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Background: Spinal cord ischemia (SCI) is a serious complication that can occur at the onset of aortic aneurysm (AA) or after AA surgery. SCI impairs ambulation in patients. However, there is a lack of evidence regarding ambulatory status and its associated factors., Objectives: To identify the ambulatory status of patients with SCI due to AA and/or AA surgery and sociodemographic and clinical characteristics factors associated with ambulatory status., Methods: A descriptive study using a retrospective medical record data was undertaken. Data were collected from the electronic health records of SCI patients resulting from AA or who underwent surgical intervention for AA from January 2009 through December 2021. We analyzed the data to determine the ambulatory status before discharge. The demographic and clinical characteristics of the patients were investigated using chi-square and Fisher's exact tests to identify factors associated with ambulatory status., Results: Among the 4,142 patients diagnosed with AA, 30 developed SCI. Of these 30 AA patients with SCI, 63.3 % were male. The median age was 70 years, ranging from 39 to 89 years. Six had SCI at the time of AA diagnosis. Among the subset of 2,994 patients who underwent aortic surgery, 24 developed SCI postoperatively. At discharge, two-thirds of the SCI patients with AA were unable to ambulate, and almost half were bedridden. The factors associated with ambulatory status were length of stay, neurogenic bladder, and pressure ulcers., Conclusions: Most patients with SCI due to AA and/or AA surgery are unable to walk before discharge. Length of stay, neurogenic bladder, and pressure ulcers were associated with poor ambulatory status. Older adults and those with medical comorbidities and complications are at particularly high risk for impaired ambulation., Competing Interests: Declaration of competing interest None., (Copyright © 2024. Published by Elsevier Inc.)

