Spinal Cord Ischemia After Thoracoabdominal Aortic Aneurysms Endovascular Repair: From the Italian Multicenter Fenestrated/Branched Endovascular Aneurysm Repair Registry

Abstract

Purpose:

The aim of this study is to report an Italian multicenter experience analyzing the incidence and the risk factors associated with spinal cord ischemia (SCI) in a large cohort of thoracoabdominal aortic aneurysms (TAAAs) treated by fenestrated-branched endovascular aneurysm repair (F-/B-EVAR).

Materials and Methods:

All consecutive patients undergoing F-/B-EVAR in 4 Italian university centers between 2008 and 2019 were prospectively recorded and retrospectively analyzed. Spinal cord ischemia, 30 day/in-hospital adverse events, and mortality were assessed as early outcomes. Risk factors for SCI were determined by multivariable analysis.

Results:

A total of 351 patients received F-/B-EVAR for a TAAA. Twenty-eight (8.0%) patients died within 30 postoperative days or during the hospitalization. Regarding SCI, 47 patients (13.4%) developed neurological symptoms related to spinal cord impaired perfusion. Among them, 17 (4.8%) had a major permanent impairment. The multivariable analysis identified that SCI was associated with Crawford extent I to III (odds ratio [OR]: 20.90, p=0.004, 95% confidence interval [CI]=2.69–162.57), and with endovascular procedures performed for ruptured TAAA (OR: 5.74, p=0.010, 95% CI=1.53–21.57). Spinal cord ischemia was also significantly associated with a grade 3 bleeding during the visceral stage (OR: 4.34, p=0.005, 95% CI=1.55–12.16) and a grade 2 renal insufficiency at 30 days (OR: 7.45, p=0.002, 95% CI=2.12–26.18).

Conclusion:

The present study indicates that SCI is still an open issue after extent I to III TAAA endovascular repair, while its incidence in extent IV TAAA and pararenal/juxtarenal aneurysms is rare. Thoracoabdominal aortic aneurysms extension, urgent TAAA repair for rupture, severe bleeding, and 30 day renal insufficiency have been identified as significant risk factors for SCI. In the presence of such factors, adjunctive strategies may be considered to reduce SCI rates, while in low-risk patients invasive or potentially-risky maneuvers might not be justified.

Keywords

spinal cord ischemia endovascular aortic aneurysm repair TAAA F-EVAR B-EVAR paraplegia fenestrated branched

Introduction

Spinal cord ischemia (SCI) is still a relevant complication after thoracoabdominal aortic aneurysm (TAAA) endovascular repair, despite the advances in stent-graft technology and new prevention protocols. Spinal cord injury is associated with increased late morbidity and mortality, as well as a dramatic decrease in the quality of life.^1,2 Its incidence was found to be 13.5%, with 5.2% of permanent paraplegia in a recent systematic review.³

Identifying risk factors and protective measures to prevent SCI after TAAA endovascular repair is crucial for better patient selection and procedural planning. However, published studies often do not differentiate between proper TAAAs and pararenal/juxtarenal aneurysms, which have an inherent lower risk of SCI due to the more limited aortic coverage, omit preoperative risk factors or include only small single-center series.⁴ Such heterogeneous reporting may lead to confusion in analyzing the true incidence and predisposing factors for the development of SCI, with only 1 study reporting more than 300 cases of extent II and III TAAA, although at a single institution.⁵

The Italian Multicenter F-/B-EVAR Registry (IMFB Registry) is a National, multicenter, retrospective, physician-initiated registry aiming at describing the outcomes of the endovascular treatment of TAAAs at 4 tertiary academic Hospitals. The aim of this study is to analyze the incidence and the factors associated with SCI in a large cohort of TAAA treated by fenestrated-branched endovascular aneurysm repair (F-/B-EVAR), with particular insights on the risk factors.

Materials and Methods

Study Design and Patient Enrollment

The IMFB Registry was founded in 2017 through the joint efforts of 4 academic vascular surgery centers.⁶ This multicenter registry is voluntary, observational, and retrospective. All consecutive patients receiving endovascular repair of juxtarenal/pararenal or thoracoabdominal aneurysms with F-/B-EVAR employing Zenith devices manufactured by Cook Medical (Bloomington, IN) at any of these 4 centers between 2008 and 2019 were included in the registry; the data were prospectively collected in local databases and pooled together after being de-identified with a coding number as required by the European General Data Protection Regulation.

Feasibility of F-/B-EVAR repair was based on the anatomical characteristics of the aortoiliac and visceral vessels and was offered to subjects at high risk for open repair.^7,8 All these patients signed a dedicated informed consent for the F-/B-EVAR procedures. Local institutional review boards approved the study. No funding was obtained from companies or other institutions in relation with the present study. No exclusion criteria were applied for retrospective inclusion of treated patients in this study.

