Mechanisms of Symptomatic Spinal Cord Ischemia After TEVAR: Insights From the European Registry of Endovascular Aortic Repair Complications (EuREC)

Abstract

Purpose

To test the hypothesis that simultaneous closure of at least 2 independent vascular territories supplying the spinal cord and/or prolonged hypotension may be associated with symptomatic spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR).

Methods

A pattern matching algorithm was used to develop a risk model for symptomatic SCI using a prospective 63-patient single-center cohort to test the positive predictive value (PPV) of prolonged intraoperative hypotension and/or simultaneous closure of at least 2 of 4 the vascular territories supplying the spinal cord (left subclavian, intercostal, lumbar, and hypogastric arteries). This risk model was then applied to data extracted from the multicenter European Registry on Endovascular Aortic Repair Complications (EuREC). Between 2002 and 2010, the 19 centers participating in EuREC reported 38 (1.7%) cases of symptomatic spinal cord ischemia among the 2235 patients in the database.

Results

In the single-center cohort, direct correlations were seen between the occurrence of symptomatic SCI and both prolonged intraoperative hypotension (PPV 1.00, 95% CI 0.22 to 1.00, p=0.04) and simultaneous closure of at least 2 independent spinal cord vascular territories (PPV 0.67, 95% CI 0.24 to 0.91, p=0.005). Previous closure of a single vascular territory was not associated with an increased risk of symptomatic spinal cord ischemia (PPV 0.07, 95% CI 0.01 to 0.16, p=0.56). The combination of prolonged hypotension and simultaneous closure of at least 2 territories exhibited the strongest association (PPV 0.75, 95% CI 0.38 to 0.75, p<0.0001). Applying the model to the entire EuREC cohort found an almost perfect agreement between the predicted and observed risk factors (kappa 0.77, 95% CI 0.65 to 0.90).

Conclusion

Extensive coverage of intercostal arteries alone by a thoracic stent-graft is not associated with symptomatic SCI; however, simultaneous closure of at least 2 vascular territories supplying the spinal cord is highly relevant, especially in combination with prolonged intraoperative hypotension. As such, these results further emphasize the need to preserve the left subclavian artery during TEVAR.

Keywords

thoracic aorta stent-graft thoracic endovascular aortic repair complication spinal cord ischemia paraplegia paraparesis hypotension hypoperfusion intercostal arteries left subclavian artery risk model

Get full access to this article

View all access options for this article.

References

Eggebrecht

Thompson

Rousseau

Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European registry on endovascular aortic repair complications.

Circulation. 2009;12011 Suppl:S276–281

Matsuda

Fukuda

Iritani

Spinal cord injury is not negligible after TEVAR for lower descending aorta.

Eur J Vasc Endovasc Surg. 2010;39:179–186

Chiesa

Melissano

Marone

Endovascular treatment of aortoesophageal and aortobronchial fistulae.

J Vasc Surg. 2010;51:1195–1202

Czerny

Zimpfer

Fleck

Successful treatment of an aortoesophageal fistula after emergency endovascular thoracic aortic stent-graft placement.

Ann Thorac Surg. 2005;80:1117–1120

Gottardi

Dumfarth

Holfeld

Symptomatic spinal cord malperfusion after stent-graft coverage of the entire descending aorta.

Eur J Cardiothorac Surg. 2010;37:1081–1085

Griepp

EB.

Spinal cord perfusion and protection during descending thoracic and thoracoabdominal aortic surgery: the collateral network concept.

Ann Thorac Surg. 2007;83:S865–869

Buth

Harris

Hobo

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

Reichenheim

ME.

Confidence intervals for the kappa statistic.

The Stata Journal. 2004;4:421–428

Landis

Koch

GG.

The measurement of observer agreement for categorical data.

Biometrics. 1977;33:159–174

10.

Czerny

Funovics

Sodeck

Longterm results of thoracic endovascular aortic repair in atherosclerotic aneurysms involving the descending aorta.

J Thorac Cardiovasc Surg. 2010;1406 Suppl:S179–184

11.

Eggebrecht

Nienaber

Neuhauser

Endovascular stent-graft placement in aortic dissection: a meta-analysis.

Eur Heart J. 2006;27:489–498

12.

Gottardi

Funovics

Eggers

Supra-aortic transposition for combined vascular and endovascular repair of aortic arch pathology.

Ann Thorac Surg. 2008;86:1524–1529

13.

Adamkiewicz

AA.

Die Blutgefässe des menschlichen Rückenmarkes. II. Die Gefässe der Rückenmarksoberfläche.

Sitzungsberichte der Kaiserlichen Akademie der Wissenschaften. Mathematisch-Naturwissenschaftliche Classe. 1882;85:101–130

14.

Wadouh

Lindemann

Arndt

The arteria radicularis magna anterior as a decisive factor influencing spinal cord damage during aortic occlusion.

J Thorac Cardiovasc Surg. 1984;88:1–10

15.

Etz

Homann

Plestis

Spinal cord perfusion after extensive segmental artery sacrifice: can paraplegia be prevented?

Eur J Cardiothorac Surg. 2007;31:643–648

16.

Fleck

Hutschala

Weissl

Cerebrospinal fluid drainage as a useful treatment option to relieve paraplegia after stent-graft implantation for acute aortic dissection type B.

J Thorac Cardiovasc Surg. 2002;123:1003–1005

17.

Schepens

Dossche

Morshuis

Introduction of adjuncts and their influence on changing results in 402 consecutive thoracoabdominal aortic aneurysm repairs.

Eur J Cardiothorac Surg. 2004;25:701–707