Objective: Paraplegia remains one of the major complications of contemporary open thoracoabdominal aortic aneurysm (TAAA) repair. Intraoperative motor-evoked potentials (MEPs) act as a surrogate measure for spinal cord homeostasis. The purpose of this study was to evaluate the results of intraoperative neuromonitoring in contemporary TAAA repair and its association with postoperative spinal cord ischemia (SCI)., Methods: Patients who underwent open type 2 or 3 TAAA or completion aortic repair using intraoperative neuromonitoring were identified between May 2006 and November 2023. Patient demographics, comorbidities, indication for the procedure, procedural details, and outcomes were recorded. The groups were divided based on type of repair, and univariate statistics were then used to evaluate the association of these metrics vs the type of repair., Results: Seventy-nine patients underwent open type 2 (N = 41) and 3 (N = 23) TAAA and completion aortic (N = 15; open in 14 and endovascular in 1) repairs by a single surgeon. The cohort was predominantly male (N = 48, 60.8%) with a mean age of 52.5 ± 16.2 years. There was a high incidence of hypertension (N = 53, 67.1%), smoking history (N = 42, 53.1%), and connective tissue disorders (N = 37, 46.8%). Operative indications included dissection-related (N = 50, 63.3%) and degenerative (N = 26, 32.9%) TAAA and dissection-related malperfusion (N = 3, 3.8%). Left heart bypass was often (N = 73, 92.4%) used for distal aortic perfusion, and cerebrospinal fluid drainage (N = 77, 97.5%) was a common adjunct. MEPs were classified as no change (N = 43, 54.4%), reversible change (N = 26, 32.9%), irreversible change (N = 4, 5.1%), and unreliable (N = 6, 7.6%). MEP changes were predominantly bilateral (N = 70, 88.6%) and occurred most often during repair of the abdominal aortic segment (N = 13, 16.5%). The median number of replaced vertebral levels was associated with MEP changes (P = .013). SCI was only observed in repairs greater than 6 replaced vertebral levels with an overall frequency of 17.7%. It was most prevalent in completion aortic repairs (26.7%). Immediate and delayed SCI occurred in 10.1% and 7.6% of patients, respectively; it was most commonly (71.8%) reversible. Permanent paraplegia occurred in four patients (5.1%), with equal immediate and delayed onsets. MEPs demonstrated poor sensitivity (53.9%) and specificity (62.3%) for SCI; however, there was a high negative predictive value (86.4%) in this population. In-hospital mortality occurred in five (6.3%) patients., Conclusions: No changes in intraoperative MEPs are highly predictive of spinal cord homeostasis. The number of replaced vertebral levels and previous aortic repair should guide intraoperative neuroprotective measures including intercostal reimplantation and should take precedence over intraoperative monitoring, especially when MEP changes occur., Competing Interests: Disclosures None., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) can cause permanent neurologic deficits and poor long-term survival. Targeted treatment of new SCI symptoms after TEVAR (rescue therapy [RT]) might improve/resolve neurologic symptoms but few data characterize the association of specific interventions with SCI outcomes. We evaluated the effectiveness of post-TEVAR RT at our tertiary aortic center., Methods: Our institutional TEVAR database was reviewed for SCI incidence and details of RT. This included cerebrospinal fluid drainage (CSFD), medical therapy, and optimization of spinal cord oxygen delivery. SCI outcomes were categorized at discharge as paralysis/paraparesis and temporary/permanent., Results: Nine hundred forty-three TEVAR procedures were performed in 869 patients from 2011 to 2020. Post-TEVAR SCI occurred in 7.8% (n = 74) with permanent paraplegia in 1.5%. Older patient age, chronic obstructive pulmonary disease, and previous abdominal aortic surgery were predictive of SCI. Half (n = 37) of SCI episodes resulted in only temporary paralysis/paraparesis. Rescue postoperative cerebrospinal fluid drains were implanted in 3.7% (n = 35) of procedures and was predicted by higher American Society of Anesthesiologists class, lower serum hemoglobin level, elevated international normalized ratio, bilateral iliac artery occlusion, nonelective procedures, and penetrating atherosclerotic ulcer/intramural hematoma indication. The most commonly used RTs were emergent placement of or increased drainage from an existing cerebrospinal fluid drain (87.8%), induced/permissive hypertension (77.0%), corticosteroid bolus (36.5%), and naloxone infusion (33.8%). Neurologic improvement occurred in 68.9% (n = 51/74). New/increased drainage was associated with improved SCI outcome., Conclusions: Permanent paraplegia from post-TEVAR SCI is rare (1.5%). Older patients with comorbidities carry greater post-TEVAR SCI risk. SCI symptoms improved/resolved with CSFD and multimodal RT in 68.9% of patients, but no intervention was independently associated with improvement. TEVAR centers should have robust protocols for timely and safe CSFD placement to augment RT strategies for SCI., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Venous thromboembolism (VTE) incidence after thoracic and fenestrated endovascular aortic repair (TEVAR/FEVAR) is high (up to 6-7%) relative to other vascular procedures; however, the etiology for this discrepancy remains unknown. Notably, patients undergoing TEVAR/FEVAR commonly receive cerebrospinal fluid drains (CSFDs) for neuroprotection, requiring interruption of perioperative anticoagulation and prolonged immobility. We hypothesized that CSFDs are a risk factor for VTE after TEVAR/FEVAR., Methods: Consecutive TEVAR/FEVAR patients at a single center were reviewed (2011-2020). Cerebrospinal fluid drains (CSFDs) were placed based on surgeon preference preoperatively or for spinal cord ischemia (SCI) rescue therapy postoperatively. The primary end-point was VTE occurrence, defined as any new deep venous thrombosis (DVT) or pulmonary embolism (PE) confirmed on imaging within 30 days postoperatively. Routine postoperative VTE screening was not performed. Patients with and without VTE, and subjects with and without CSFDs were compared. Logistic regression was used to explore associations between VTE incidence and CSFD exposure., Results: Eight hundred ninety-seven patients underwent TEVAR/FEVAR and 43% (n = 387) received a CSFD at some point during their care (preoperative: 94% [n = 365/387]; postoperative SCI rescue therapy: 6% [n = 22/387]). CSFD patients were more likely to have previous aortic surgery (44% vs. 37%; P = 0.028) and received more postoperative blood products (780 vs. 405 mL; P = 0.005). The overall VTE incidence was 2.2% (n = 20). 70% (14) patients with VTE had DVT, 50% (10) had PE, and 20% (4) had DVT and PE. Among TEVAR/FEVAR patients with VTE, 65% (n = 13) were symptomatic. Most VTEs (90%, n = 18) were identified inhospital and the median time to diagnosis was 12.5 (interquartile range 7.5-18) days postoperatively. Patients with VTE were more likely to have nonelective surgery (95% vs. 41%; P < 0.001), had higher American Society of Anesthesiologists classification (4.1 vs. 3.7; P < 0.001), required longer intensive care unit admission (24 vs. 12 days; P < 0.001), and received more blood products (1,386 vs. 559 mL; P < 0.001). Venous thromboembolism (VTE) incidence was 1.8% in CSFD patients compared to 3.5% in non-CSFD patients (odds ratio 0.70 [95% confidence interval 0.28-1.78, P = 0.300). However, patients receiving CSFDs postoperatively for SCI rescue therapy had significantly greater VTE incidence (9.1% vs. 1.1%; P = 0.044)., Conclusions: CSFD placement was not associated with an increased risk of VTE in patients undergoing TEVAR/FEVAR. Venous thromboembolism (VTE) risk was greater in patients undergoing nonelective surgery and those with complicated perioperative courses. Venous thromboembolism (VTE) risk was greater in patients receiving therapeutic CSFDs compared to prophylactic CSFDs, highlighting the importance of careful patient selection for prophylactic CSFD placement., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: Thoracic endovascular aortic repair is the method of choice in patients with complicated type B acute aortic dissection. However, thoracic endovascular aortic repair carries a risk of periprocedural neurological events including stroke and spinal cord ischemia. We aimed to look at procedure-related neurological complications within a large cohort of patients with type B acute aortic dissection treated by thoracic endovascular aortic repair., Methods: Between 1996 and 2021, the International Registry of Acute Aortic Dissection collected data on 3783 patients with type B acute aortic dissection. For this analysis, 648 patients with type B acute aortic dissection treated by thoracic endovascular aortic repair were included (69.4% male, mean age 62.7 ± 13.4 years). Patients were excluded who presented with a preexisting neurologic deficit or received adjunctive procedures. Demographics, clinical symptoms, and outcomes were analyzed. The primary end point was the periprocedural incidence of neurological events (defined as stroke, spinal cord ischemia, transient neurological deficit, or coma). Predictors for perioperative neurological events and follow-up outcomes were considered as secondary end points., Results: Periprocedure neurological events were noted in 72 patients (11.1%) and included strokes (n = 29, 4.6%), spinal cord ischemias (n = 21, 3.3%), transient neurological deficits (n = 16, 2.6%), or coma (n = 6, 1.0%). The group with neurological events had a significantly higher in-hospital mortality (20.8% vs 4.3%, P < .001). Patients with neurological events were more likely to be female (40.3% vs 29.3%, P = .077), and aortic rupture was more often cited as an indication for thoracic endovascular aortic repair (38.8% vs 16.5%, P < .001). In patients with neurological events, more stent grafts were used (2 vs 1 stent graft, P = .002). Multivariable logistic regression analysis showed that aortic rupture (odds ratio, 3.12, 95% confidence interval, 1.44-6.78, P = .004) and female sex (odds ratio, 1.984, 95% confidence interval, 1.031-3.817, P = .040) were significantly associated with perioperative neurological events., Conclusions: In this highly selected group from dedicated aortic centers, more than 1 in 10 patients with type B acute aortic dissection treated by thoracic endovascular aortic repair had neurological events, in particular women. Further research is needed to identify the causes and presentation of these events after thoracic endovascular aortic repair, especially among women., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to investigate whether prophylactic use of cerebrospinal fluid (CSF) drainage in endovascular descending thoracic aortic aneurysm (DTAA) and thoraco-abdominal aortic aneurysm (TAAA) repair contributes to a lower rate of post-operative spinal cord ischaemia (SCI)., Data Sources: MEDLINE, Embase, and CINAHL., Review Methods: A literature review was conducted in accordance with PRISMA guidelines (PROSPERO registration no. CRD42021245893). Risk of bias was assessed through the Newcastle-Ottawa scale (NOS), and the certainty of evidence was graded using the GRADE approach. A proportion meta-analysis was conducted to calculate the pooled rate and 95% confidence interval (CI) of both early and late onset SCI. Pooled outcome estimates were calculated using the odds ratio (OR) and associated 95% CI. The primary outcome was SCI, both early and lateonset. Secondary outcomes were complications of CSF drainage, length of hospital stay, and peri-operative (30 day or in hospital) mortality rates., Results: Twenty-eight observational, retrospective studies were included, reporting 4 814 patients (2 599 patients with and 2 215 without CSF drainage). The NOS showed a moderate risk of bias. The incidence of SCI was similar in patients with CSF drainage (0.05, 95% CI 0.03 ‒ 0.08) and without CSF drainage (0.05, 95% CI 0.00 ‒ 0.14). No significant decrease in SCI was found when using CSF drainage (OR 0.67, 95% CI 0.29 ‒ 1.55, p = .35). The incidence rate of CSF drainage related complication was 0.10 (95% CI 0.04 ‒ 0.19). The 30 day and in hospital mortality rate with CSF drainage was 0.08 (95% CI 0.05 ‒ 0.12). The 30 day and in hospital mortality rate without CSF drainage and comparison with late mortality and length of hospital stay could not be determined due to lack of data. The quality of evidence was considered very low., Conclusion: Pre-operative CSF drainage placement was not related to a favourable outcome regarding SCI rate in endovascular TAAA and DTAA repair. Due to the low quality of evidence, no clear recommendation on pre-operative use of CSF drainage placement can be made., (Copyright © 2023 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: Staged endovascular repair of complex aortic aneurysms with first-stage thoracic endovascular aortic repair may decrease the risk of spinal cord ischemia (SCI) associated with fenestrated-branched endovascular aortic repair (FB-EVAR) of thoracoabdominal aortic aneurysms or optimize the proximal landing zone in the cases requiring total aortic arch repair. However, a limitation of multistaged procedures is the risk of interval aortic events (IAEs) including mortality from a ruptured aneurysm. We aim to identify the incidence of and risk factors associated with IAEs during staged FB-EVAR., Methods: This was a single-center, retrospective review of patients who underwent planned staged FB-EVAR from 2013 to 2021. Clinical and procedural details were reviewed. End points were the incidence of and risk factors associated with IAEs (defined as rupture, symptoms, and unexplained death) and outcomes in patients with or without IAEs., Results: Of 591 planned FB-EVAR patients, 142 underwent first-stage repairs. Twenty-two did not have a planned second stage because of frailty, preference, severe comorbidities, or complications after the first stage and were excluded. The remaining 120 patients (mean age: 73 ± 6 years, 51% female) were planned for second-stage completion FB-EVAR and comprised our cohort. The incidence of IAEs was 13% (16 of 120). This included confirmed rupture in 6 patients, possible rupture in 4, symptomatic presentation in 4, and early unexplained interval death with possible rupture in 2. The median time to IAEs was 17 days (range: 2-101 days), and the median time to uncomplicated completion repairs was 82 days (interquartile range: 30-147 days). Age, sex, and comorbidities were similar between the groups. There were no differences in familial aortic disease, genetically triggered aneurysms, aneurysm extent, or presence of chronic dissection. Patients with IAEs had significantly larger aneurysm diameters than those without IAEs (76.6 vs 66.5 mm, P ≤ .001). This difference persisted with indexing for body surface area (aortic size index: 3.9 vs 3.5 cm/m 2 , P = .04) and height (aortic height index: 4.5 vs 3.9 cm/m, P ≤ .001). IAE mortality was 69% (11 of 16) compared with no perioperative deaths for those with uncomplicated completion repairs., Conclusions: The incidence of IAEs was 13% in patients planned for staged FB-EVAR. This represented a notable morbidity, including rupture, which must be balanced with SCI and landing zone optimization when planning repair. Larger aneurysms, especially when adjusted for body surface area, are associated with IAEs. Minimizing time between stages vs single-stage repairs for larger (>7 cm) complex aortic aneurysms in patients with reasonable SCI risk should be considered when planning repair., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

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.