Preoperative Planning and Stent-Graft

Preoperative planning was performed on computed tomography angiography, usually performed within 3 months of the actual procedure for “off-the-shelf devices” or before the stent-graft planning for “custom-made” devices. Post-processing was performed with different software packages (OsiriX MD 11.0 – Pixmeo SARL, Geneve Swiss; 3mensio – Vascular Imaging, Bilthoeven; TeraRecon – Aquarius, Foster City, CA). Stent-grafts employed included both “off-the-shelf” and “custom-made” devices that were planned and sized by the local surgeons in conjunction with the Cook Zenith Planning Centre. An “off-the-shelf” solution with a multibranched stent-grafts (t-Branch) was employed in case of anatomical feasibility in patients with nonelective TAAAs or in elective cases if it did not lead to a longer coverage of healthy thoracic aorta compared with a custom-made stent-graft. Branches or fenestrations were used to re-vascularize the renal and splanchnic arteries based on the size and characteristics of the aorta at that level.⁹ The procedures and the perioperative and postoperative protocols were described in previous reports.^10,11

Spinal Cord Ischemia Prevention Protocols

Different SCI prevention protocols were used at each institution and included: early lower limb/pelvic reperfusion, intraoperative and perioperative high mean arterial pressure (MAP; >80 mmHg), and hemoglobin (Hb) >10 mg/dL. These maneuvers were applied in case of Crawford extent I to III TAAAs or extent IV TAAAs with hypogastric artery (HA) occlusion or previous aortic repair. In addition, the patency of left subclavian artery (LSA) and both HA was always maintained through surgical or endovascular procedures. Early lower/limb reperfusion is favored by release of all aortic components prior to visceral vessel cannulation/bridging whenever possible. This permits to reduce the flow limitation of the large introducer sheaths by closing the femoral access or downsizing it to a 7F or 10F by tightening the purse-string suture in case of surgical access or partially closing the suture-mediated vascular closure devices in case of percutaneous access.^11
–13

Regarding cerebrospinal fluid drainage (CSFD), 3 centers almost routinely employed a preoperative CSFD placement during F-/B-EVAR implants, while the remaining center employs it selectively in patients considered at high risk for SCI (eg, nonelective patients, prior SCI events). When it is not prophylactically positioned, a CSFD is put in place in all centers if a patient develops new SCI symptoms during the postoperative course. Usually, prophylactically-placed CSFD is left to drain for 48 hours, then put in pause for 24 hours and removed in the absence of intercurrent neurologic events. Duration of drainage varies in symptomatic patients based on clinical status, perfusion pressure, degree, and rapidity of spinal cord function recovery.

Endovascular procedures were performed in a single stage or were divided into 2 or more stages according to the standard clinical practice of the different institutions. The SCI prevention protocols adopted by each center were described in previous published papers.^10,11

Definitions and Endpoints

We employed the 2021 SVS Reporting standards to classify preoperative comorbidities, aneurysm anatomy, operative risk, and postoperative complications.¹⁴ Preoperative motor function was evaluated according to the modified Tarlov scale, with a score of 5 indicating normal function, 3 and 4 indicating paraparesis, and 0 to 2 indicating paraplegia.¹⁵ We evaluated SCI and 30 day major adverse events (MAEs) as early outcomes. Major adverse events included mortality, myocardial infarction, respiratory failure, renal failure, bowel ischemia, major stroke, and paraplegia. Patients developing symptoms of SCI were evaluated by a neurologist to confirm the diagnosis and assign a grading. Spinal cord ischemia was reported as grade 1: resolution within 24 hours, grade 2: resolution within 1 month or minor permanent deficit, and grade 3: major permanent deficit.¹⁴ Risk factors for SCI were also analyzed and reported as mild (grade 1), moderate (grade 2), and severe (grade 3). Bleeding is reported according to SVS Reporting standards with grade 3 bleeding indicating need for ≥3 units homologous blood transfusions, laparotomy, thoracotomy, or necessitated exposure in addition to initial vessel cutdown to control bleeding.¹⁶

Statistical Analysis

Continuous data are reported as mean and standard deviation. Categorical data are expressed as frequency. Risk factors for SCI were determined by multivariable analysis. Independent variables were included in the multivariable analysis if they had a univariable p value <.05. Statistical analysis was performed by Wizard (Version 1.9.48; Apple, Cupertino, CA) on a MacBook Pro.

