Aortic Intervention & Spinal Cord Ischemia Alexander J Gregory MD, FRCPC Department of Anesthesia, University of Calgary Calgary, Alberta, Canada May 30,

Slides:

Advertisements

Similar presentations

(1) Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta Arch Debranching versus Elephant Trunk Procedures for Hybrid Repair.

Advertisements

Antegrade Stent Grafting of Descending Thoracic Aorta During Acute Debakey I Dissection: Early and Midterm Outcomes Prashanth Vallabhajosyula MD, Joseph.

Spinal cord protection in surgery of descending thoracic aorta Present by R1 康庭瑞.

Division of Cardiovascular Surgery Xijing Hospital, Xi’an, China

Hybrid Repair of Kommerell’s Diverticulum

Results of “Type II” Hybrid Arch Repair with Zone 0 Stent Graft Deployment Jehangir Appoo, William Kent, Eric Herget, Jason Wong, Alberto Pochettino and.

Risk Assessment for Perioperative Pulmonary Complications in Patients Undergoing Noncardiothoracic Surgery Joanne D. So, MS4 Tulane University School of.

Open Repair of Ruptured Descending Thoracic and Thoracoabdominal Aortic Aneurysms in 100 Consecutive Cases Mario F. Gaudino, Christopher Lau, Monica Munjal,

Outcomes of 3309 Thoracoabdominal Aortic Aneurysm Repairs

Should We Be Doing This? Sealing Dissections: Thoracic Stenting Dr Peter Wilde – Consultant Cardiac Radiologist Dr K Balachandran – Cardiology SpR Mr A.

Impact of Concomitant Tricuspid Annuloplasty on Tricuspid Regurgitation Right Ventricular Function and Pulmonary Artery Hypertension After Degenerative.

What Is Peripheral Vascular Disease? Daniel B. Walsh, M.D. Professor of Surgery, Section of Vascular Surgery Vice-Chair, Department of Sugery Dartmouth-Hitchcock.

SIR-RFS AngioClub Ethan M. Dobrow, PGY-4 Maine Medical Center, Portland, Maine (The Freeman Hospital, Newcastle-Upon-Tyne, UK)

Endovascular Repair of Thoracic Arch Aneurysms

The Use of Thoracic Endovascular Stent Grafting in Acute Aortic Tragedies as Compared to Open Surgical Repair Tyler J. Wallen, BA, Wilson Y. Szeto, MD,

Osaka University Department of Cardiovascular Surgery Osaka University Department of Cardiovascular Surgery The efficacy of debranching TEVAR for arch.

TOTAL AORTIC ARCH REPLACEMENT WITH THORAFLEX HYBRID FROZEN ELEPHANT TRUNK PROSTHESIS: RESULTS OF FIRST 100 PATIENTS Malakh Shrestha, Heike Krueger, Tim.

Utilization of Motor Evoked Potential Monitoring During TEVAR: Can the Incidence of Spinal Cord Injury Be Reduced? Ali Shahriari The Indiana Heart Hospital.

Aortic Symposium 2012 Short Term Outcomes in Endovascular and Open Repair of Thoracic Aortic Aneurysms Are Controversial Through NSQIP Alexander I. Kraev,

Aortic Remodeling after Endovascular Repair of the Descending Thoracic Aorta G. William Moser CRNP, Patrick Moeller BS, Thomas Bavaria Jr. BS, Ahmad Zeeshan.

Osaka University Graduate School of Medicine Division of Cardiovascular Surgery Strategy of TEVAR for acute aortic dissection Osaka University Graduate.

Aortic Emergencies LISA BROUGHTON, PHD, RN, CCRN.

Hybrid Arch for Acute Type A Aortic Dissection

Hybrid Arch for Acute Type A Aortic Dissection

Using speckle tracking echocardiography to measure aortic compliance: methodology and early results Alexander J Gregory MD, FRCPC Department of Anesthesia,

Ali Khoynezhad, MD1, Carlos E. Donayre, MD2,

Complex Ostial Disease of the Aortic Arch Vessels

Spinal Cord Ischemia during TEVAR

TEVAR for Chronic Type B Dissection

Open Repair of Ruptured Descending Thoracic and Thoracoabdominal Aortic Aneurysms in 100 Consecutive Cases Mario F. Gaudino, Christopher Lau, Monica Munjal,

Protocol implementation of selective postoperative lumbar spinal drainage after thoracic aortic endograft Charles J. Keith, BA, Marc A. Passman, MD,

Use of custom Dacron branch grafts for “hybrid” aortic debranching during endovascular repair of thoracic and thoracoabdominal aortic aneurysms G. Chad.

