Society For Clinical Vascular Surgery

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National Incidence, Mortality Outcomes, and Predictors of Spinal Cord Ischemia after Thoracic Endovascular Aortic Repair
Salvatore T. Scali, M.D.1, Grace Wang, M.D, M.S.2, Kristina A. Giles, M.D.1, Dean J. Arnaoutakis, M.D., M.B.A.1, Gilbert R. Upchurch, M.D.1, Thomas S. Huber, M.D., Ph.D1, Adam W. Beck, M.D.3.
1University of Florida-Gainesville, Gainesville, FL, USA, 2University of Pennsylvania, Philadelphia, PA, USA, 3University of Alabama-Birmingham, Birmingham, AL, USA.

OBJECTIVES: Spinal cord ischemia(SCI) is a dreaded complication of thoracic endovascular aortic repair(TEVAR). There are limited national data describing the incidence and influence of SCI recovery on survival. Moreover, no robust preoperative SCI risk assessment tools currently exist. The purpose of this analysis was to analyze the Vascular Quality Initiative(VQI) to determine the survival impact of SCI with or without in-hospital recovery, and develop a validated SCI prediction clinical decision aid tool.
METHODS: All VQI TEVAR procedures(2011-18) were reviewed. The primary end-point was in-hospital SCI, defined as any new neurologic deficit and/or paralysis not attributable to intracranial pathology. Secondary end-points were disease-specific SCI rates and long-term survival(verified through SSDI). Kaplan-Meier methodology was used to estimate survival. A logistic regression model of candidate predictors(P<.2) was created using backward step-wise elimination. The model was validated by bootstrapping.
RESULTS: The overall SCI rate was 4.7%(N=436/9217; transient, 1.6%[n=148]; permanent, 3.1%[n=288]). The survival impact of SCI is highlighted in the Figure. Patients who had SCI but experienced symptom resolution before discharge had similar survival to those without SCI(1-year: SCI+recovery-80±3% vs. No SCI-89±1%;log-rank P-value=.06). However, patients without SCI in-hospital recovery had significantly worse overall survival(1-year: SCI without recovery-62±3% vs. No SCI-89±1%;P<.0001). Pathologic specific incidence of any SCI was: acute dissection(6.6%), intra-mural hematoma(6.4%), traumatic transection(5%), chronic dissection(4.6%), aortic thrombus(4.5%), degenerative aneurysm(4.2%), and PAU/IMH(3.2%). Preoperative predictors of SCI included ASA class(OR 1.8, 95%CI 1.4-2.3;p<.001), prior aortic/infrainguinal bypass(OR 1.8, 1.2-2.7;p=.008), non-elective presentation(OR 1.6, 1.2-2.1;p=.001), hypertension(OR 1.6, 1.1-1.6;p=.03), COPD(OR 1.4, 1.05-1.8;p=.02), preoperative creatinine>1.78(OR1.4, 0.9-2.0;p=.09), age(OR 1.0 per year increase, 1.0-1.02;p=.03), and female gender(OR1.2, 1-1.7;p=.01)(AUC=.75;Hosmer-Lemeshow P=.7, Intercept=-.3, Slope=-.9).
CONCLUSIONS: SCI is a devastating complication after TEVAR that has a significant impact on overall survival, particularly when no functional recovery occurs by time of hospital discharge. Disease specific, real world benchmarks for SCI rates are provided which may inform quality improvement initiatives focused on reducing this complication. Importantly, this analysis is the first description of a preoperative prediction tool derived from national data for determining SCI risk after TEVAR. We have identified variables that can inform the use of interventions to mitigate SCI risk, thereby improving resource utilization and TEVAR outcomes nationally.


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