Results

A total of 596 patients with a complex aortic aneurysm received a F-/B-EVAR at 1 of 4 Italian institutions (240 in Bologna, 99 in Milan-San Raffaele, 106 in Florence, and 151 in Perugia). Among them, 351 (58.9%) patients were treated for TAAA (including extent I–IV and visceral aortic patch dilatation after previous thoracoabdominal open repair), and 245 were treated with a complex endovascular repair for juxtarenal (124 patients, 20.8%) and pararenal (121 patients, 20.3%) aneurysms.

Due to the rare occurrence of SCI symptoms in patients treated for juxtarenal and pararenal aneurysms in the literature and in this series (0/245, 0%), statistical analysis was performed only on the TAAA group.^4,17 The demographics, comorbidities, and risk factors of patients in TAAA group are summarized in Table 1.

Table 1.

Demographics, Preoperative Comorbidities, and Cardiovascular Risk Factors in the TAAA Group.

TAAA group: 351 patients	n	%
Male	276	78.6
Age
<70	98	27.9
70–79	199	56.7
>80	54	15.4
Body mass index >30	37	10.5
Hypertension	338	96.3
Smoke	253	72.1
Diabetes	89	25.4
Dyslipidemia	237	67.5
Chronic renal failure	122	34.8
Serum creatinine level <2.4 mg/dL	97	27.6
Serum creatinine level 2.5–5.9 mg/dL	18	5.1
Serum creatinine level ≥6.0 mg/dL/dialysis/transplant	7	2.0
Chronic obstructive pulmonary disease	213	60.7
Coronary artery disease	169	48.1
Peripheral arterial occlusive disease	192	54.7
American Society of Anesthesiologists score >2	331	94.3
Preoperative modified Tarlov scale
5	345	98.3
4	3	1.1
3	2	0.6
2	1	0.3
	Mean	SD
Age (years)	73	7
Creatinine (mg/dL)	1.4	1.2

Continuous data are presented as the means and standard deviation. Categorical data are given as the counts (%).

Abbreviation: SD, standard deviation; TAAA, thoracoabdominal aortic aneurysm

Among 351 patients included in the TAAA group, 283 (80.6%) were treated in elective setting and in 68 (19.4%) cases nonelective repair was needed due to diameter >80 mm (44 cases, 12.5%), symptoms (9 cases, 2.6%), and contained rupture (15 cases, 4.3%). Two hundred fifty-two patients (71.8%) were treated for degenerative aneurysms, 62 (17.7%) for false aneurysms after previous aortic surgery, and 37 (10.5%) for chronic aortic dissection. Thoracoabdominal aortic aneurysm extensions according to the Crawford’s classification, considering the proximal and the distal stent-graft sealing zones, are reported in Table 2. The employed stent-graft was an off-the-shelf 4 branches device (t-Branch, Cook Medical, Bloomington, IN) in 60 patients (17.1%), while a custom-made device was designed for the remaining 291 patients (82.9%). Regarding the design of the custom-made devices, 119 were fenestrated, 78 were branched, and 94 were a combination of both branches and fenestration. The celiac trunk, superior mesenteric artery, right renal artery, and left renal artery were, respectively, addressed with branches/fenestrations in 143/113, 132/147, 82/182, and 76/189 cases.

Table 2.

TAAA Extensions According to the Crawford’s TAAA Classification in the TAAA Group.

TAAA extension	N (%)
I	32 (9.1)
II	103 (29.3)
III	118 (33.6)
IV	88 (25.1)
Visceral aortic patch aneurysm after previous TAAA open repair	10 (2.9)

Data are given as the counts (%).

Abbreviation: TAAA, thoracoabdominal aortic aneurysm.

A previous open or endovascular procedure was performed in 201 (57.3%) patients, with 121 patients (34.5%) having isolated abdominal aortic repairs, 25 patients (7.1%) having thoracic or thoracoabdominal aortic repair, and 55 patients (15.7%) with both an abdominal and a thoracic or thoracoabdominal aortic repair. A LSA stenosis >75%, or occlusion, was identified in 8 patients (2.3%), and the incidence of at least 1 HA impairment (stenosis >75%, or occlusion) in 48 patients (13.7%). At least 1 thoracic endovascular component was implanted above the fenestrated/branched stent-graft in 215 (61.3%) patients, and in 247 (70.4%) at least 1 distal component to seal the aneurysm at the infrarenal aortic level or at the level of the iliac arteries was used.

No patent HA or LSA was covered without revascularization during endovascular TAAA exclusion. Moreover, 1 patient with LSA impairment received a preemptive LSA revascularization procedure (before F-/B-EVAR), and patients with HA impairment received 3 unilateral and 1 bilateral preemptive endovascular HA endovascular revascularizations during the thoracic or visceral step of TAAA exclusion.

