Optimization Of Factors For The Prevention Of Spinal Cord Ischemia In Thoracic Endovascular Aortic Repair
Matthew J. Rossi, MD1, Michelle Sulzinski2, Abdullah A. Alfawaz, MD1, Steven D. Abramowitz, MD1, Misaki M. Kiguchi, MD1, Joshua A. Dearing, MD1, Javairiah Fatima, MD1, Christian C. Shults, MD1, Edward Y. Woo, MD1.
1Medstar Washington Hospital Center, Washington, DC, USA, 2Georgetown University School of Medicine, Washington, DC, USA.
Objectives
Spinal cord ischemia is a devastating complication following thoracic endovascular aortic repair. This study seeks to demonstrate how a standardized protocol to prevent spinal cord ischemia decreases its incidence in patients undergoing thoracic endovascular aortic repair (TEVAR).
Methods
Using CPT codes 33880 and 33881, all TEVAR procedures performed at a single tertiary care center from January 2017 to December 2018 were examined. Comorbid conditions, procedural characteristics, anatomic factors, peri-procedural management strategies, and post-operative outcomes were collected and analyzed. Patients were grouped by adherence to the standardized protocol, and rates of spinal cord ischemia were compared using Fisher’s exact test.
Results
138 patients undergoing TEVAR were examined for four perioperative variables: initial postoperative hemoglobin greater than 10g/dL, subclavian revascularization, preoperative lumbar drain placement, and somatosensory evoked potential monitoring. All conditions were met in 47% of procedures; 42% in emergent/urgent cases and 54% in elective cases. Of patients that required subclavian coverage, 86% underwent revascularization prior to TEVAR. 68% of patients received lumbar drains preoperatively. 61% of patients had SSEP monitoring. Out of all patients, five (3.6%) developed spinal cord ischemia; four of which were done under an emergent/urgent setting. Two of the five patients met all optimization conditions. The other three patients required emergent interventions, precluding pre-operative lumbar drain placement and/or SSEP monitoring. Of those three patients, one underwent lumbar drain placement and subclavian revascularization on POD1. None of the patients suffered from prolonged intraoperative or postoperative hypotension. Four patients regained ambulatory function, and one patient suffered a non-survivable neurological insult after cardiac arrest on post-operative day 16. There was no significant difference in spinal cord ischemia between patients with full adherence and partial adherence to the standardized protocol even when stratified by urgency of procedure.
Conclusions
Institution of a standardized protocol for the prevention of spinal cord ischemia after TEVAR is recommended. Although statistical significance was not reached, overall the rate of spinal cord ischemia was low, which was likely due in part to our protocol.
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