Current strategies to prevent spinal cord ischemia in TAAA...

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.



– Aneurysm

– Spinal cord circulation



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




– CSF drainage

– Cooling

– SA artery reattachment/distal aortic perfusion

– Spinal cord function monitoring

– Staged repair


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.


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.



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




– CSF drainage

– Cooling

– SA artery reattachment/distal aortic perfusion

– Spinal cord function monitoring

– Staged repair


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

• Staging TEVAR implantation

• Creating type III endoleak

– Sac perfusion branch

– Leaving branch open

– Stent between SG components

– Don’t connect iliac limb



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.


• 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


• 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





– 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.

Current strategies to prevent spinal cord ischemia in TAAA...

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