According to the specific aortic center’s standard clinical practice and to the patients’ risk factors, 149 procedures (42.5%) were performed with a single-stage endovascular approach, while 202 (57.5%) patients were treated with a staged approach with ≥2 stages. In 181 (51.6%) patients, CSFD was placed before thoracic or visceral step. Cerebrospinal fluid drainage was also placed postoperatively in case of SC symptoms. During the visceral stage, a total of 54 complementary open procedures were performed including 26 common femoral artery repairs, 12 iliac conduits, 8 bypass grafts to lower limbs, 2 upper extremity access repairs, 4 supra-aortic trunks debranching procedures, and 2 visceral vessels retrograde revascularization procedures.

All patients completed the 30 day follow-up, and the mean follow-up was 25 ± 7 months. Overall, 28 (8.0%) patients died within 30 postoperative days or during the hospitalization. Thirty-day MAE and SCI after the endovascular procedures are reported in Table 3.

Table 3.

Thirty-Day Outcome After TAAA Endovascular Treatment.

Thirty-day outcomes in 351 patients with TAAA	N (%)
Number of MAEs of any severity
Not any	171 (48.7)
1	101 (28.8)
2	56 (16.0)
≥3	23 (6.6)
Spinal cord complications
Grade 0	304 (86.6)
Grade 1 (resolution within 24 hours)	12 (3.4)
Grade 2 (resolution within 1 month or minor permanent deficit, able to walk without support)	18 (5.1)
Grade 3 (major permanent deficit)	17 (4.8)

Results are reported according to the SVS reporting standards.¹⁴ Data are given as the counts (%).

Abbreviations: MAEs, major adverse events; SVS, Society for Vascular Surgery; TAAA, thoracoabdominal aortic aneurysm.

Regarding SCI, 47 (13.4%) patients developed neurological symptoms related to spinal cord impaired perfusion. Overall, 50 SCI events were observed in 47 patients, with 3 patients treated with a staged approach who developed SCI symptoms in 2 different stages. Among them, 1 patient treated with a 2 stages approach developed a grade 2 SCI after the thoracic stage and grade 3 SCI after the visceral stage; another patient treated with a 3 stages approach experienced grade 2 SCI during the thoracic stage and grade 1 SCI after the third stage; last, 1 patient treated with a 3 stages approach developed grade 1 SCI after both the thoracic and the visceral stages. In patients with more than 1 event, only the most severe one was reported. Among the 47 patients who developed SCI symptoms, 12 (3.4%) experienced grade 1 SCI, 18 (5.1%) patients developed grade 2 SCI, and 17 (4.8%) patients had a grade 3 SCI. The median onset of symptoms was 1 day (interquartile range=0–2 days, range 0–10 days): in 13 patients, symptoms were noticed on arousal from anesthesia or during the very early hours after surgery completion; in the other 34 patients, symptoms developed during the postoperative course (in 14 patients on postoperative day 1) after initial normal neurological functions. Among 15 patients treated for contained TAAA rupture, of which 5 died in-hospital without SCI, 2 experienced SCI and died in-hospital, and 1 survived with a major permanent deficit.

Univariable analysis identified significant associations between SCI and preoperative, intraoperative, and postoperative risk factors which are reported in Table 4. The multivariable analysis identified that SCI was associated with Crawford extent I to III (odds ratio [OR]=20.90, p=0.004, 95% confidence interval [CI]=2.69–162.57), and with endovascular procedures performed in a nonelective setting for contained ruptured TAAA (OR: 5.74, p=0.010, 95% CI=1.53–21.57). Spinal cord ischemia was also significantly associated with a grade 3 bleeding during visceral stage (OR: 4.34, p=0.005, 95% CI=1.55–12.16) and a grade 2 renal insufficiency (temporary dialysis, prolonged hospitalization, permanently-reduced function) at 30 days (OR: 7.45, p=0.002, 95% CI=2.12–26.18).

Table 4.

Univariable and Multivariable Analysis of SCI and Risk Factors.

Univariable analysis		Multivariable analysis
Risk factor	p	OR	95% CI	p
Female sex	0.011
Hyperlipidemia – grade 3	0.011
COPD – grade 2	0.008
Preoperative SC impairment (Tarlov <5)	0.023
ASA score
2	0.004
5	0.006
Crawford extent I to III	<0.001	20.90	2.69–162.57	0.004
Ruptured TAAA	0.002	5.74	1.53–21.57	0.010
Thoracic aortic diameter	0.044
Need of thoracic component	0.003
Open procedures during visceral stage	0.037
Bleeding visceral stage – grade 3	<0.001	4.34	1.55–12.16	0.005
Renal insufficiency at 30 days – grade 2	<0.001	7.45	2.12–26.18	0.002

Bold faced values were underlined to emphasize significance at multivariable analysis. All the other values were not significant at multivariable analysis.