Objective: The rate of endovascular repair of thoracoabdominal aortic aneurysms (TAAA-ER) has increased considerably in recent years. Although the mortality and morbidity rates have improved, the incidence of spinal cord ischemia (SCI) has not declined significantly. The aim of the present systematic review and meta-analysis was to examine the SCI rates with respect to the efficacy of the different approaches., Methods: Cohort studies and case series (>20 patients) reporting SCI rates after TAAA-ER were eligible for inclusion. The primary outcome measure was the evaluation of SCI. The moderators considered were primarily the staged vs nonstaged approach, the use of cerebrospinal fluid drainage (CSFD), and TAAA extension. The permanent SCI and mortality rates were extracted., Results: A total of 27 studies with 2333 patients were included in the meta-analysis. The pooled estimate for SCI was 11% (95% confidence interval [CI], 8%-15%; I 2 , 79%). For extent I, II, III, and V TAAA, the pooled SCI rate was 13% (95% CI, 10%-17%; I 2 , 69%). For extent IV TAAA, the pooled SCI rate was 6% (95% CI, 3%-10%; I 2 , 62%). A staged TAAA-ER approach was used in 20 studies and a nonstaged approach in 8 (1 study had included both). A lower pooled SCI rate was identified after staged than after nonstaged TAAA-ER (9% vs 18%, respectively; P = .02). Staging was accomplished in >1 month in nine studies and ≤1 month in two studies, leading to similar SCI rates (7% vs 11%, respectively; P = .26). The method of staging (thoracic endoprosthesis or temporary aortic sac perfusion) did not affect the SCI rates. Symptomatic CSFD was associated with a similar pooled rate of SCI compared with prophylactic CSFD (10% vs 10%, respectively; P = .99). The pooled permanent SCI rate was 6% (6% for extent I, II, III, and V TAAA; and 3% for extent IV TAAA). The pooled rate of 30-day mortality was 7%, with a similar incidence for the staged and nonstaged approaches (6% vs 9%, respectively). Interstage mortality was reported in 9 studies, with a pooled estimate rate of 1.6%., Conclusions: SCI had occurred in 11% of TAAA-ER, and one half of these cases were permanent. A staged approach can reduce SCI rates independently of the timing and method adopted. The overall mortality rate for staged TAAA-ER was 7%, with one fifth of the deaths (1.6%) occurring between stages., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Spinal cord ischemia following thoracic endovascular aortic repair (TEVAR) is a devastating complication. This study seeks to demonstrate how a standardized protocol to prevent spinal cord ischemia affects incidence in patients undergoing TEVAR., Methods: Using CPT codes 33880 and 33881, all TEVAR procedures performed at a single tertiary care center from January 2017 to December 2018 were examined. Patients who had concomitant ascending aortic repairs or a TEVAR for traumatic indications were excluded from analysis, leaving 130 TEVAR procedures. Comorbid conditions, procedural characteristics, extent of coverage, peri-procedural management strategies, and post-operative outcomes were collected and analyzed retrospectively., Results: One hundred thirty patients undergoing TEVAR were examined for four perioperative variables: postoperative hemoglobin greater than 10 g/dL, subclavian revascularization, preoperative spinal drain placement, and somatosensory evoked potential monitoring (SSEP). All conditions were met in 46.2% (60/130) of procedures; 37.8% (28/74) in emergent/urgent cases and 61.5% (32/52) in elective cases. Of patients who required subclavian coverage, 87.1% (54/62) underwent subclavian revascularization; 70.8% (92/130) of patients received spinal drains preoperatively; 68.5% (89/130) of patients had SSEP monitoring; 73.8% (93/130) of patients obtained a postoperative hemoglobin of >10 g/dL. Out of all patients, two (1.5%) developed spinal cord ischemia., Conclusion: Incidence of spinal cord ischemia in our cohort was low at 1.5% (2/130). Individual and bundled interventions for the prevention of spinal cord ischemia were unable to demonstrate a statistically significant effect given the low rate. Nonetheless, we advocate for a proactive approach for the prevention of spinal cord ischemia given our experience in this complex population.

Background: This study aimed to investigate the impact of segmental artery reimplantation and its patency on spinal cord ischemia (SCI) in thoracoabdominal aorta replacement., Methods: For 193 patients who underwent early postoperative computed tomographic (CT) angiography after thoracoabdominal aorta replacement, the technique of segmental artery reimplantation, their patency, and postoperative SCI were retrospectively investigated., Results: The early patency rate of reimplanted segmental artery was 83.3% (210 of 252), as 13 were taken down intraoperatively and 42 were not visualized in the postoperative CT angiography. The patency rate differed according to the reimplantation technique: 93.6% (131/140) for en bloc patch, 95.6% (43/45) for small individual patch, and 53.7% (36/67) for graft interposition. SCI occurred in 13 (6.3%) patients, 4 of whom (2.0%) remained paraplegic permanently. SCI was significantly more frequent (P=0.044) in the patients in whom segmental artery reimplantation was not successful (take-down or occlusion, 6/37=16.2%) than in those who had all segmental arteries sacrificed intentionally (2/64=3.1%) and those who showed patency of all reimplanted segmental arteries (5/92=5.4%). Especially, there was no permanent paraplegia in the last group. Failure of intended segmental artery reimplantation was a significant risk factor of postoperative SCI in logistic regression analysis (P=0.012; odds ratio 4.65, 95% confidence interval 1.41-15.36)., Conclusions: During thoracoabdominal aorta replacement, attention should be paid to the segmental artery reimplantation technique, which affects the risk of occlusion or intraoperative take-down and thereby may have impact on postoperative SCI.

Objectives: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has been used clinically to limit torso bleeding and restore central perfusion. The objective of this study was to determine the sequelae of prolonged REBOA in a nonhuman primate animal model., Summary Background Data: Prolonged duration of REBOA is associated with adverse clinical outcomes. Threshold occlusion values tied to relative risk have yet to be determined., Methods: Juvenile baboons were subjected to 40% to 55% total blood volume hemorrhage to achieve profound hypotension and shock. Zone I REBOA was performed for 60 minutes to assess acute injury and survival at 4 hours (group 1; n = 7). Post-REBOA 10-day survival and complications were then compared between 60 minutes (group 2; n = 8) and 30 minutes (group 3; n = 6) REBOA animals., Results: Overall survival was 20/21 (95%). IL-6 and IL-8 were elevated at 1 and 4 hours in group 1 (P = 0.005; P = 0.001). Comparing 60-minute REBOA with 30-minute REBOA, there was (1) hypertension compared with normotension (P = 0.005), (2) increased base deficit (P = 0.003), (3) elevated Troponin I (P = 0.04), and histological evidence of kidney injury (P = 0.004). In addition, group 2 demonstrated paralysis with histopathologic changes of spinal cord ischemia (SCI) in 4/8 (50%), with no SCI in group 3 (P = 0.033)., Conclusions: REBOA limits mortality in the primate model of severe hemorrhagic shock. However, unopposed balloon inflation in the distal thoracic aorta for 60 minutes results in high rates of spinal cord ischemia, an effect mitigated by limiting balloon inflation to 30 minutes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: This study aimed to determine the effect of intervention timing, from symptom onset to thoracic endovascular aortic repair (TEVAR), on early and late outcomes in high risk patients with uncomplicated type B aortic dissection (uTBAD)., Methods: The study retrospectively evaluated 267 uTBAD patients with high risk radiographic features who underwent pre-emptive TEVAR during the acute and subacute periods. Demographics, comorbidities, pre-operative imaging features, peri-procedural details, and follow up outcomes were analysed., Results: Among the 267 pre-emptive TEVARs for high risk uTBAD, 130 were performed in the acute phase (1-14 days); and 137 in the subacute phase (15-90 days), from initial presentation. The mean age was 55.9 ± 11.0 years and 222 (83.1%) were men. The 30 day mortality rate in the acute group was five times higher than that in the subacute group (3.8% vs. 0.7%), although without statistically significant difference (p = .11). No statistically significant difference in 30 day outcomes (aortic rupture, retrograde type A dissection [RTAD], immediate type Ia endoleak, stroke, spinal cord ischaemia, and re-intervention) was noted (p > .05 for each). Of note, aortic rupture, RTAD, and disabling stroke were observed only in the acute group. Multivariable logistic analyses showed that intervention timing was not associated with 30 day outcomes. The median clinical follow up was 48.2 ± 25.9 months (range 1 - 106 months). There were no significant differences in all cause mortality, dissection related death, late intervention, or aortic related late events among timing cohorts (p > .05 for each). Furthermore, aortic remodelling, by analysing the flow status of the false lumen and evaluation of aortic diameters, either at the thoracic aorta level or the abdominal aorta level, was similar between the two groups. Multivariable Cox analyses showed that intervention timing was not associated with late outcomes., Conclusion: The present study indicates that TEVAR for high risk uTBAD in the acute phase was associated with a trend toward higher rates of early complications, while the long term outcomes were comparable with those of the subacute phase., (Copyright © 2021 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: The purpose of this study was to evaluate the outcome of t-Branch (Cook Medical, Bloomington, Ind) stent graft for the treatment of thoracoabdominal and pararenal aortic aneurysms in patients who had previous infrarenal aortic repair., Methods: A retrospective two-center study was undertaken. All consecutive patients who underwent endovascular repair using t-Branch stent graft after previous infrarenal aortic repair between January 2010 and August 2018 were included. Demographics, past medical history, cardiovascular risk factors, and intraoperative and perioperative details were recorded. Technical success and early (30-day) mortality, morbidity, target vessel patency, and presence of endoleak were analyzed. During the first year of follow-up, survival, freedom from reintervention, and patency rates were recorded., Results: There were 32 patients (mean age, 74 ± 7 years; 81% male) included in the study; 24 (75%) patients had prior open surgical repair, and 8 (25%) patients had undergone standard endovascular aneurysm repair. The index operation was performed 9 ± 5 years earlier, including 10 ± 5 years for open surgical repair and 8 ± 6 years for endovascular aortic repair. The indication was progression of the disease in 26 patients (81%) and type IA endoleak in 6 patients (19%). The total number of target vessels incorporated was 117 arteries (3.8 ± 0.6 target vessels per patient). Eleven patients had only three vessels incorporated; celiac trunk was occluded in three patients, and eight patients had one functioning kidney. Technical success rate was 97% (31/32). There was a single technical failure in one patient who had a type IA endoleak after endovascular repair with suprarenal fixation. The stenotic right renal artery was not catheterized at the initial procedure, and retrograde access was achieved through a right subcostal incision 3 days later with successful completion of the repair. Early mortality rate was 13%, and spinal cord ischemia rate was 22% (7/32); four patients had permanent and three had transient neurologic deficits. Early target vessel patency was 100%, and the rate of any endoleak was 9% (3/32); two patients had type II endoleaks and one patient had type III endoleak. The mean follow-up was 5.4 ± 5.9 months. The cumulative survival rate was 82% and 73% at 6 and 12 months, respectively. The freedom from aorta-related mortality was 92% at 6 and 12 months. The cumulative freedom from reintervention during follow-up was 90% at 6 and 12 months. The overall target vessel patency rate was 100% and 97.5% at 6 and 12 months, respectively., Conclusions: The use of t-Branch off-the-shelf stent graft for the treatment of aortic disease in patients who had previous infrarenal aortic repair appears to be feasible, with acceptable early outcomes in terms of morbidity and mortality., (Copyright © 2020 Society for Vascular Surgery. All rights reserved.)

