Post on 11-Jul-2019
Current strategies to prevent spinal cord
ischemia in TAAA repair
Geert Willem SchurinkBarend Mees
Noud PeppelenboschMichiel de HaanMichael Jacobs
Maastricht University Medical Center,
the Netherlands
European Vascular Center Aachen-Maastricht,
Germany and the Netherlands
Disclosures
• Proctor for COOK Medical
Blood supply spinal cord
Adamkiewicz artery
0.5 -1.2 mm
T5 - T8 25%
T9 - L2 75%
Left side 75%
Collateral Network Theory
Strategies to prevent SCI
• Selection of Patients
– Aneurysm
– Spinal cord circulation
• Operative Strategies
• Postoperative Strategies
Cleveland Clinic Experience
Greenberg et al.Circulation. 2008;118:808-81
ER: sicker, older, more prior Ao repair
SCI in 12% SCI in 0%
No collaterals (n=24) Collaterals (n=31)
Post-dissection vs Degenerative TAAA
Backes WH, et. JVS. 2008;48(2):261-71.
Strategies to prevent SCI
• Selection of Patients
– Aneurysm
– Spinal cord circulation
• Operative Strategies
• Postoperative Strategies
L1 aka
asa
asa
L1
Results
14 patients (32%)
YES
44 patients (73%)
YES 30 patients (68%)
NO
60 patients (100%)
0 patients (0%)
YES
16 patients (27%)
NO 16 patients (100%)
NO
Inclusion X-clamping SA-AKA Decline of MEPs
Strategies to prevent SCI
• Selection of Patients
• Operative Strategies
– CSF drainage
– Cooling
– SA artery reattachment/distal aortic perfusion
– Spinal cord function monitoring
– Staged repair
• Postoperative Strategies
Strategies to prevent SCI
• Selection of Patients
• Operative Strategies
– CSF drainage
– Cooling
– SA artery reattachment/distal aortic perfusion
– Spinal cord function monitoring
– Staged repair
• Postoperative Strategies
Strategies to prevent SCI
• Selection of Patients
• Operative Strategies
– CSF drainage
– Cooling
– SA artery reattachment/distal aortic perfusion
– Spinal cord function monitoring
– Staged repair
• Postoperative Strategies
cross-clamping entire aorta
0
0,5
1
1,5
2
2,5
39
.36
11
.15
11
.31
11
.42
11
.58
12
.14
12
.27
12
.35
12
.44
12
.52
13
.00
13
.10
13
.17
13
.25
13
.34
13
.42
13
.57
14
.10
14
.21
14
.30
14
.48
15
.05
15
.24
15
.39
time
ME
P a
mp
litu
des [
mV
]
right ant.tib.m.
left ant.tib.m.
right abd.poll.br.
left abd.poll.br.
cross-clamping entire aorta
0
0,5
1
1,5
2
2,5
39
.36
11
.15
11
.31
11
.42
11
.58
12
.14
12
.27
12
.35
12
.44
12
.52
13
.00
13
.10
13
.17
13
.25
13
.34
13
.42
13
.57
14
.10
14
.21
14
.30
14
.48
15
.05
15
.24
15
.39
time
ME
P a
mp
litu
des [
mV
]
right ant.tib.m.
left ant.tib.m.
right abd.poll.br.
left abd.poll.br.
cross-clamping entire aorta
cross-clamping entire aorta
0
0,5
1
1,5
2
2,5
39
.36
11
.15
11
.31
11
.42
11
.58
12
.14
12
.27
12
.35
12
.44
12
.52
13
.00
13
.10
13
.17
13
.25
13
.34
13
.42
13
.57
14
.10
14
.21
14
.30
14
.48
15
.05
15
.24
15
.39
time
ME
P a
mp
litu
des [
mV
]
right ant.tib.m.
left ant.tib.m.
right abd.poll.br.
left abd.poll.br.