Abbreviations: ASA, American Society of Anesthesiologists; CI, confidence interval; COPD, chronic obstructive pulmonary disease; OR, odds ratio; SCI, spinal cord ischemia; TAAA, thoracoabdominal aortic aneurysm.

Discussion

Since the early days of thoracic aortic surgery, it was clear that, in patients undergoing TAAA surgery, neurologic complications were common and severe. In Dr Crawford’s 1986 series of 605 TAAA, an 11% overall paraplegia rate was reported, with 28% in extent II aneurysms.¹⁸ Three decades later, in Dr Coselli’s 2016 series of 3309 patients, a cumulative incidence of 9.6% of spinal cord events was reported, with 13.9% in extent II TAAA.¹⁹ These results are, however, hardly reproducible in other centers.

Meanwhile, endovascular treatment was introduced and showed to be feasible in the thoracic endovascular aortic repair (TEVAR) as well as the abdominal (EVAR) aorta, with benefits over open surgery.²⁰ The early reports of TEVAR showed triumphantly-low rates of SCI; however, it was very soon clear that these results were influenced by the fact that the first thoracic stent-grafts only allowed the treatment of very limited (10–15 cm) mid aortic aneurysms. As it became technically possible to treat extensive thoracic and even TAAAs with endovascular means, SCI rates rapidly rose to rates similar to those of open surgery, with Eagleton reporting in 2016 a 16% SCI incidence for extent II TAAA treated endovascularly.⁵

Many lessons learned as well as a better patient selection, technological improvements in both the stent-grafts and the imaging, and new prevention protocols lead to a decrease in neurologic complications also in endovascular aortic repair; however, Oderich et al in 2021 still reported a 12% SCI rate in a series of 77 patients undergoing endovascular repair for extent II and III TAAA.²¹ Similar to the open surgery, these outstanding results are not reproduced by most other institutions performing these procedures.

The impact of TAAA extension on SCI rates has been well documented in the literature,^{4,19,22
–24} with a clear difference between Crawford extent IV and extent I to III confirmed at the multivariable analysis also in the present study (OR: 20.90, p=0.004). This independent correlation finds an anatomical explanation in the amount of sacrificed segmental arteries which in patients with extent I, II, or III include the entire descending thoracic aorta, to guarantee adequate proximal sealing. The low incidence of SCI in the extent IV cohort (1.1%) is in line with pooled data from meta-analysis reporting a 2% incidence for extent IV TAAA treated with open or endovascular repair, with a significantly (p=0.02) lower incidence of SCI in the F-/B-EVAR cohort. This must be put into perspective with previous anatomical studies reporting the extent of “sacrificed healthy aorta” during F-/B-EVAR procedures which, as opposed to open repair, excludes a higher number of segmental arteries in the proximal neck, particularly when an off-the-shelf device is employed (ie, t-Branch).²⁵ In the present study, extent IV endovascular treatment does not seem to affect SCI rates, and the same is true for the 236 juxtarenal and pararenal aneurysms treated endovascularly in the IMFB Registry, with a reported 0% incidence of SCI, demonstrating once more that it is a completely-different pathology even though it can be similarly treated with F-/B-EVAR techniques. This striking difference is missed in any study that pools together results on juxtarenal/pararenal and thoracoabdominal aneurysms.

Ruptured and symptomatic TAAAs are burdened by a higher rate of mortality and morbidity, including SCI, even when treated endovascularly, with pooled incidence ranging from 3% to 27% in different published series.^26
–28 Moreover, SCI incidence could be underestimated as early/intraoperative death acts as a competing factor which does not permit neurological evaluation. Several factors could possibly play a role in determining spinal cord damage: hypotension, low Hb levels, increased proximal aortic coverage due to the use of off-the-shelf devices, and decreased access to preoperative CSFD placement.

The presence of even mild hypotension was found to be associated with paraplegia in 2 matched cohorts of TAAA patients treated by open repair.²⁹ In an endovascular TAAA cohort, sustained hypotension (systolic blood pressure <90 mm Hg for >15 minutes) independently predicted SCI.³⁰ Blood loss could also lead to an impairment in SC perfusion, and transfusions are routinely employed to expand circulatory volume while maintaining Hb levels above 10 g/dL, as suggested by experiences from high-volume centers and in international surgical societies’ position papers.^31
–34 Moreover, sac thrombosis, particularly in large aneurysms, can contribute to reduce circulating Hb levels and platelet count due to consumption coagulopathy.³⁵ Volume repletion together with “permissive hypertension” with MAP above 80 mmHg is part of the multimodal approach to prevent SCI, with the use of vasoactive amines if necessary.^31,36