Thoracic Aortic Frontier: Review of Current Applications and Directions of Thoracic Endovascular Aortic Repair (TEVAR) Jehangir J. Appoo, MDCM, FRCSC,

Risk factors, outcomes, and clinical manifestations of spinal cord ischemia following thoracic endovascular aortic repair Brant W. Ullery, MD, Albert.

Low incidence of paraplegia after thoracic endovascular aneurysm repair with proactive spinal cord protective protocols Joseph L. Bobadilla, MD, Martha.

Thoracic Endovascular Aortic Repair

Magnetic resonance angiography of collateral blood supply to spinal cord in thoracic and thoracoabdominal aortic aneurysm patients Walter H. Backes,

Initial clinical experience with a new low-profile thoracic endograft

Extent of Aortic Coverage and Incidence of Spinal Cord Ischemia After Thoracic Endovascular Aneurysm Repair Robert J. Feezor, MD, Tomas D. Martin, MD,

Effect of extended cross-clamp time during thoracoabdominal aortic aneurysm repair Hazim J Safi, MD, Anders Winnerkvist, MD, Charles C Miller, PhD, Dimitrios.

Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair Judson B. Williams, MD, MHS, Nicholas D. Andersen,

Gerald R. Fortuna, MD, Alexa Perlick, BS, Joseph J

The effect of left subclavian artery coverage on morbidity and mortality in patients undergoing endovascular thoracic aortic interventions: A systematic.

Mancini JG, et al. Am J Cardiol.

Risk factors, outcomes, and clinical manifestations of spinal cord ischemia following thoracic endovascular aortic repair Brant W. Ullery, MD, Albert.

Daniel J. Amaranto, BA, Edward C. Wang, PhD, Mark K

Incidence and risk factors of renal dysfunction after thoracic endovascular aortic repair George T. Pisimisis, MD, Ali Khoynezhad, MD, PhD, Khalid Bashir,

Simplified hybrid repair with true lumen recycling for retrograde renovisceral perfusion in a complex chronic aortic dissection Ricardo Castro-Ferreira,

Angiographic localization of spinal cord blood supply and its relationship to postoperative paraplegia G.Melville Williams, MD, Bruce A. Perler, MD,

Chronic type B aortic dissection in a pregnant patient managed by simultaneous thoracic endovascular aortic repair and cesarean section in the hybrid.

Raghuveer Vallabhaneni, MD, Luis A. Sanchez, MD

Nicholas D. Andersen, MD, Michael E. Barfield, MD, Jennifer M

Fenestrated and branched endovascular aneurysm repair outcomes for type II and III thoracoabdominal aortic aneurysms Matthew J. Eagleton, MD, Matthew.

Neurological complications after left subclavian artery coverage during thoracic endovascular aortic repair: A systematic review and meta-analysis David.

Efficacy and durability of the chimney graft technique in urgent and complex thoracic endovascular aortic repair Adel Bin Jabr, MD, Bengt Lindblad, MD,

Hybrid repair of an aortic arch aneurysm with complex anatomy: Right aortic arch and anomalous origin of supra-aortic vessels Roberto Chiesa, MD, Germano.

Stent graft migration after endovascular aneurysm repair: importance of proximal fixation Christopher K Zarins, MD, Daniel A Bloch, PhD, Tami Crabtree,

Paraplegia after coronary artery bypass surgery: An uncommon complication in a patient with history of thoracic endovascular aortic repair Aurélien Vallée,

Retrograde segmental aortic repair for type II thoracoabdominal aortic aneurysm Teruhisa Kazui, MD, Katsushi Yamashita, MD, Hitoshi Terada, MD, Naoki.

Subclavian revascularization in the age of thoracic endovascular aortic repair and comparison of outcomes in patients with occlusive disease Salvatore.

Late neurological recovery of paraplegia after endovascular repair of an infected thoracic aortic aneurysm Barend M.E. Mees, MD, PhD, Frederico Bastos.

Systematic review of clinical outcomes in hybrid procedures for aortic arch dissections and other arch diseases Piergiorgio Cao, MD, FRCS, Paola De Rango,

Aortoiliac surgery in renal transplant patients

Branch graft patency after open repair of thoracoabdominal aortic aneurysms Nicholas T. Kouchoukos, MD, Alexander Kulik, MD, MPH, Catherine Castner, RN,

Hazim J Safi, MD, Charles C Miller, PhD The Annals of Thoracic Surgery

Operative Strategy for Descending and Thoracoabdominal Aneurysm Repair With Preoperative Demonstration of the Adamkiewicz Artery Kojiro Furukawa, MD,

Influence of preservation or perfusion of intraoperatively identified spinal cord blood supply on spinal motor evoked potentials and paraplegia after.

