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

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Preoperative prediction of spinal cord ischemia after thoracic endovascular aortic repair Salvatore T. Scali, MD, S. Keisin Wang, MD, Robert J. Feezor, MD, Thomas S. Huber, MD, PhD, Tomas D. Martin, MD, Charles T. Klodell, MD, Thomas M. Beaver, MD, MPH, Adam W. Beck, MD Journal of Vascular Surgery Volume 60, Issue 6, Pages 1481-1490.e1 (December 2014) DOI: 10.1016/j.jvs.2014.08.103 Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 1 This image demonstrates the method for obtaining aortic length from the sinotubular junction (red arrow demonstrates the left coronary artery, white arrows are the region of the proximal stent boundary) to the aortic bifurcation. This patient's total aortic length was 525 mm along the centerline. A measurement of the total stent coverage, which is equivalent to the total aortic coverage length, was determined by measurement of the centerline distance from the most proximal stent boundary to the most distal stent boundary. The percentage of aortic coverage was derived by dividing the total aortic coverage length by total aortic length × 100. Additional measurements were taken from the most distal stent boundary to the top of the celiac and superior mesenteric artery origins as well as to the aortic bifurcation. The total number of aortic zones that were covered was tabulated and included total and partial zone coverages (eg, if the distal stent boundary extended only partially into zone 5, this was tabulated as a covered zone). Journal of Vascular Surgery 2014 60, 1481-1490.e1DOI: (10.1016/j.jvs.2014.08.103) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 2 This graph demonstrates the indications for thoracic endovascular aortic repair (TEVAR) in our data set and the prevalence of any form of spinal cord ischemia (SCI) in each group at the top of each bar. The most common indication was thoracic aneurysm, with an overall SCI rate of 8.8%. The highest rate of SCI was within the thoracoabdominal aortic aneurysm (TAAA) group and was 15.4%. cTBAD, Complex type B aortic dissection; PAU, penetrating aortic ulcer; TAT, traumatic aortic transection. Journal of Vascular Surgery 2014 60, 1481-1490.e1DOI: (10.1016/j.jvs.2014.08.103) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 3 These graphs demonstrate the association of age (A) and coverage length (B) to spinal cord ischemia (SCI). There is essentially a linear relationship with these two variables to the occurrence of SCI. Journal of Vascular Surgery 2014 60, 1481-1490.e1DOI: (10.1016/j.jvs.2014.08.103) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 4 Left, The model developed from our multivariable analysis. The sample case is a 65-year-old patient with 30 cm of coverage length and a history of hypertension. The probability of spinal cord ischemia (SCI) in this patient is 6.9% based on those parameters. Right, The receiver operating curve, which demonstrates an area under the curve (AUC) of 0.84 from the bootstrapped iterative sampling. CI, Confidence interval. Journal of Vascular Surgery 2014 60, 1481-1490.e1DOI: (10.1016/j.jvs.2014.08.103) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 5 This figure demonstrates the estimated probability of spinal cord ischemia (SCI) related to each of the demonstrated combinations of risk factors. A 65-year-old patient with a short coverage length of 100 mm and no history of hypertension (HTN) would have a preoperative predicted rate of post-thoracic endovascular aortic repair (TEVAR) SCI of <1%, whereas an 80-year-old patient with a long coverage length of 300 mm and a history of hypertension would have a predicted SCI rate that can approach 20%. O/E, Observed/expected. Journal of Vascular Surgery 2014 60, 1481-1490.e1DOI: (10.1016/j.jvs.2014.08.103) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Supplementary Fig (online only) This figure demonstrates the all-cause mortality after thoracic endovascular aortic repair (TEVAR) for patients with and without any degree of spinal cord ischemia (SCI) (log-rank, P < .001). The standard error of the mean is < 10% for all displayed intervals. Journal of Vascular Surgery 2014 60, 1481-1490.e1DOI: (10.1016/j.jvs.2014.08.103) Copyright © 2014 Society for Vascular Surgery Terms and Conditions