In a retrospective registry, it is difficult to retrieve the severity and duration of a hypotensive state to demonstrate its impact on SCI, and blood losses are also hard to estimate during percutaneous procedures. Severe bleeding could be a potential surrogate marker to address low Hb levels and relevant blood losses, and this finding is frequently associated with temporary hypotension.¹⁶ In the present study, SCI was independently associated with a grade 3 bleeding during the visceral stage of endovascular TAAA repair (OR: 4.34, p=0.005). This result suggests how blood losses is a risk factor for SCI and should be avoided in order to maintain hemodynamic stability and an adequate SC perfusion.

The onset of acute kidney injury (AKI) during the postoperative course was associated with an increased risk of SCI at multivariable analysis (OR=7.45; p=0.002). This finding confirms what has already been demonstrated for open TAAA repair by previously-published studies by Schepens et al and Coselli et al with ORs ranging from 1.61 to 10.^37,38 Preoperative renal insufficiency is also linked to AKI development and overall worse outcomes. Therefore, AKI prevention could possibly have positive influence on SCI prevention and must be a key aim in perioperative patient management. Although the association of AKI and SCI can be non-causative, being both possible consequences of low-flow states, hypotension itself could be determined by diuretics use or intermittent dialysis, employed to address AKI. In this scenario, AKI prevention by reducing contrast volume administration with the use of advanced imaging techniques and meticulous preoperative planning may be important.³⁹

Study limitations include the retrospective design, which can generate disparities in data gathering and interpretation across different centers with possible reporting biases. Moreover, the different policies on CSFD across the 4 institutions reduce the study power to determine its impact on SCI incidence and outcomes. Last, the 11 year timespan between the first and the last patient enrolled in the registry is an asset in the interest of a comprehensive description of a large cohort of patients encompassing each institution’s learning curve with B/FEVAR; however, the rapid development of stent-grafts, bridging components, and techniques can alter the interpretation of outcomes from the early and the late period.

Conclusion

This study reports a nationwide experience at 4 different academic vascular surgery centers in a “real-world” scenario. The results reported in this series underline that SCI is still an open issue in extent I to III TAAA endovascular repair, while is rare event after extent IV TAAA, and was never reported for juxtarenal and pararenal aneurysms. Extent I to III TAAA, urgent procedures for contained rupture, severe bleeding, and 30 day renal insufficiency have been identified as independent risk factors for SCI and they may be considered in order to better understand this dramatic complication. In particular, the presence of such factors would call for more liberal use of adjunctive strategies to reduce SCI rates, while in low-risk patients invasive or potentially-risky maneuvers (such as CSFD placement) might not be justified, but further focused researches are needed to ascertain this.

Footnotes

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr L. Bertoglio is consultant and proctor for Cook Medical. Prof. G. Faggioli is a proctor of Cook Medical. Dr E. Gallitto is a proctor of Cook Medical. Prof. M. Gargiulo is consultant and proctor for Cook Medical. Prof. G. Melissano is consultant for Cook Medical.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Enrico Rinaldi

Andrea Melloni

Enrico Gallitto

Aaron Fargion

Andrea Kahlberg

Luca Bertoglio

Gianluca Faggioli

References

Vaislic

Alsac

J-M

, et al. Economic impacts of treatment for type II or III thoracoabdominal aortic aneurysm in the United States. Res Cardiovasc Med. 2014;3(1):e9568. doi:10.5812/cardiovascmed.9568.

Conrad

Chung

, et al. Spinal cord complications after thoracic aortic surgery: long-term survival and functional status varies with deficit severity. J Vasc Surg. 2008;48(1):47–53. doi:10.1016/j.jvs.2008.02.047.

Rocha

Lindsay

Friedrich

, et al. Systematic review of contemporary outcomes of endovascular and open thoracoabdominal aortic aneurysm repair. J Vasc Surg. 2020;71(4):1396–1412e12. doi:10.1016/j.jvs.2019.06.216.

Gaudino

Khan

Rahouma

, et al. Spinal cord injury after open and endovascular repair of descending thoracic and thoracoabdominal aortic aneurysms: a meta-analysis. J Thorac Cardiovasc Surg. 2020:1–14. doi:10.1016/j.jtcvs.2020.04.126.

Eagleton

Follansbee

Wolski

, et al. Fenestrated and branched endovascular aneurysm repair outcomes for type II and III thoracoabdominal aortic aneurysms. J Vasc Surg. 2016;63(4):930–942. doi:10.1016/j.jvs.2015.10.095.

