Minimally invasive segmental artery coil embolization for spinal cord ischemia prevention prior to fenestrated/branched endovascular aortic repair.

Abstract

To report our institutional experience with minimally invasive segmental artery coil embolization (MISACE) before fenestrated/branched endovascular aortic repair (F/BEVAR) and to compare post-F/BEVAR outcomes between patients treated in the MISACE era and those treated earlier without MISACE. MISACE was implemented at our institution beginning in 2018 as part of a multidisciplinary spinal protection strategy. Patients who underwent F/BEVAR with prior MISACE between March 2018 and September 2023 (MISACE group, n = 42) were retrospectively compared with patients treated before MISACE implementation (non-MISACE group, n = 50; November 2007 to February 2018). Extent IV aortic repair coverage in the non-MISACE cohort was excluded. The primary end point was in-hospital spinal cord ischemia (SCI) after F/BEVAR. Univariate and multivariable logistic regression were used to assess factors associated with SCI. Patients in the MISACE cohort were younger (70 ± 9.0 vs 75.1 ± 5.8 years, P = .003) and more frequently had aortic dissections (36% vs 12%, P = .014), but there were no significant differences in previous aortic surgery (64% vs 50%, P = .17) or presentation with extent I-III aneurysms (76.2% vs 80%, P = .66). MISACE was performed in a single session in 95.2% of patients, targeting a median of 3 [2, 4] vessels, with a median interval of 72 [35, 110] days before F/BEVAR. There were no differences in the rates of thoracic endovascular repair staging (50% vs 36%, P = .25), F/BEVAR technical success (88% vs 80%, P = .45), or extent I-III aortic repair coverage (83.3% vs 96%, P = .074). SCI occurred less frequently in the MISACE cohort (9.5% vs 30%, P = .016). There were no significant differences in in-hospital mortality (7.1% vs 12%, P = .5); however, the median length of hospital stay was significantly shorter in the MISACE cohort (7 [5, 12] vs 11 [7, 20] days, P = .022). On univariate analysis, MISACE was associated with reduced odds of SCI (odds ratio: 0.25, 95% confidence interval: 0.07-0.75; P = .013). However, on multivariable analysis, only prior aortic surgery remained independently associated with reduced SCI (odds ratio: 0.29, 95% confidence interval: 0.09-0.89; P = .036). MISACE is a technically feasible and safe spinal protection adjunct to F/BEVAR, with no added procedural or neurologic risk. Although associated with lower SCI rates on univariate analysis, its independent effect was not statistically significant after adjustment. Prospective randomized data are needed to clarify the role of MISACE in spinal cord protection.