Risk factors for spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms Theodosios Bisdas, MD, PhD, Giuseppe Panuccio, MD,

Salvatore T. Scali, MD, S. Keisin Wang, MD, Robert J

Presentation transcript:

Aortic Intervention & Spinal Cord Ischemia Alexander J Gregory MD, FRCPC Department of Anesthesia, University of Calgary Calgary, Alberta, Canada May 30, 2014 Thoracic Aortic Rounds aorta.ca

OBJECTIVES

Cervical Plexus (Vertebrals) Hypogastric Plexus (Iliacs) Lumbar Segmentals Intercostal Segmentals

Risk

SCI incidence TAAA= 8-28% TAA= 2-3% TEVAR = 2-3% HAR = 0-4%

Risk Factors > 1 territory of blood supply lost Peri-operative hypotension Chronic renal failure Stent coverage Artery of Adamkiewicz sacrifice Atherosclerotic aorta Smoking Complicated Type-B, HAR & aortic transection Age

Risk Factors > 1 territory of blood supply lost Peri-operative hypotension Chronic renal failure ? Stent coverage ? Artery of Adamkiewicz sacrifice ?? Atherosclerotic aorta ?? Smoking ?? Complicated Type-B, HAR & aortic transection ?? Age

LSCA Bypass

Semin Thorac Cardiovasc Surg 2009; 21: Ishimaru Classification

Arm Ischemia

Vertebrobasilar Ischemia

SCI

Recommendation 1: In patients who need elective TEVAR where achievement of a proximal seal necessitates coverage of the left subclavian artery, we suggest routine preoperative revascularization, despite the very low-quality evidence (GRADE 2, level C). J Vasc Surg 2009;50:1155-8

Semin Vasc Surg 2012; 25:

Routine revascularization is unnecessary in the majority of patients requiring zone II coverage during thoracic endovascular aortic repair: A longitudinal outcomes study using United States Medicare population data. Wilson JE, Galiñanes EL, Hu P, Dombrovskiy Vym and Vogel TR. Vascular Sep 3. [Epub ahead of print] Medicare & Medicaid Services- Inpatient claims n= 2676 TEVAR, 869 LSCA covered, 49 LSCA bypassed TEVAR + LSCA w/out bypass = 1.9% bypassed in 1 st year TEVAR + LSCA + bypass = 12.8% vs 3.8% stroke & higher mortality

LSCA bypass Prophylactic LSCA bypass: LIMA AV fistula L hand dominance Supra-aortic or COW abnormalities LSCA bypass for clinically relevant malperfusion SCI does not appear to be substantially increased in most patients

Collateral Network

J Thorac Cardiovasc Surg 2011;141: = ASA = DP  T L 

J Thorac Cardiovasc Surg 2011;141:1020-8

J Thorac Cardiovasc Surg 2011;141:

Nat 24h 120h

J Thorac Cardiovasc Surg 2011;141:

J Thorac Cardiovasc Surg 2010;140:S125-30

T & L SA sacrifice

J Thorac Cardiovasc Surg 2010;140:S T & L SA sacrifice L only SA sacrifice

J Thorac Cardiovasc Surg 2010;140:S T & L SA sacrifice L only SA sacrifice T SA sacrifice 7d later

CSF Drains

Hanna et al , TEVAR, n=381 Prev aortic surgery + >75% + below T6 or Hybrid repair Crawford I-III Pre-op CSFd= 21% (81/381) Post-op CSFd for SCI= 1% (3/300) Group SCI= 6.6% (25/381), 1.8% (7/381) permanent Pre-op CSFd SCI= 14.8% (12/81), 7.4% (6/81) permanent No CSFd SCI= 4.3% (13/300), 0.3% (1/300) permanent CSFd complications= 11.1% (9/81), HA 5, leak 2, minor SDH 2 No CSF drained 32% (26/81) Keith et al , TEVAR, n=266 Pre-op CSFd excluded, post-op SCI protocol SCI= 6% (16/266), 3.4% (9/266) permanent CSFd req’d= 3.8% (10/266) CSFd reversed SCI= 30% (3/10) CSFd complications= 10% (1/10), SDH 1 Time of SCI onset to CSFd= 8.2 +/ hrs