Gallitto

Faggioli

Melissano

, et al. Predictors of clinical outcome of fenestrated and branched endovascular repair of complex aortic aneurysms in a national multicenter registry. J Vasc Surg. 2021;74(6):1795–1806.e6. doi:10.1016/j.jvs.2021.04.072.

Chaikof

Dalman

Eskandari

, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 2018;67(1):2–77.e2. doi:10.1016/j.jvs.2017.10.044.

Fillinger

Greenberg

McKinsey

, et al. Reporting standards for thoracic endovascular aortic repair (TEVAR). J Vasc Surg. 2010;52(4):1022–331033. doi:10.1016/j.jvs.2010.07.008.

Greenberg

Eagleton

Mastracci

. Branched endografts for thoracoabdominal aneurysms. J Thorac Cardiovasc Surg. 2010;140(6 suppl.):S171–S178. doi:10.1016/j.jtcvs.2010.07.061.

10.

Bertoglio

Katsarou

Loschi

, et al. Elective multistaged endovascular repair of thoraco-abdominal aneurysms with fenestrated and branched endografts to mitigate spinal cord ischaemia. Eur J Vasc Endovasc Surg. 2019;59(4):565–576. doi:10.1016/j.ejvs.2019.10.003.

11.

Gallitto

Faggioli

Pini

, et al. Endovascular repair of thoraco-abdominal aortic aneurysms by fenestrated and branched endografts. Eur J Cardio-Thoracic Surg. 2019;56(5):993–1000. doi:10.1093/ejcts/ezz125.

12.

Verhoeven

ELG

Katsargyris

Bekkema

, et al. Editor’s choice—ten-year experience with endovascular repair of thoracoabdominal aortic aneurysms: results from 166 consecutive patients. Eur J Vasc Endovasc Surg. 2015;49(5):524–531. doi:10.1016/j.ejvs.2014.11.018.

13.

Melloni

Grandi

Melissano

, et al. Safety and feasibility of percutaneous purse-string-like downsizing for femoral access during complex endovascular aortic repair. Cardiovasc Intervent Radiol. 2020;43(7):1084–1090. doi:10.1007/s00270-020-02508-3.

14.

Group

Oderich

Forbes

, et al. Reporting standards for endovascular aortic repair of aneurysms involving the renal-mesenteric arteries. J Vasc Surg. 2021;73(1):4S–52S. doi:10.1016/j.jvs.2020.06.011.

15.

Bisdas

Panuccio

Sugimoto

, et al. Risk factors for spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms. J Vasc Surg. 2015;61(6):1408–1416. doi:10.1016/j.jvs.2015.01.044.

16.

Chaikof

Blankensteijn

Harris

, et al. Reporting standards for endovascular aortic aneurysm repair. J Vasc Surg. 2002;35(5):1048–1060. doi:10.1067/mva.2002.123763.

17.

Juszczak

Murray

Koutsoumpelis

, et al. Elective fenestrated and branched endovascular thoraco-abdominal aortic repair with supracoeliac sealing zones and without prophylactic cerebrospinal fluid drainage: early and medium-term outcomes. Eur J Vasc Endovasc Surg. 2019;57(5):639–648. doi:10.1016/j.ejvs.2018.12.012.

18.

Crawford

Safi

, et al. Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients. J Vasc Surg. 1986;3(3):389–404. doi:10.1067/mva.1986.avs0030389.

19.

Coselli

LeMaire

Preventza

, et al. Outcomes of 3309 thoracoabdominal aortic aneurysm repairs. J Thorac Cardiovasc Surg. 2016;151(5):1323–1337. doi:10.1016/j.jtcvs.2015.12.050.

20.

Cheng

Martin

Shennib

, et al. Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease: a systematic review and meta-analysis of comparative studies. J Am Coll Cardiol. 2010;55(10):986–1001. doi:10.1016/j.jacc.2009.11.047

21.

Tenorio

Ribeiro

Banga

, et al. Prospective assessment of a protocol using neuromonitoring, early limb reperfusion, and selective temporary aneurysm sac perfusion to prevent spinal cord injury during fenestrated-branched endovascular aortic repair. Ann Surg. 2021. doi:10.1097/sla.0000000000004624.

22.

Murana

Castrovinci

Kloppenburg

, et al. Open thoracoabdominal aortic aneurysm repair in the modern era: results from a 20-year single-centre experience. Eur J Cardiothorac Surg. 2016;49(5):1374–1381. doi:10.1093/ejcts/ezv415.

23.

Estrera

Sandhu

Charlton-Ouw

, et al. A quarter century of organ protection in open thoracoabdominal repair. Ann Surg. 2015;262(4):660–668. doi:10.1097/SLA.0000000000001432.

24.