Background: This study reports the clinical impact of iliac artery aneurysms (IAAs) in a population of patients with juxtarenal and thoracoabdominal aortic aneurysms being treated with fenestrated or branched aortic endografts., Methods: Data from 364 patients with IAA (33%) were extracted from the 1118 patients treated for juxtarenal or thoracoabdominal aortic aneurysms with a fenestrated or branched aortic endograft in a physician-sponsored investigational device exemption trial (2001-2016). IAAs were defined as ≥21 mm in diameter, as measured by an imaging core laboratory. Outcomes were assessed by univariate and multivariable analysis., Results: IAAs were unilateral in 219 (60%) and bilateral in 145 (40%) of the 364 patients. Treatment was iliac leg endoprosthesis without coverage of the hypogastric artery (seal distal to the IAA in the common iliac artery), placement of a hypogastric branched endograft in 105 (21%), and hypogastric artery coverage with extension into the external iliac artery in 103 (20%); 67 (13%) were untreated. Procedure duration was longer for those with IAA (5.3 ± 1.79 hours vs 4.6 ± 1.74 hours; P < .001), although hospital stay was not. There was no difference in aneurysm-related mortality and all-cause mortality for patients with unilateral and bilateral IAAs compared with those without an IAA. Treatment of patients with a hypogastric branched endograft had similar all-cause mortality compared with treatment of patients without a hypogastric branched endograft but also with an IAA. Reintervention rates were significantly higher in those with bilateral IAAs compared with no IAA (hazard ratio, 1.886; P < .001). Spinal cord ischemia trended higher in patients with bilateral IAA., Conclusions: IAA management at the time of fenestrated or branched endovascular aneurysm repair increases procedure time without increasing hospitalization. The reintervention rate and spinal cord ischemia rate are higher in patients with bilateral IAA compared with those with no IAA., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to determine predictors and outcomes associated with spinal cord ischemia (SCI) after elective fenestrated or branched endovascular aneurysm repair (F/BEVAR) of thoracoabdominal aortic aneurysm (TAAA), abdominal aortic aneurysm (AAA), or aortic dissection., Methods: Health insurance claims data of Germany's third largest insurance provider, DAK-Gesundheit, were used to investigate SCI in elective F/BEVAR performed between 2008 and 2017. The International Classification of Diseases and German Operation and Procedure Classification System were used. We stratified the results into F/BEVAR with one or two (AAA) vs three or more (TAAA) fenestrations or branches., Results: A total of 877 patients (18.9% female; 5.8% with SCI) matching the inclusion criteria were identified during the study period. SCI occurred more often after F/BEVAR of TAAA vs AAA (10.7% vs 3.0%; P < .001). SCI was associated with female sex in the AAA group (odds ratio, 3.87; 95% confidence interval [CI], 1.25-11.15; P = .014) and with cardiac arrhythmias in the TAAA group (odds ratio, 2.98; 95% CI, 1.24-7.06; P = .013). Compared with patients without SCI, SCI patients were more likely to suffer from drug use disorders (eg, opioids, cannabinoids, sedatives) in the TAAA group (17.6% vs 2.1%; P < .05). After F/BEVAR of TAAA, the occurrence of SCI was associated with higher 90-day mortality (14.7% vs 1.1%; P < .05), longer postoperative hospital stay (22 vs 9 days; P < .05), and severe adverse events, such as acute respiratory insufficiency (44.1% vs 12.7%), acute renal failure (35.3% vs 11.3%), and pneumonia (29.4% vs 4.9%; all P < .05). In adjusted analyses, SCI was associated with worse long-term survival after F/BEVAR for TAAA (hazard ratio, 2.54; 95% CI, 1.37-4.73; P < .003)., Conclusions: Female AAA patients and TAAA patients with cardiac arrhythmias are at highest risk for development of SCI after F/BEVAR. The occurrence of this event was strongly associated with higher major complication rates and worse short-term and long-term survival. This emphasizes a need to further illuminate the value of spinal cord protection protocols in F/BEVAR., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Paralysis (paraplegia or quadriplegia) after posterior fossa surgery is a rare but devastating complication. We investigated previous reports of this complication to examine similarities among patients, risk factors, and methods by which it may be prevented., Methods: A systematic review was completed according to PRISMA guidelines. Electronic databases were searched until November 2019 using keywords "paraplegia," "quadriplegia," or "spinal cord injury" added to "posterior fossa surgery.", Results: Thirteen case reports published between 1996 and 2019 were included. Five (38.5%) involved quadriplegia/quadriparesis and 8 (61.5%) involved paraplegia after surgery. Ten cases (76.9%) were tumor resections and 3 (23.1%) were posterior fossa decompressions (2 for Chiari malformations and 1 for Morquio syndrome). Seven surgeries (53.8%) were performed in the sitting position and 6 (46.2%) were prone. Proposed mechanisms of paralysis involved cervical hyperflexion yielding spinal cord ischemia in 8 patients (61.5%), arterial hypotension in 2 patients (15.4%), spinal cord compression from hematoma in 1 patient (7.7%), and decreased cardiac output in 1 patient (7.7%) (1 study did not propose a cause). Cervical hyperflexion was equally likely in the sitting and prone positions (4 patients each). Only 3 patients (23.1%) involved intraoperative complications (all cardiopulmonary in nature)., Conclusions: Paralysis after posterior fossa surgery often involves spinal cord infarction apparently caused by cervical hyperflexion. Extreme care during patient positioning is needed in both the sitting or prone positions. Electrophysiologic monitoring might enable early identification of spinal cord dysfunction to minimize or avoid this complication., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Spinal cord ischemia (SCI) is a dreaded complication of thoracic endovascular aortic repair (TEVAR). There are limited national data describing the incidence and influence of in-hospital SCI recovery on survival. Moreover, no robust preoperative SCI risk assessment models currently exist. The purpose of this analysis was to analyze the Vascular Quality Initiative to determine the national incidence, survival association, and preoperative predictors of SCI after TEVAR., Methods: All Vascular Quality Initiative TEVAR procedures (June 2014-June 2019) were reviewed. The primary end point was development of in-hospital SCI, defined as any new neurologic deficit or paralysis not attributable to intracranial disease. Secondary end points were disease-specific SCI rates and long-term out-of-hospital survival. Functional outcomes (transient vs permanent SCI) were independently determined by treating physicians. Kaplan-Meier analysis and Cox proportional hazards methodology were used to assess the association of SCI with survival. A logistic regression model of candidate preoperative SCI predictors was created, and bootstrapped backward elimination (retaining predictors with ≥50% selection frequency) was used for model reduction. Model fit and performance statistics were validated by adjustment for Efron's optimism., Results: The overall rate of SCI was 3.7% (n = 422/11,473; transient, 1.6% [n = 179]; permanent, 2.1% [n = 243]). Patients who developed any SCI had significantly lower Kaplan-Meier survival estimate compared with those without SCI (1-year survival: SCI, 65%; no SCI, 87%; P < .0001), and patients with permanent SCI had notably worse survival than patients with transient SCI (1-year survival: permanent SCI, 54%; transient SCI, 80%; P < .0001). Disease-specific incidence of any SCI was as follows: aneurysm, 3.4%; dissection, 5.3%; aneurysm from dissection, 4.1%; trauma, 1.1%; penetrating ulceration, 2.4%; intramural hematoma, 5.7%; penetrating ulceration and intramural hematoma, 4.3%; and aortic thrombus, 4.8%. Several factors were selected on multivariable analysis as the most robust preoperative predictors of any SCI, including distal landing zone 5 to zone 10, nonelective case, creatinine concentration >1.38 mg/dL, smoking history, American Society of Anesthesiologists class, adjunctive procedure, nonwhite race, and preoperative hypertension (area under the curve = 0.72; Nagelkerke R 2  = 0.06)., Conclusions: SCI is a devastating complication after TEVAR that is associated with worse overall survival, particularly when no functional recovery occurs by hospital discharge. Disease-specific, real-world benchmarks for SCI rates are provided that may inform quality initiatives focused on reducing this complication. Importantly, this analysis is the first description of a preoperative prediction model derived from national data for determining SCI risk after TEVAR. These predictors should be used to identify high-risk patients to balance the risk of SCI and its associated increased short-term mortality with the risk of the underlying disease. Furthermore, all available adjunctive measures should be implemented in these high-risk patients to reduce risk of SCI., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The frozen elephant trunk technique's safety regarding spinal cord ischemia has been questioned. We used a meta-analysis to determine the rates of adverse neurologic events and mortality., Methods: We searched PubMed/Medline, Embase, Scopus, and Cochrane databases (inception to April 2018) to identify studies of neurologic events after the frozen elephant trunk procedure. Separate meta-analyses were conducted with random-effects models to assess frozen elephant trunk associations with spinal cord ischemia, stroke, operative mortality, and all adverse events combined. Subgroup analyses compared outcomes in patients with acute versus nonacute type A dissection and aneurysm and with different extents of coverage., Results: Thirty-five studies (total N = 3154) met inclusion criteria. The pooled rates of the outcomes of interest were 4.7% (95% confidence interval, 3.5-6.2) for spinal cord ischemia, 7.6% (95% confidence interval, 5.0-11.5) for stroke, and 8.8% (95% confidence interval, 7.0-10.9) for operative mortality. The spinal cord ischemia event rate was higher with stent length 15 cm or greater or coverage to T8 or beyond than with stent length of 10 cm (11.6% vs 2.5%, P < .001). Adverse event rates in patients with acute type A aortic dissection versus nonacute dissection or aneurysm were as follows: mortality 9.2% versus 7.6% (P = .46), stroke 9.3% versus 6.6% (P = .51), and overall adverse events 22.0% versus 16.5% (P = .41)., Conclusions: As the frozen elephant trunk procedure becomes more popular, accurate data regarding outcomes are vital. We associated the frozen elephant trunk technique with (nonsignificantly) more adverse events overall in acute type A dissection cases. Stent length of 10 cm was associated with significantly less risk of spinal cord ischemia. Using a stent 15 cm or greater or coverage extending to T8 or farther should be avoided., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. Published by Elsevier Inc. All rights reserved.)