Hanna et al , TEVAR, n=381 Prev aortic surgery + >75% + below T6 or Hybrid repair Crawford I-III Pre-op CSFd= 21% (81/381) Post-op CSFd for SCI= 1% (3/300) Group SCI= 6.6% (25/381), 1.8% (7/381) permanent Pre-op CSFd SCI= 14.8% (12/81), 7.4% (6/81) permanent No CSFd SCI= 4.3% (13/300), 0.3% (1/300) permanent CSFd complications= 11.1% (9/81), HA 5, leak 2, minor SDH 2 No CSF drained 32% (26/81) Keith et al , TEVAR, n=266 Pre-op CSFd excluded, post-op SCI protocol SCI= 6% (16/266), 3.4% (9/266) permanent CSFd req’d= 3.8% (10/266) CSFd reversed SCI= 30% (3/10) CSFd complications= 10% (1/10), SDH 1 Time of SCI onset to CSFd= 8.2 +/ hrs

Hanna et al , TEVAR, n=381 Prev aortic surgery + >75% + below T6 or Hybrid repair Crawford I-III Pre-op CSFd= 21% (81/381) Post-op CSFd for SCI= 1% (3/300) Group SCI= 6.6% (25/381), 1.8% (7/381) permanent Pre-op CSFd SCI= 14.8% (12/81), 7.4% (6/81) permanent No CSFd SCI= 4.3% (13/300), 0.3% (1/300) permanent CSFd complications= 11.1% (9/81), HA 5, leak 2, minor SDH 2 No CSF drained 32% (26/81) Keith et al , TEVAR, n=266 Pre-op CSFd excluded, post-op SCI protocol SCI= 6% (16/266), 3.4% (9/266) permanent CSFd req’d= 3.8% (10/266) CSFd reversed SCI= 30% (3/10) CSFd complications= 10% (1/10), SDH 1 Time of SCI onset to CSFd= 8.2 +/ hrs

Hanna et al , TEVAR, n=381 Prev aortic surgery + >75% + below T6 or Hybrid repair Crawford I-III Pre-op CSFd= 21% (81/381) Post-op CSFd for SCI= 1% (3/300) Group SCI= 6.6% (25/381), 1.8% (7/381) permanent Pre-op CSFd SCI= 14.8% (12/81), 7.4% (6/81) permanent No CSFd SCI= 4.3% (13/300), 0.3% (1/300) permanent CSFd complications= 11.1% (9/81), HA 5, leak 2, minor SDH 2 No CSF drained 32% (26/81) Keith et al , TEVAR, n=266 Pre-op CSFd excluded, post-op SCI protocol SCI= 6% (16/266), 3.4% (9/266) permanent CSFd req’d= 3.8% (10/266) CSFd reversed SCI= 30% (3/10) CSFd complications= 10% (1/10), SDH 1 Time of SCI onset to CSFd= 8.2 +/ hrs

Hanna et al , TEVAR, n=381 Prev aortic surgery + >75% + below T6 or Hybrid repair Crawford I-III Pre-op CSFd= 21% (81/381) Post-op CSFd for SCI= 1% (3/300) Group SCI= 6.6% (25/381), 1.8% (7/381) permanent Pre-op CSFd SCI= 14.8% (12/81), 7.4% (6/81) permanent No CSFd SCI= 4.3% (13/300), 0.3% (1/300) permanent CSFd complications= 11.1% (9/81), HA 5, leak 2, minor SDH 2 No CSF drained 32% (26/81) Keith et al , TEVAR, n=266 Pre-op CSFd excluded, post-op SCI protocol SCI= 6% (16/266), 3.4% (9/266) permanent CSFd req’d= 3.8% (10/266) CSFd reversed SCI= 30% (3/10) CSFd complications= 10% (1/10), SDH 1 Time of SCI onset to CSFd= 8.2 +/ hrs

Hanna et al , TEVAR, n=381 Prev aortic surgery + >75% + below T6 or Hybrid repair Crawford I-III Pre-op CSFd= 21% (81/381) Post-op CSFd for SCI= 1% (3/300) Group SCI= 6.6% (25/381), 1.8% (7/381) permanent Pre-op CSFd SCI= 14.8% (12/81), 7.4% (6/81) permanent No CSFd SCI= 4.3% (13/300), 0.3% (1/300) permanent CSFd complications= 11.1% (9/81), HA 5, leak 2, minor SDH 2 No CSF drained 32% (26/81) Keith et al , TEVAR, n=266 Pre-op CSFd excluded, post-op SCI protocol SCI= 6% (16/266), 3.4% (9/266) permanent CSFd req’d= 3.8% (10/266) CSFd reversed SCI= 30% (3/10) CSFd complications= 10% (1/10), SDH 1 Time of SCI onset to CSFd= 8.2 +/ hrs

CSFd Current FMC Strategy Selective use Intra-op CSF pressure 70 mmHg CSF drainage < 10 mL/hr SSEP Fast-track general anesthesia Post-op q1h neuro vitals Neuro normal= CSF pressure 65 mmHg SCI protocol