Positive impact of standardized perioperative management on spinal cord ischemia rate during endovascular repair of thoracoabdominal aneurysms.

Abstract

Despite endovascular repair of thoracoabdominal aortic aneurysms minimizing the occurrence of spinal cord ischemia (SCI), postoperative SCI remained a frequent complication in our clinic. Therefore, beginning in 2015, we implemented an SCI prevention protocol, including no prophylactic cerebrospinal fluid drainage (CSFD), early reperfusion of iliac arteries, staging in selective cases, adjusting perioperative management, and ensuring circulatory stability. The objective of this study was to examine whether we were able to reduce the risk of postoperative SCI with our SCI prevention protocol. A consecutive cohort of patients with thoracoabdominal aortic aneurysms with fenestrated or multibranched endografts between 2010 and 2021 was divided into patients treated before 2015 (control group) and since 2015 (intervention group). For better comparison between both groups, we performed a propensity score matching using the optimal matching algorithm. The main outcome of the study was the occurrence of SCI, classified by severity and duration. Further outcomes were overall survival, 30-day mortality, and CSF-associated complications. A total of 210 patients were included in the study, 105 in the control group and 105 in the intervention group. SCI developed in 25 (23.8%) vs 8 (7.6%) patients (P < .001) and paraplegia occurred in 7 (6.7%) vs 2 (1.9%) patients in the control group vs the intervention group, respectively. Although most patients showed improvement in symptoms over time, permanent paraplegia occurred in 4 (3.8%) patients in the control group and 1 (1%) in the intervention group. No difference in 30-day overall survival was observed: control group 94.1% (95% confidence interval: 87.2%-97.3%) and intervention group 96.2% (95% confidence interval: 90.2%-98.6%). Of 57 patients who received CSFD, complications related to CSFD were reported in 6 patients (10.5%). Implementation of our SCI prevention protocol decreased the occurrence of SCI from 23.8% to 7.6% (P < .001).