Background: As many as 20% of patients who have undergone previous thoracic aortic repair will require reintervention, which could entail thoracic endovascular aortic repair (TEVAR). A paucity of data is available on mortality and the incidence of spinal cord ischemia (SCI) and other postoperative complications associated with TEVAR after previous aortic repairs exclusive to the thoracic aorta. The aim of the present study was to assess the effect of previous thoracic aortic repair on the 30-day mortality and SCI outcomes for patients after TEVAR., Methods: The Society for Vascular Surgery Vascular Quality Initiative database was queried for all cases of TEVAR from 2012 to 2018. Patients were excluded if they had undergone previous abdominal aortic repair, the TEVAR had extended beyond aortic zone 5, or SCI data were missing. The 3 cohorts compared were TEVAR with previous ascending aortic or aortic arch repair (group 1), TEVAR with previous descending thoracic aortic repair (group 2), and TEVAR without previous repair (group 3). The primary outcomes of interest were 30-day mortality and SCI. The secondary outcomes included stroke, myocardial infarction, cardiac complications, respiratory complications, postoperative length of stay, and reintervention. The patient variables were compared using χ 2 tests, analysis of variance, or Kruskal-Wallis tests, as appropriate. Logistic regression analysis was performed to identify the predictors of 30-day mortality and SCI., Results: A total of 4010 patients met the inclusion criteria, with 470 in group 1, 132 in group 2, and 3408 in group 3. The 30-day mortality was 4% (19 of 470) in group 1, 6% (8 of 132) in group 2, and 6% (213 of 3408) in group 3 (P = .17). The incidence of SCI was 3% (14 of 470) in group 1, 3% (4 of 132) in group 2, and 3.8% (128 of 3408) in group 3 (P = .65). Stroke, reintervention, myocardial infarction, and cardiac complications were not significantly different among the 3 groups. The incidence of respiratory complications was greatest for group 3 (11%; 360 of 3408) compared with groups 1 (9%; 44 of 470) and 2 (4%; 5 of 132; P = .034). Similarly, the postoperative length of stay was longest for group 3 (9.6 ± 19.4 days vs 8.2 ± 18.3 days for group 1 and 5.9 ± 8.6 days for group 2; P = .038). The independent predictors of 30-day mortality for all TEVAR patients included units of packed red blood cells transfused intraoperatively, urgent or emergent repairs, older age, increasing serum creatinine level, inability to perform self-care, total procedure time, occlusion of the left subclavian artery intraoperatively, distal endograft landing zone 5, and diabetes. The predictors of SCI included the total procedure time, urgent and emergent repairs, and increasing serum creatinine level., Conclusions: TEVAR after previous thoracic aortic repair was not associated with an increased risk of SCI or 30-day mortality compared with TEVAR without previous aortic repair., (Published by Elsevier Inc.)

Background: Spinal cord ischemia (SCI) and paraplegia are complications of surgery for type A acute aortic dissection (TAAAD). Since the segmental arteries play a key role in SCI, this study evaluated the association between SCI and false lumen segmental arteries (FLSAs: segmental arteries originating from the false lumen)., Methods: The study included 101 consecutive TAAAD patients (mean age, 66±13; range, 34-89 years) who underwent surgery from January 2011 to April 2017. The diagnosis of TAAAD and the number of FSLAs were determined by preoperative computed tomography (CT). Patients were divided into two groups according to the number of FLSAs at the Th9-L2 level: Group A (N.=13), ≥8 FLSAs; and group B (N.=88), ≤7 FLSAs. Preoperative, perioperative, and postoperative findings were compared between the groups, and risk factors for SCI were evaluated., Results: The frequency of preoperative paralysis was significantly higher in Group A than Group B (P=.0070). The overall incidence of postoperative SCI was 8% (8/101) and significantly higher in Group A than Group B (5/13 [45%] vs. 3/88 (4%), P<0.0001). Hospital mortality was 8% (8/101) and significantly higher in Group A than Group B (3/13 [23%] vs. 5/88 [6%], P=.0302). Multivariate analysis showed that the independent risk factors for SCI were ≥8 FLSAs at Th9-L2 (odds ratio [OR], 20.4; 95% confidence interval [95% CI], 3.34-124.9, P=0.0011) and diabetes mellitus (OR, 22.3; 95% CI, 1.69-294.5; P=0.0184)., Conclusions: In patients who underwent surgery for TAAAD, ≥8 FLSAs at the Th9-L2 levels on preoperative CT was a risk factor for SCI.

