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Elevated incidence of spinal cord ischemia among patients undergoing TEVAR for type B aortic dissections
Robert J. Feezor, MD, Salvatore T. Scali, MD, Tomas D. Martin, MD, Philip J. Hess, Jr., MD, Thomas M. Beaver, MD, MPH, Charles T. Klodell, MD, Adam W. Beck, MD.
University of Florida, Gainesville, FL, USA.

OBJECTIVES: Spinal cord ischemia (SCI) is a dreaded complication of thoracic endovascular aortic repair (TEVAR), and has been reported to have lower rates in dissection patients when compared to other aortic pathologies. Techniques to prevent SCI are inconsistently applied, potentially due to the unclear risk factors, and are often not used in dissection patients due to the low reported incidence of SCI in those patients. We sought to assess our incidence of SCI among patients undergoing TEVAR for both acute and chronic type B aortic dissections, and the potential implication of spinal drainage.
METHODS: A TEVAR database from a single institution was queried for patients with acute (<14 days from symptom onset) or chronic dissection (>14 days). Pre-operative and post-operative variables were compared.
RESULTS: Between 2000 and 2010, 137 TEVARs were performed for aortic dissections, which represented 22.9% of the 598 TEVARs performed overall. 66 (48.2%) were performed for chronic dissection-related pathology and 71 (51.8%) for urgent/emergent dissection-related pathology. Aortic coverage length and proximal landing zone was similar between acute and chronic patients. A shift in clinical practice occurred during the study period, with 16.7% of patients having spinal drains placed between 2000 and 2006, and 83.2% having spinal drains placed between 2007 and 2011 (p<0.0001). For the entire study, the overall rate of SCI was 14.6%, with permanent SCI occurring in 9.5%. Acute dissection patients had higher overall rates of SCI and permanent SCI compared to chronic dissection patients (overall: 18.3% vs.10.6%; permanent 11.3% vs. 7.6%) (p=0.23 and 0.56, respectively). The shift to a higher rate of spinal drain usage in the later study period was not associated with a decline in the rate of overall SCI or permanent SCI (overall: 16.7% vs. 14.0%, p=0.77; permanent: 10.0% vs. 9.3%, p=1.0).
CONCLUSIONS: The rate of SCI in our patient population is much higher in both acute and chronic dissection patients than rates previously reported in the literature. The reason for this is unclear, but may be attributed to a liberal definition of SCI. Although SCI was observed more frequently in our acute patients, there was no statistically significant difference between the groups. There was no reduction in incidence of SCI or permanent SCI with a more aggressive approach to spinal drainage.


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