To describe a direct anatomical treatment approach using an induced type Ib endoleak to increase spinal cord perfusion and reverse paraplegia occurring after endovascular exclusion of a type 2 thoracoabdominal aortic aneurysm (TAAA).
Technique:
The approach is illustrated in an 82-year-old woman who underwent branched endovascular repair of an asymptomatic, 6.8-cm-diameter type 2 TAAA. In 4-hour procedure, 3 aortic components were implanted beginning 50 mm distal to the origin of the left subclavian artery and ending 33 mm proximal to the aortic bifurcation. Upon awakening, the patient had sluggish movement in her legs. She responded to vasoactive agents and cerebrospinal fluid (CSF) drainage, but 3 recurrent episodes of paraplegia within 24 hours and severe headache indicated that the limits of CSF drainage had been reached. The patient was taken back to the operating room, and a type Ib (distal) endoleak was created by placing a balloon-expandable stent between the distal end of the infrarenal stent-graft component and the aortic wall, partially re-establishing flow into the aneurysm. The patient had no further recurrence of lower extremity paraplegia or paraparesis. At 3.5 months postoperatively, a Palmaz stent was deployed inside the distal end of the infrarenal stent-graft component to crush and occlude the Express LD stent, re-establishing a complete seal to preclude flow into the aneurysm. The patient remains clinically stable without lower extremity neurological deficit 3 months after the last procedure and 7 months after endovascular TAAA repair.
Conclusion:
A direct anatomical approach to reverse spinal cord ischemia following endovascular TAA or TAAA repair is feasible by creating a type I or type III endoleak to afford partial, temporary reperfusion of the excluded aorta.
AcherCWWynnM.A modern theory of paraplegia in the treatment of aneurysms of the thoracoabdominal aorta: An analysis of technique specific observed/expected ratios for paralysis. J Vasc Surg. 2009;49:1117–1124.
2.
SafiHJEstreraALMillerCC. Evolution of risk for neurological deficit after descending and thoracoabdominal aortic repair. Ann Thorac Surg. 2005;80:2173–2179.
3.
SchepensMDosscheKMorshuisW. Introduction of adjuncts and their influence on changing results in 402 consecutive thoracoabdominal aortic aneurysm repairs. Eur J Cardiothorac Surg. 2004;25:701–707.
4.
ChiesaRMelissanoGCiviliniE. Ten years experience of thoracic and thoracoabdominal aortic aneurysm surgical repair: Lessons learned. Ann Vasc Surg. 2004;18:514–520.
5.
CowanJADimickJBHenkePK. Surgical treatment of intact thoracoabdominal aortic aneurysms in the United States: Hospital and surgeon volume-related outcomes. J Vasc Surg. 2003;37:1169–1174.
6.
AmabilePGrisoliDGiorgiR. Incidence and determinants of spinal cord ischaemia in stent-graft repair of the thoracic aorta. Eur J Vasc Endovasc Surg. 2008;35:455–461.
7.
ButhJHarrisPLHoboR. Neurologic complications associated with endovascular repair of thoracic aortic pathology: Incidence and risk factors. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) Registry. J Vasc Surg. 2007;46:1103–1111.e2.
8.
HnathJCMehtaMTaggertJB. Strategies to improve spinal cord ischemia in endovascular thoracic aortic repair: Outcomes of a prospective cerebrospinal fluid drainage protocol. J Vasc Surg. 2008;48:836–840.
9.
SchlösserFJVerhagenHJLinPH. TEVAR following prior abdominal aortic aneurysm surgery: Increased risk of neurological deficit. J Vasc Surg. 2009;49:308–314.
10.
GreenbergRKReschTNymanU. Endovascular repair of descending thoracic aortic aneurysms: An early experience with intermediate-term follow-up. J Vasc Surg. 2000;31:147–156.
11.
FattoriRNienaberCARousseauH. Results of endovascular repair of the thoracic aorta with the Talent Thoracic stent graft: The Talent Thoracic Retrospective Registry. J Thorac Cardiovasc Surg. 2006;132:332–339.