Perfusion of
reimplantated segmental
arteries
Strategies to prevent SCI
• Selection of Patients
• Operative Strategies
– CSF drainage
– Cooling
– SA artery reattachment/distal aortic perfusion
– Spinal cord function monitoring
– Staged repair
• Postoperative Strategies
Δt 5 years
Staged repair in Open TAAA
Staged repair in EndoTAAA
• Staging TEVAR implantation
• Creating type III endoleak
– Sac perfusion branch
– Leaving branch open
– Stent between SG components
– Don’t connect iliac limb
Staged repair in EndoTAAA
• Staging TEVAR implantation
• Creating type III endoleak
– Sac perfusion branch
– Leaving branch open
– Stent between SG components
– Don’t connect iliac limb
Staged repair in EndoTAAA
Staged repair in EndoTAAA
Sac perfusion(n=40)
No Sac Perfusion(n=43)
Temp. paraparesis 13% 2%
Paraplegia 5% 21%
Kasprzak P et al. EJVES. 2014;48(3):258-65.
Staged repair in EndoTAAA
• General:
– CSF drainage
– BP management
– Preserve LSA and HA perfusion
– Limit limb ischemia
• Since June 2012
– Staging by only TEVAR first (type II TAAA)
– B/FEVAR:• Spinal cord function monitoring (MEP)
• Last branch: 15 min balloon occlusion
• Decision to leave branch open (MEP >50% )
electrical stimulation
500 V; ~1.2 A, 5 serial stimuli
MEP response
abd. poll. brevis muscle
MEP response
tibialis anterior muscle
SCI ischemia
Peripheral
ischemia
MEPS @ Crawford extent 2 endoTAAA repair with multivessel BEVAR
0
10
20
30
40
50
60
70
80
90
100
110
0
100
200
300
400
500
600
700
800
900
1000
1100
1200
1300
1400
1500
ME
P a
mp
litu
de [
mV
]
time
tib.ant.Re
tib.ant.Li
abd.poll.br.Re
abd.poll.br.Li
rect.fem.R
rect.fem.L
T1%
Peripheral
ischemia Right
Leg
Spinal Cord
Ischemia
Pitfall
• MEPs 100% @ branch test
• 4 branches connected
• Completion angio: endoleak
• Delayed paraparese
• Cta: thrombosis endoleak
0
10
20
30
40
50
60
70
80
90
100
110
0
500
1000
1500
2000
2500
3000
3500
4000
4500
time
tib.ant.Re
tib.ant.Li
Peripheral
ischemia
Staged repair in EndoTAAA
• General:– CSF drainage– BP management– Preserve LSA and HA perfusion
• Since June 2012– Staging by only TEVAR first (type II TAAA)– B/FEVAR:
• Spinal cord function monitoring (MEP)• Last branch: 15 min balloon occlusion• Decision to leave branch open
– MEP >50% – Endoleak on angiography– Aneurysms Sac Pressure
SINCE 2
YEARS
Revised Protocol
Results
• 28 patients
• 30-day mort: 3,5%
• SCI: 7% (partial;reversible): both walking again
64% (18 pts) NO “open branch” staging:
* 5% (1 pt) SCI
36% (10 pts) “open branch” staging:
* 10% (1pt) SCI
0,0%
5,0%
10,0%
15,0%
20,0%
25,0%
30,0%
35,0%
40,0%
extent1
extent2
extent3
extent4
Crawford TAAA Classification
Strategies to prevent SCI
• Selection of Patients
• Operative Strategies
• Postoperative Strategies
– Hemodynamic situation (BP; Hb; CVP)
– CSF drainage
Conclusions
• Paraplegia is still the most disabelingcomplication in treatment of TAAA
• Several pre - intra – postoperative strategiesare available to decrease SCI– Staging is the most promising both in open and
endo repair– MEPs are important for decision making in open
repair– MEPs in combination with sac pressurements and
angiography help to select patients how needstaging in endo repair.