Objectives: The aim of this study was to investigate the incidence and predictors of early and mid term neurological complications following thoracic endovascular repair (TEVAR) in the Global Registry for Endovascular Aortic Treatment (GREAT)., Methods: The GREAT is a prospective observational multicentre registry on Gore aortic endografts that was initiated in 2010. Only isolated thoracic aortic pathologies were included (aortic arch and descending thoracic aneurysms, type B dissections, penetrating ulcers, intramural haematomas, pseudoaneurysms, and transections). Thoraco-abdominal aneurysms and concomitant abdominal aneurysms were excluded. Neurological complications were classified as cerebrovascular accidents (CVA) and spinal cord injuries (SCI). Clinical, procedural, and technical data were evaluated for their association with early (30 day) and mid term CVAs and SCIs., Results: In total, 833 patients were included: 28 with arch aneurysms (3.4%), 329 with descending thoracic aneurysms (39.5%), 273 with type B dissections (32.8%), and 203 (24.4%) with other thoracic pathologies. Altogether, 593 (71.2%) were elective procedures and 240 (28.8%) were urgent. Aortic coverage >20 cm was performed in 42.1% (n = 351); proximal landing zone 0-1-2 was adopted in 267 patients (32.1%) and of these 98 (36.7%) underwent left subclavian artery (LSA) revascularisation. There were 13 early CVAs (1.5%) and the four year freedom from CVA rate was 96.3%. On multivariable analysis, aortic arch aneurysm was the only independent predictor of early CVA (odds ratio 16.7, p = .001). LSA coverage (hazard ratio [HR] 3.31, p = .005) and hypercholesterolaemia (HR 2.96, p = .024) were independent predictors of mid term ischaemic CVAs. There were 15 (1.8%) early SCIs, and the four year freedom from SCI rate was 97.8%. No independent predictors of early SCI were identified, but length of coverage was an independent predictor of SCI at four years (HR 1.24; p = .044)., Conclusions: In this real world registry, the overall rate of neurological complication after TEVAR for isolated thoracic aortic pathologies was low. Aortic arch aneurysms were associated with increased peri-operative CVA risk. Length of coverage was an independent predictor of mid term SCIs, as LSA coverage was associated with late CVAs., (Copyright © 2019 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: The aim of our study was to analyze the incidence of spinal cord ischemia (SCI) in patients presenting with complex aortic aneurysms treated with endovascular aneurysm repair (EVAR) and to identify risk factors associated with this complication., Methods: A retrospective study was undertaken of prospectively collected data including patients presenting with complex aortic aneurysm (pararenal abdominal aortic aneurysm and thoracoabdominal aortic aneurysm) treated with fenestrated EVAR (F-EVAR) or branched EVAR (B-EVAR). The primary end point was the incidence of SCI and the assessment of any associated factors., Results: Between January 2011 and August 2017, a total of 243 patients (mean aneurysm diameter, 65.2 ± 15.3 mm; mean age, 72.4 ± 7.5 years; 73% male) were treated with F-EVAR or B-EVAR. Asymptomatic patients were treated in 73% of the cases (177/243, in contrast to 27% urgent), and 52% (126/243) were treated for thoracoabdominal aortic aneurysm (in contrast to 48% for pararenal abdominal aortic aneurysm). F-EVAR (mean number of fenestrations, 3.3/case) and B-EVAR (mean number of branches, 3.7/case) were undertaken in 67% (164/243) and 33% (79/243), respectively. The total incidence of SCI was 17.7% [43/243; paraplegia in 4% (10/243) and paraparesis in 13.7% (33/243)]. Most of the patients with SCI presented with immediate postoperative symptoms (72% [31/43]). A spinal drain was preoperatively placed in 53% (130/243) and was associated with the prevention of SCI (SCI with spinal drainage, 12% [16/130]; SCI without spinal drainage, 24% [27/113]; P = .018). The 30-day mortality rate was 9% (21/243). After multiple logistic regression analysis, SCI was associated with preoperative renal function (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m 2 : odds ratio [OR], 2.43; 95% confidence interval [CI], 1.18-4.99; P = .016) and the number of vertebral segments covered (SCI with higher position of proximal stent in terms of vertebra: OR, 1.2; 95% CI, 1.1-1.3; P = .000). A similar outcome was derived when the height of the proximal end of the stent graft was replaced by the total length of aortic coverage (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m 2 : OR, 2.36 [95% CI, 1.11-5.00; P = .025]; SCI with longer length of aortic coverage: OR, 1.01 [95% CI, 1.003-1.009; P = .000])., Conclusions: The majority of SCI incidence after F-EVAR or B-EVAR of complex aortic aneurysms is manifested immediately postoperatively. The use of preoperative spinal drainage may prevent SCI. Patients with GRF <60 mL/min/1.73 m 2 and with longer aortic stent graft coverage are at higher risk of SCI., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Spinal cord ischemia (SCI) after abdominal aortic aneurysm (AAA) endovascular abdominal aortic aneurysm repair (EVAR) is a rare but devastating complication. The mechanism underlying the occurrence of SCI after EVAR seems to be multifactorial and is underreported and not fully elucidated. The aim of the study was to investigate the clinical outcomes in patients with this serious complication., Methods: A systematic review of the current literature, as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines, was performed to evaluate the incidence of SCI after elective EVAR. PubMed and Scopus databases were systematically searched. Studies reporting on thoracic endovascular aneurysm repair, open repair of AAAs, and symptomatic or ruptured AAAs were excluded., Results: In total, 18 articles reporting 25 cases were included. The mean age was 74.6 ± 7.6 (range: 60-90) years. The mean diameter of AAAs was 5.96 ± 1.0 cm (range: 4.7-8.3). Six cases also had aneurysms in the common iliac arteries. Seventy-one percent of AAAs had characteristics that made EVAR difficult and technically demanding. The mean operative time was prolonged, 254 ± 104.6 min, and associated with extensive intravascular handling. In 41.6% of cases, additional procedures were performed because of the difficult anatomy. Thirty-two percent of the cases had 1 internal iliac artery (IIA) embolized with coils or covered with the stent graft, and 14% had both IIAs compromised. In most of the cases, SCI symptoms presented immediately after the operation, and in 14.8% of patients, the symptoms had late presentation. Almost all cases had motor loss in the form of paraparesis or paraplegia, 54% of the cases also had diminished sensation, and 29.1% of the cases had urinary and/or fecal incontinence. Heterogeneity was observed regarding the management of the disease; in 6 of the cases, cerebrospinal fluid (CSF) drainage was performed, steroids were administered in 5, and in the other cases, an expectant strategy was selected. In 50% of the cases, only small improvement was seen at follow-up. In 25% of the cases, no improvement was seen, and 25% had almost complete recovery., Conclusions: Our study identified a common pattern among patients who present SCI after EVAR: difficult anatomy, prolonged operative time, additional procedures, and extensive intravascular handling that may have led to embolization. Patency of pelvic circulation preoperatively is also of importance. Regarding outcomes, only 25% of patients recovered, and in certain cases, CSF drainage may have significantly improved chances for recovery., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Spinal cord ischemia (SCI) may develop in patients presenting with acute aortic dissection. We sought to determine how SCI and its recovery affect outcomes., Methods: We reviewed patients with SCI in acute type A aortic dissection (ATAAD) and acute type B aortic dissection (ATBAD) from September 1999 to May 2014. SCI was defined as paraplegia or paraparesis present on admission. Monoparesis/plegia, paraesthesia, or numbness was defined as ischemic neuropathy. All ATBAD patients were managed with antiimpulse therapy, with selective intervention for rupture, rapid aortic expansion, malperfusion, or intractable pain. ATAAD patients were managed with urgent proximal aortic replacement., Results: Neurologic symptoms were present in 178 (18.2%) of 978 acute dissections (482 ATAAD and 496 ATBAD). Of these 178 patients, SCI presented in 52 patients (29.2%; 80.1% male; mean age, 57 years). On admission paraplegia was present in 24 (46.2%), paraparesis in 10 (19.2%), paresthesia/numbness in 27 (51.9%), and leg ischemia in 25 (48.1%). Aortic operations were performed in 27 SCI patients (51.9%). Symptom resolution was seen in 30 (57.7%). The 30-day mortality was 19.2% and was significantly less in those with resolution of SCI (6.7% vs 36.4%, p = 0.012). When surgical intervention was required in ATBAD with SCI, mortality was 50% (p = 0.039). SCI and symptom resolution significantly affected overall survival. SCI is associated with significantly increased risk of overall mortality (hazard ratio, 2.9; p < 0.001), and SCI resolution completely offsets this risk (hazard ratio, 0.28; p = 0.003). These effects were consistent between ATAAD and ATBAD (p = 0.554)., Conclusions: SCI in acute aortic dissection portends a poor prognosis. However, reversal of deficits is associated with a long-term survival outcome comparable to patients unaffected with SCI., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Spinal cord ischaemia (SCI) is a serious complication of thoracic endovascular aortic repair (TEVAR). The purpose of this study was to assess the incidence, risk factors, clinical manifestations of SCI after TEVAR and which type of patients could benefit from cerebrospinal fluid drainage., Methods: A retrospective review was conducted for 175 patients who underwent TEVAR from January 2008 to July 2014. All patients were divided into groups with and without SCI, and they were compared to identify significant risk factors for SCI., Results: The incidence of SCI after TEVAR including paraplegia and paraparesis was 6.9%. SCI usually occurred within 24 h, but delayed SCI was observed after 5 days in 1 patient. In all patients with SCI, we tried to increase the blood pressure to improve spinal perfusion. Three patients recovered completely, and the 6 patients with some remaining neurological deficit included 3 with motion against gravity and bladder dysfunction and the 3 remaining patients with only bladder dysfunction. Three patients did not recover. In our study, significant risk factors for SCI were as follows: rupture, shaggy aorta, chronic obstructive pulmonary disease, 1-stage procedure, the coverage of more than 9 segments, the coverage from Th8 to Th12, minimum of postoperative haemoglobin and the number of postoperative patent segmental arteries., Conclusions: Sufficient perioperative care should be given to high-risk patients who have endografts that cover more than 9 segments and endografts that cover segments from Th8 to Th12. Adequate haemoglobin levels and mean arterial pressure are needed to provide sufficient spinal cord perfusion.