12.
GreenbergRKLuQRoselliEE. Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: A Comparison of endovascular and open techniques. Circulation. 2008;118:808–817.
OrendKHScharrer-PamlerRKapferX. Endovascular treatment in diseases of the descending thoracic aorta: 6-year results of a single center. J Vasc Surg. 2003;37:91–99.
CheungATPochettinoAMcGarveyML. Strategies to manage paraplegia risk after endovascular stent repair of descending thoracic aortic aneurysms. Ann Thorac Surg. 2005;80:1280–1289.
24.
ChiesaRMelissanoGMarrocco-TrischittaMM. Spinal cord ischemia after elective stent-graft repair of the thoracic aorta. J Vasc Surg. 2005;42:11–17.
25.
GladeGJVahlACWisselinkW. Mid-term survival and costs of treatment of patients with descending thoracic aortic aneurysms: Endovascular vs open repair: A Case-control study. Eur J Vasc Endovasc Surg. 2005;29:28–34.
26.
KawaharadaNMorishitaKKurimotoY. Spinal cord ischemia after elective endovascular stent-graft repair of the thoracic aorta. Eur J Cardiothorac Surg. 2007;31:998–1003.
27.
KhoynezhadADonayreCEBuiH. Risk factors of neurologic deficit after thoracic aortic endografting. Ann Thorac Surg. 2007;83:S882–889.
28.
MoralesJPTaylorPRBellRE. Neurological complications following endoluminal repair of thoracic aortic disease. Cardiovasc Intervent Radiol. 2007;30:933–939.
29.
BarilDTCarroccioAEllozySH. Endovascular thoracic aortic repair and previous or concomitant abdominal aortic repair: Is the increased risk of spinal cord ischemia real?Ann Vasc Surg. 2006;20:188–194.
30.
MakarounMSDillavouEDKeeST. Endovascular treatment of thoracic aortic aneurysms: Results of the phase II multicenter trial of the GORE TAG thoracic prosthesis. J Vasc Surg.2005;41:1–9.
31.
HansenCJBuiHDonayreCE. Complications of endovascular repair of high-risk and emergent descending thoracic aortic aneurysms and dissectionsJ Vasc Surg. 2004;40:228–234.
32.
NajibiSTerramaniTTWeissVJ. Endoluminal versus open treatment of descending thoracic aortic aneurysms. J Vasc Surg. 2002;36:732–737.
33.
SandroussiCWalthamMHughesCF. Endovascular grafting of the thoracic aorta, an evolving therapy: 10-year experience in a single centre. ANZ J Surg. 2007;77:974–980.
34.
ChangCKChuterTAReillyLM. Spinal arterial anatomy and risk factors for lower extremity weakness following endovascular thoracoabdominal aortic aneurysm repair with branched stent-grafts. J Endovasc Ther. 2008;15:356–362.
35.
WeigangEHartertMSiegenthalerMP. Perioperative management to improve neurological outcome in thoracic or thoracoabdominal aortic stent-grafting. Ann Thorac Surg. 2006;82:1679–1687.
36.
CarroccioAMarinMLEllozyS. Pathophysiology of paraplegia following endovascular thoracic aortic aneurysm repair. J Card Surg. 2003;18:359–366.
37.
FeezorRJMartinTDHessPJ. Extent of aortic coverage and incidence of spinal cord ischemia after thoracic endovascular aneurysm repair. Ann Thorac Surg. 2008;86:1809–1814.
38.
EstreraALMillerCCHuynhTT. Neurological outcome after thoracic and thoracoabdominal aortic aneurysm repair. Ann Thorac Surg. 2001;72:1225–1231.
39.
EstreraALMillerCCHuynhTT. Preoperative and operative predictors of delayed neurological deficit following repair of thoracoabdominal aortic aneurysm. J Thorac Cardiovasc Surg. 2003;126:1288–1295.
40.
