Spinal Cord Ischemia during TEVAR

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Presentation transcript:

Spinal Cord Ischemia during TEVAR John J Ricotta MD FACS Professor of Surgery Georgetown University Chair of Surgery Washington Hospital Center CRT February 2012

I have no real or apparent conflicts of interest to report. John J. Ricotta, MD I have no real or apparent conflicts of interest to report.

Objectives To define the Incidence of SCI after TEVAR To Identify Factors associated with SCI To Delineate Strategies to reduce/treat SCI To discuss potential new diagnostic methods for early detection of SCI

SCI after TEVAR SCI occurs in 5-20% of Open TAA SCI occurs in 3-8% of TEVAR Incidence of SCI is related to the indication for intervention and the extent of TAA Results from decreased SC perfusion from inadequate collateral perfusion or I/R injury Presentation and Prevention of SCI differs somewhat from Open Surgery.

Vascular Anatomy SC

Factors associated with SCI in TEVAR Length of Operation Hypotension Extent of TA coverage Indication for Intervention Female Gender Adequacy Collateral Circulation - Left SCA Coverage - prior AAA repair

Differences in SCI: OPEN vs. EV OPEN – poor collateral flow during X clamp is a factor, as is prolonged hypotension RX: retrograde perfusion, cooling, CSF drainage, intercostal reimplantation, delayed deficits less common TEVAR – no X clamp, limited hypotension, reimplantation is impossible RX: limit coverage of important arteries, maintain SPP, delayed deficit is more common than with Open repair

Prevention of SCI Early Diagnosis is Critical!! Increase SPPF – reduce CSFP to < 10 mm - increase MAP to >90mm Identify and avoid covering important Spinal Arteries - CTA Create Type I or Type IV endoleak Treat Reperfusion Injury - naloxone , scavengers

Effect of Intervention on Paparplegia Rate (Acher C Effect of Intervention on Paparplegia Rate (Acher C. JTCV Surg 140 (Suppl 6) S142-6,2010)

CTA to Identify Spinal Arteries (Furukawa et al Ann Thor Surg 2010;90:1840-6)

Distribution of Artery of Adamkewicz (Furukawa et al Ann Thoracic Surg 2010;90:1840-6)

Creation of Type 1 Endoleak (Reilly LM, Chuter TAM, JEVT 2010;17:21-9)

TEVAR Modification (Ilic N et al , JTCVS 2011;141:604-6)

Monitoring to Guide Therapy Evoked Potentials Systemic Markers I/R – not useful, delayed, non specific CSF Markers of I/R lactate SC O2 tension Heat Shock Proteins -HSP 70, HSP 27

Summary SCI remains a major morbidity after TEVAR, although the incidence in less than after OSR High risk patients include females, those with long areas of TA coverage, extensive aneurysmal disease, Prior AAA repair, Left SCA coverage Careful Preoperative planning with identification of critical arteries is important Prevention: Limit length of Coverage, keep MAP>90, employ CSF drains and keep CSFP<10, elective revascularization of LSCA

Summary SCI is often delayed in TEVAR as compared to OSR – postoperative monitoring is critical CSF drain and mild hypertension must continue postoperatively in high risk groups Monitoring using Clinical exam , EP and perhaps in the future biomarkers will be critical to early detection and treatment Creating “endoleaks” for later closure may be of use in some complex cases.