Objective: To review rates of permanent paraplegia and lumbar drain-related complications in patients undergoing thoracic endovascular aortic repair (TEVAR) surgery with prophylactic cerebrospinal fluid (CSF) drainage at the authors' institution., Design: Retrospective cohort study., Setting: Tertiary care, academic medical center., Participants: Patients who underwent TEVAR with a high risk for ischemic spinal cord injury and prophylactic lumbar CSF drainage over a 5-year period., Interventions: None., Measurements and Main Results: One hundred and two patients underwent TEVAR with lumbar CSF drainage. Thirty-day mortality was 5.9%, and the rate of permanent paraplegia was 2%. Drain complications occurred in 4 (3.9%) patients, but no patient experienced permanent injury related to CSF drainage. Two patients in the cohort had complete resolution of paraplegia with increased CSF drainage and mean arterial blood pressure increases aimed to increase spinal cord perfusion pressure by 25%. A third patient experienced improvement in lower extremity strength but remained paraplegic, and a fourth patient demonstrated no improvement in symptoms. The 6 patients taking clopidogrel experienced no bleeding complications, and there were no apparent risk factors for bleeding in the 5 patients who had bloody drain output or in 1 patient who developed an epidural hematoma., Conclusion: Prophylactic CSF drainage was associated with low paraplegia and drain-related complication rates. These data further support the safety of prophylactic CSF drainage in patients undergoing TEVAR with a high risk for ischemic spinal cord injury., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Thoracoabdominal aortic aneurysms are among the most challenging pathologic conditions vascular surgeons have to face. Endovascular treatment brought the prospect of being able to treat these complex aneurysms with less invasiveness and recent outcomes already challenge those of open repair. Plus, this technique offers a therapeutic option for patients who had none, due to significant comorbidities limiting open repair. Spinal cord injury is a major complication after complex aneurysm repair that dramatically affects patient's quality of life, even if technical success - aneurysm exclusion from circulation - has been achieved. Several strategies to prevent this terrible outcome have been developed, with remarkable success in narrowing down the number of patients who will suffer this complication. This comprehensive review covers how the standard of care for thoracoabdominal aortic aneurysms has evolved over time, how the understanding of spinal cord perfusion has changed in light of the collateral network concept, the risk factors associated with SCI, and details preventive strategies applied in current practice to lessen even further the frequency of spinal cord injury. Strategies covered go from the traditional adjuncts comprising hemodynamic control, neuroprotective drugs, neuromonitoring and cerebrospinal fluid drainage to emerging and innovative techniques such as near-infrared spectroscopy, two-step repair, minimally-invasive selective segmental artery coil-embolization, temporary aneurysm sac perfusion, and techniques for earlier pelvic and lower limb reperfusion.

Background: Hypotensive events (HEs) following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) can lead to delayed neurologic postoperative deficits (DNPD). This study aimed to determine the incidence of HEs (mean arterial pressure [MAP] <60 mmHg) after PSF for AIS and identify predictors for HEs., Methods: Medical records of 99 consecutive patients who had PSF for AIS were retrospectively reviewed (2011-2013). Perioperative data were collected. Patients were divided into two groups based on MAP readings by an arterial line in the pediatric intensive care unit immediately postoperatively into postoperative day one: Group 1 (MAP ≥60 mmHg) and Group 2 (multiple occurrences of MAPs <60 mmHg). Mean values were compared using the independent t test. Multiple logistic regression was used to estimate the association of preoperative and intraoperative parameters with multiple HEs., Results: Group 1 had 68 patients (68.7%) and Group 2 had 31 patients (31.3%). None of the compared parameters were associated significantly with multiple HE. However, patients who did not exhibit HEs within the first four hours postoperatively remained stable throughout the rest of the postoperative period. Only those with HEs in the first four hours experienced subsequent HEs in the first 24 hours. There were no DNPD or other major complications., Conclusion: Results showed that the incidence of HEs after PSF in AIS can be as high as 31.3%. We did not find any significant risk factors. Although DNPD after PSF is a rare complication and we had none in this series, we suggest that these patients with multiple HEs may be at risk for DNPD as a result of hypotension and potential for cord ischemia. Therefore, all patients after PSF should be monitored in a pediatric intensive care unit-type environment or postanesthesia recovery room initially. If stable for, at least, the initial four hours, then patients should be good candidates for a less intensive environment., Level of Evidence: Level 3., (Copyright © 2017 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: The rate of spinal cord infarction (SCI) after surgical or endovascular repair of an aortic aneurysm or dissection is unclear., Methods: Using administrative claims data, we identified adult patients discharged from nonfederal acute care hospitals in California, New York, and Florida who underwent surgical or endovascular repair of an aortic aneurysm or dissection between 2005 and 2013. Patients with SCI diagnosed before the aortic repair were excluded. Our primary outcome was an SCI during the index hospitalization for aortic repair. Descriptive statistics were used to estimate crude rates of SCI. Analyses were stratified by whether the aneurysm or dissection had ruptured and by type of repair (surgical versus endovascular)., Results: We identified 91 212 patients who had repair of an aortic aneurysm or dissection. SCI occurred in 235 cases (0.26%; 95% confidence interval [CI], 0.22%-0.29%). In patients with ruptured aneurysm or dissection, the rate of SCI was 0.74% (95% CI, 0.60%-0.88%) compared with 0.16% (95% CI, 0.13%-0.19%) with unruptured aneurysm. In secondary analyses, rates of SCI were similar after endovascular repair (0.91%; 95% CI, 0.62%-1.19%) compared with surgical repair (0.68%; 95% CI, 0.53%-0.83%; P =0.147) of ruptured aortic aneurysm or dissection; however, rates of SCI were higher after surgical repair (0.20%; 95% CI, 0.15%-0.25%) versus endovascular repair (0.11%; 95% CI, 0.08%-0.14%; P <0.001) of unruptured aneurysm., Conclusions: SCI occurs in ≈1 in 130 patients undergoing aortic dissection or ruptured aortic aneurysm repair and in 1 in 600 patients undergoing unruptured aortic aneurysm repair., (© 2017 American Heart Association, Inc.)