Kasprzak

Gallis

Cucuruz

, et al. Editor’s choice—temporary aneurysm sac perfusion as an adjunct for prevention of spinal cord ischemia after branched endovascular repair of thoracoabdominal aneurysms. Eur J Vasc Endovasc Surg. 2014;48(3):258–265. doi:10.1016/j.ejvs.2014.05.020.

25.

Bertoglio

Cambiaghi

Ferrer

, et al. Comparison of sacrificed healthy aorta during thoracoabdominal aortic aneurysm repair using off-the-shelf endovascular branched devices and open surgery. J Vasc Surg. 2018;67(3):695–702. doi:10.1016/j.jvs.2017.08.052.

26.

Silingardi

Gennai

Leone

, et al. Standard “off-the-shelf” multibranched thoracoabdominal endograft in urgent and elective patients with single and staged procedures in a multicenter experience. J Vasc Surg. 2018;67(4):1005–1016. doi:10.1016/j.jvs.2017.08.068.

27.

Gallitto

Gargiulo

Freyrie

, et al. Off-the-shelf multibranched endograft for urgent endovascular repair of thoracoabdominal aortic aneurysms. J Vasc Surg. 2017;66(3):696–704. doi:10.1016/j.jvs.2016.12.129.

28.

Spanos

Kölbel

Theodorakopoulou

, et al. Early outcomes of the t-branch off-the-shelf multibranched stent-graft in urgent thoracoabdominal aortic aneurysm repair. J Endovasc Ther. 2018;25(1):31–39. doi:10.1177/1526602817747282.

29.

Etz

Luehr

Kari

, et al. Paraplegia after extensive thoracic and thoracoabdominal aortic aneurysm repair: does critical spinal cord ischemia occur postoperatively. J Thorac Cardiovasc Surg. 2008;135(2):324–330. doi:10.1016/j.jtcvs.2007.11.002.

30.

Sobel

Vartanian

Gasper

, et al. Lower extremity weakness after endovascular aneurysm repair with multibranched thoracoabdominal stent grafts. J Vasc Surg. 2015;61(3):623–628. doi:10.1016/j.jvs.2014.10.013.

31.

Oderich

Ribeiro

Reis de Souza

, et al. Endovascular repair of thoracoabdominal aortic aneurysms using fenestrated and branched endografts. J Thorac Cardiovasc Surg. 2017;153(2):S32–S41.e7. doi:10.1016/j.jtcvs.2016.10.008.

32.

Maurel

Delclaux

Sobocinski

, et al. Editor’s choice—the impact of early pelvic and lower limb reperfusion and attentive peri-operative management on the incidence of spinal cord ischemia during thoracoabdominal aortic aneurysm endovascular repair. Eur J Vasc Endovasc Surg. 2015;49(3):248–254. doi:10.1016/j.ejvs.2014.11.017.

33.

Melloni

Grandi

Spelta

, et al. Outcomes of routine use of percutaneous access with large-bore introducer sheaths (>21F outer diameter) during endovascular aneurysm repair. J Vasc Surg. 2021;73(1):81–91. doi:10.1016/j.jvs.2020.04.504.

34.

Etz

Weigang

Hartert

, et al. Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European association for cardio-thoracic surgery. Eur J Cardiothorac Surg. 2015;47(6):943–957. doi:10.1093/ejcts/ezv142.

35.

Kahlberg

Rinaldi

Tshomba

, et al. Volumetric analysis of aneurysm thrombosis after thoracic endovascular aortic repair predicts postoperative changes in platelet count and coagulation parameters. J Cardiovasc Surg (Torino). 2018;59(3):419–427. doi:10.23736/S0021-9509.16.09061-3.

36.

Melissano

Bertoglio

Mascia

, et al. Spinal cord ischemia is multifactorial: what is the best protocol. J Cardiovasc Surg (Torino). 2016;57(2):191–201.

37.

Schepens

Heijmen

Ranschaert

, et al. Thoracoabdominal aortic aneurysm repair: results of conventional open surgery. Eur J Vasc Endovasc Surg. 2009;37(6):640–645. doi:10.1016/j.ejvs.2009.03.011.

38.

Coselli

Amarasekara

Zhang

, et al. The impact of preoperative chronic kidney disease on outcomes after Crawford extent II thoracoabdominal aortic aneurysm repairs. J Thorac Cardiovasc Surg. 2018;156(6):2053–2064. doi:10.1016/j.jtcvs.2018.05.101.

39.

Loschi

Melloni

Kahlberg

, et al. Kidney protection in thoracoabdominal aortic aneurysm surgery. J Cardiovasc Surg (Torino). 2021;62(4):326–338. doi:10.23736/S0021-9509.20.11745-2.