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Preventing Spinal Cord Ischemia in Complex Endovascular Aortic Aneurysm Repair
Stephen C. Hanley1, Oren K. Steinmetz2, Kent MacKenzie2, Daniel Obrand3, Marc Corriveau2, Heather L. Gill2, Cherrie Z. Abraham3.
1McGill University, Montreal, QC, Canada, 2McGill University Health Centre, Montreal, QC, Canada, 3Jewish General Hospital, Montreal, QC, Canada.

OBJECTIVES: Complex endovascular aortic aneurysm repair (cEVAR) with branched and fenestrated aortic stent grafts has revolutionized the treatment of complex aortic aneurysms. While the risks of cEVAR appear to be less than those of open repair, devastating complications may still arise, particularly with repair of aneurysms of the thoracoabdominal aorta. One of the most severe complications of cEVAR is spinal cord ischemia (SCI), with a reported risk in the range of 10-15%. While multiple strategies have been proposed to reduce the risk of SCI, the use of 'paraplegia-prevention branches' (PPBs) to maintain temporary perfusion of the aneurysm sac allows for a staged approach to endovascular repair of complex aneurysms.
METHODS: Patients undergoing cEVAR who were deemed high risk for SCI, based mainly on extensive aortic coverage or previous aortic intervention, were treated with custom-made stent grafts with PPBs, consisting of one or two upward-pointing 6mm branches, ideally in proximity to large patent intercostal arteries. These branches were left open during the initial intervention, maintaining perfusion to the aneurysm sac. Routine institutional SCI prevention strategies were employed. During a planned secondary procedure, PPBs were then occluded using Amplatzer occluder devices, under local anesthesia. Demographic and peri-operative data were collected retrospectively for patients identified from a prospectively maintained database of all patients undergoing EVAR at our institution, and compared for patients undergoing cEVAR with and without PPBs.
RESULTS: Between 2010 and 2014, 71 patients underwent cEVAR for complex abdominal or thoracoabdominal aneurysms. Seven patients underwent cEVAR using PPBs, with a time-to-occlusion of 19±8 days. The overall rate of SCI was 12.7%, however none of the patients treated with PPBs developed SCI. Likewise, peri-operative mortality was 9.0%, consistent with reports in the literature. None of the patients treated with PPBs died in the peri-operative period.
CONCLUSIONS: Staged endovascular repair of complex aortic aneurysms using PPBs may represent a means of reducing the risk of SCI. Our experience adds to the growing body of literature supporting the notion of staged endovascular repair of complex aortic aneurysms. Further study is necessary to determine whether PPBs significantly reduce the risk of SCI.


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