ConradMFCrawfordRSDavisonJKCambriaRP. Thoracoabdominal aneurysm repair: A 20-year perspective. Ann Thorac Surg. 2007;83:S856–861.
41.
CambriaRPClouseWDDavisonJK. Thoracoabdominal aneurysm repair: Results with 337 operations performed over a 15-year interval. Ann Surg. 2002;236:471–479.
42.
CoselliJSBozinovskiJLeMaireSA. Open surgical repair of 2286 thoracoabdominal aortic aneurysms. Ann Thorac Surg. 2007;83:S862–864.
43.
CoselliJSLeMaireSAConklinLD. Morbidity and mortality after extent II thoracoabdominal aortic aneurysm repair. Ann Thorac Surg. 2002;73:1107–1116.
44.
KawanishiYOkadaKMatsumoriM. Influence of perioperative hemodynamics on spinal cord ischemia in thoracoabdominal aortic repair. Ann Thorac Surg. 2007;84:488–492.
45.
ChuterTAGordonRLReillyLM. An endovascular system for thoracoabdominal aortic aneurysm repair. J Endovasc Ther. 2001;8:25–33.
SafiHJMillerCCHuynhTT. Distal aortic perfusion and cerebrospinal fluid drainage for thoracoabdominal and descending thoracic aortic repair. Ann Surg. 2003;238:372–381.
48.
CoselliJSConklinLDLeMaireSA. Thoracoabdominal aortic aneurysm repair: Review and update of current strategies. Ann Thorac Surg. 2002;74:S1881–1884.
49.
CoselliJSLemaireSAKoksoyC. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: Results of a randomized clinical trial. J Vasc Surg. 2002;35:631–639.
50.
SvenssonLGHessKRD'AgostinoRS. Reduction of neurological injury after high-risk thoracoabdominal aortic operation. Ann Thorac Surg. 1998;66:132–138.
51.
AllenBTDavisCGOsborneD. Spinal cord ischemia and reperfusion metabolism: The effect of hypothermia. J Vasc Surg. 1994;19:332–329.
52.
LimKHConnollyMRoseD. Prevention of reperfusion injury of the ischemic spinal cord: Use of recombinant superoxide dismutase. Ann Thorac Surg. 1986;42:282–286.
53.
WuGJChenWFSungCS. Preventive effects of intrathecal methylprednisolone administration on spinal cord ischemia in rats: The role of excitatory amino acid metabolizing systems. Neuroscience. 2007;147:294–303.
54.
NylanderWAPlunkettRJHammonJW. Thiopental modification of ischemic spinal cord injury in the dog. Ann Thorac Surg. 1982;33:64–68.
55.
MichenfelderJDMildeJH. The relationship among canine brain temperature, metabolism, and function during hypothermia. Anesthesiology. 1991;75:130–136.
56.
LaschingerJCCunninghamJNCooperMM. Prevention of ischemic spinal cord injury following aortic cross-clamping: Use of corticosteroids. Ann Thorc Surg. 1984;38:500–507.
57.
RokkasCKCroninCSNittaT. Profound systemic hypothermia inhibits the release of neurotransmitter amino acids in spinal cord ischemia. J Thorac Cardiovasc Surg. 1995;110:27–35.
58.
KuniharaTMatsuzakiKShiiyaN. Naloxone lowers cerebrospinal fluid levels of excitatory amino acids after thoracoabdominal aortic surgery. J Vasc Surg. 2004;40:681–690.
59.
MarcheixBDambrinCBolducJP. Midterm results of endovascular treatment of atherosclerotic aneurysms of the descending thoracic aorta. J Thorac Cardiovasc Surg. 2006;132:1030–1036.
60.
BavariaJEAppooJJMakaroundMS. Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low-risk patients: A Multicenter comparative trial. J Thorac Cardiovasc Surg. 2007;133:369–377.
61.
SchepensMAHeijmenRHRanschaertW. Thoracoabdominal aortic aneurysm repair: Results of conventional open surgery. Eur J Vasc Endovasc Surg. 2009;37:640–645.
