risk for SCI. Since that publication, our algorithm has evolved with preoperative CSFD avoided in all patients undergoing isolated descending TEVAR with or without arch involvement (+/- arch TEVAR). This study evaluated the updated algorithm in a contemporary cohort.
METHODS
Patients who underwent TEVAR for descending aortic +/-arch pathology between February 2012 and September 2018 at a single center were identified from an institutional aortic surgery database. The algorithm includes left subclavian artery (LSA) revascularization in cases of coverage with no preservation of antegrade flow, permissive hypertension, and use of evoked potential monitoring. The primary end points were SCI or postoperative CSFD.
RESULTS
During the study interval, 225 patients underwent descending +/- arch TEVAR. CSFD was used before TEVAR in 2 patients (0.9%) in violation of the algorithm, and they were excluded from the study cohort. Endograft coverage below T6 occurred in 81%. The LSA was fully covered in 100 patients (47%), all of whom underwent LSA revascularization. Following the updated algorithm, the incidence of temporary or permanent SCI was 0%. No patient required postoperative CSFD.
CONCLUSIONS
A restrictive lumbar CSFD algorithm, including permissive hypertension and LSA revascularization in the setting of descending +/- arch TEVAR, appears safe, with a 0% incidence of SCI in 223 consecutive patients treated during a 6.5-year interval. We recommend consideration of further prospective study to evaluate this algorithm.
Identifiants
pubmed: 32535042
pii: S0003-4975(20)30903-6
doi: 10.1016/j.athoracsur.2020.04.101
pmc: PMC7768303
mid: NIHMS1650864
pii:
doi:
Substances chimiques
Antihypertensive Agents
0
Types de publication
Journal Article
Research Support, N.I.H., Extramural
Langues
eng
Sous-ensembles de citation
IM
Pagination
1469-1474Subventions
Organisme : NHLBI NIH HHS
ID : R38 HL143612
Pays : United States
Commentaires et corrections
Type : CommentIn
Informations de copyright
Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
Références
Eur J Vasc Endovasc Surg. 2017 Jan;53(1):4-52
pubmed: 28081802
Ann Thorac Surg. 2013 Jun;95(6):1968-74; discussion 1974-5
pubmed: 23635449
Ann Vasc Surg. 2019 Jul;58:384.e9-384.e14
pubmed: 30769073
Eur J Vasc Endovasc Surg. 2018 Nov;56(5):644-651
pubmed: 30122331
J Vasc Surg. 2017 Aug;66(2):343-352.e1
pubmed: 28366304
Eur Heart J. 2014 Nov 1;35(41):2873-926
pubmed: 25173340
J Clin Neurophysiol. 2007 Aug;24(4):328-35
pubmed: 17938601
Ann Vasc Dis. 2019 Jun 25;12(2):233-235
pubmed: 31275481
Circulation. 2010 Apr 6;121(13):e266-369
pubmed: 20233780
J Vasc Surg. 2014 Jul;60(1):11-9, 19.e1
pubmed: 24589160
Eur J Vasc Endovasc Surg. 2018 Jun;55(6):829-841
pubmed: 29525741
Thorac Cardiovasc Surg. 2019 Aug;67(5):379-384
pubmed: 29715704
J Vasc Surg. 2019 Mar;69(3):701-709
pubmed: 30528402
J Vasc Surg. 2018 Feb;67(2):363-368
pubmed: 28847657
Ann Vasc Surg. 2019 Nov;61:124-133
pubmed: 31344465
Semin Thorac Cardiovasc Surg. 2017 Winter;29(4):451-459
pubmed: 29698653
J Vasc Surg. 2020 Apr;71(4):1109-1118.e2
pubmed: 31564581
J Vasc Surg. 2009 Jan;49(1):29-34; discussion 34-5
pubmed: 18951749
Ann Thorac Surg. 2011 Jul;92(1):97-102; discussion 102-3
pubmed: 21718834
Ann Vasc Surg. 2018 Oct;52:72-78
pubmed: 29886219
Br J Anaesth. 2018 May;120(5):904-913
pubmed: 29661408
J Thorac Cardiovasc Surg. 2020 Apr;159(4):1228-1230
pubmed: 31280896
J Vasc Surg. 2019 Aug;70(2):393-403
pubmed: 30704799
J Thorac Cardiovasc Surg. 2012 Sep;144(3):612-6
pubmed: 22898505
J Vasc Surg. 2016 Nov;64(5):1228-1238
pubmed: 27444368