Objectives: Spinal cord protection during thoracoabdominal aortic surgery is challenging for surgeons. We performed thoracoabdominal replacement using a strategy for maintaining spinal cord perfusion pressure. Here, we report our experience with this procedure and the surgical outcomes., Methods: Between January 2000 and December 2014, 130 patients [male: 91 (74.6%), female: 39 (25.4%); mean age: 66.6 ± 12.8 years] underwent thoracoabdominal replacement using cardiopulmonary bypass at Hiroshima Shimin Hospital, Japan. The surgical outcomes of these patients were analysed., Results: The in-hospital mortality rate of all patients was 2.5%. The incidence of postoperative paraplegia was 3.8%. Aortic event-free survival rates at 1, 3 and 5 years were 98.2%, 93.9% and 80.7%, respectively., Conclusions: The present study suggests that our strategy for maintaining spinal cord perfusion pressure provides acceptable outcomes., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Despite the improved understanding of spinal cord anatomy and spinal cord ischemia pathophysiology, the rate of debilitating postoperative paraparesis or paraplegia is still not negligible after procedures for thoracic or thoracoabdominal aortic disease. Single studies have demonstrated the role of different treatment modalities to prevent or treat spinal cord ischemia. A multimodal approach, however, is advocated by most authors. Even after the employment of endovascular techniques become routine, the rate of spinal cord ischemia after treatment of thoracoabdominal aortic pathology remained unchanged over time. Spinal cord ischemia is often treatable by different means that concur to improve indirect spinal perfusion through collateral circulation; it should, therefore, be managed promptly and aggressively due to its potential reversibility. Ongoing technical improvements of non-invasive diagnostic tools may allow a better preoperative assessment of the spinal vascular network and a better planning of both open and endovascular thoracic or thoracoabdominal repair.

Background: Preoperative radiological identification of the Adamkiewicz artery and intraoperative neurologic monitoring are known to be helpful for preventing paraplegia after thoracoabdominal aorta replacement. To answer whether they should be used routinely, we investigated the incidence of spinal cord ischemia after extensive descending aortic repair without using such modalities., Methods: We retrospectively reviewed the outcome of 95 patients who underwent extensive descending thoracic (DTA) or thoracoabdominal aorta (TAA) repair without the Adamkiewicz artery identification or neurologic monitoring from 2006 through 2010. Spinal cord protection strategy consisted of distal aortic perfusion, cerebrospinal fluid drainage, mild hypothermia, and maintenance of hypertension (systolic≥120mmHg) through the second postoperative day. A few segmental arteries were empirically selected for reimplantation based on the size and the amount of backbleeding; overall 1.4 per patient, 0.3 for DTA, 1.4 for type I, 2.4 for type II, 0.9 for type III, and 0 for type IV TAA., Results: Two patients died early after surgery. All the remaining patients awoke without paraplegia or paraparesis. Delayed deficit occurred in 7 patients (7.4%) after hypotensive events caused by sedation, bleeding, respiratory distress, or cardiac dysfunction. Three patients (3.2%) became permanently paraplegic and the other four recovered completely within 48 hours after cerebrospinal fluid drainage and elevation of systemic blood pressure., Conclusion: Even without the Adamkiewicz artery identification and neuromonitoring, the incidence of immediate paraplegia could be kept low by applying the strategy based on the modern concept of cord perfusion. The relatively high incidence of delayed deficit suggests the importance of postoperative hemodynamic management and prevention of cardiopulmonary complications.

Objective: To analyze the incidence and short-term outcome of SCI after endovascular repair of thoracoabdominal aneurysms (eTAAA)., Methods: All patients undergoing eTAAA with branched and fenestrated stent grafts between 2008 and 2014 were retrospectively reviewed concerning pre-, intra- and post-operative clinical data and imaging., Results: Seventy-two patients (53 males, 68 [64-73] years old) underwent eTAAA (51 elective, 21 acute including 7 ruptures). Patients were classified anatomically according to Crawford: type I (n=11), type II (n=26), type III (n=18), and type IV (n=17). Thirty-day mortality was 6.9 % (3.9% for elective, 7.1% for symptomatic and 28.6% for ruptures, including one intra-operative death). Twenty-two of the 71 patients who survived the operation (31.0%) developed SCI: type I (n=2, 20.0%), type II (n=13, 50.0 %), type III (n=3, 16.7%), type IV (n=4, 23.5%). SCI incidence decreased in the latter part of the experience (23.7% vs. 39.4%, p = .201). SCI development was independently associated with Crawford type II TAAA (OR 4.497 (1.331-15.195), p = .016) and higher contrast volume (OR 3.736 [1.054-13.242], p = .041). Fifteen of these 22 patients with SCI showed some improvement of their deficits before hospital discharge. The introduction of a standardized protocol in the last 38 patients aiming at the early diagnosis and treatment of SCI led to more frequent regression of SCI symptoms (100% vs. 46.2%, p = .017) and a higher rate of regaining ambulatory capacity (55.6% vs. 15.4%, p = .027). After the introduction of this protocol, the residual SCI rate at hospital discharge was 13.2% as opposed to 33.3% in the initial group., Conclusion: eTAAA has low peri-operative mortality, but SCI incidence is high albeit that it decreased with increasing experience. More extensive repair and use of larger volumes of contrast were associated with higher risk of SCI. Acute repair does not significantly increase SCI risk. A standardized protocol for early diagnosis and treatment of SCI leads to a higher recovery rate with a greater likelihood of regaining ambulatory capacity., (Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: The outcome of patients with acute type B aortic dissection (ABAD) is strongly related to their clinical presentation. The purpose of this study was to investigate predictors for mortality among patients presenting with ABAD and to create a predictive model to estimate individual risk of in-hospital mortality using the International Registry of Acute Aortic Dissection (IRAD)., Methods and Results: All patients with ABAD enrolled in IRAD between 1996 and 2013 were included for analysis. Multivariable logistic regression analysis was used to investigate predictors of in-hospital mortality. Significant risk factors for in-hospital death were used to develop a prediction model. A total of 1034 patients with ABAD were included for analysis (673 men; mean age, 63.5±14.0 years), with an overall in-hospital mortality of 10.6%. In multivariable analysis, the following variables at admission were independently associated with increased in-hospital mortality: increasing age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.00-1.06; P=0.044), hypotension/shock (OR, 6.43; 95% CI, 2.88-18.98; P=0.001), periaortic hematoma (OR, 3.06; 95% CI, 1.38-6.78; P=0.006), descending diameter ≥5.5 cm (OR, 6.04; 95% CI, 2.87-12.73; P<0.001), mesenteric ischemia (OR, 9.03; 95% CI, 3.49-23.38; P<0.001), acute renal failure (OR, 3.61; 95% CI, 1.68-7.75; P=0.001), and limb ischemia (OR, 3.02; 95% CI, 1.05-8.68; P=0.040). Based on these multivariable results, a reliable and simple bedside risk prediction tool was developed., Conclusions: We present a simple prediction model using variables that are independently associated with in-hospital mortality in patients with ABAD. Although it needs to be validated in an independent population, this model could be used to assist physicians in their choice of management and for informing patients and their families., (© 2014 American Heart Association, Inc.)

Thoracic endovascular aortic repair (TEVAR) has become an attractive alternative treatment option for thoracic aortic disease. New devices and advanced image-guided procedures are continuously expanding the indications. This article focuses on currently available endovascular solutions for thoracic aortic disease and future 'all endovascular' directions of TEVAR. Currently available endovascular solutions, such as hybrid operations, chimney stent grafting and transapical stent graft deployment, for ascending aortic pathologies are presented. Additionally, the impact of upcoming new technologies, such as endovascular treatment of Stanford Type A dissections of the ascending aorta, is elaborated. With improving device technology, diverse available stent grafts and imaging modalities, TEVAR has become safer and holds promising potential to expand treatment options, especially for the ascending aorta and the aortic arch., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-thoracic Surgery. All rights reserved.)

Introduction: Endovascular technology can now support total endovascular thoracoabdominal aortic aneurysm repair with branches maintaining visceral and renal perfusion thus avoiding the need for massive open surgery. High-volume centres have reported encouraging results. We report our Australasian experience of 10 cases including the first-in-man 'off-the-shelf' graft., Methods: Ten consecutive endovascular repairs performed with prospective data collection have been retrospectively analysed., Results: Six men and four women with an average age of 72.4 years (range 55-85) were treated between 2009 and 2012. The mean aneurysm diameter was 7 cm (range 4.8-10.0) with aneurysms across all five Crawford classifications. One hundred per cent procedural technical success was achieved and all branches and fenestrations were patent at a median follow up of 12 months. In total, 30 branches were utilized together with seven fenestrations. One death from respiratory failure occurred on day 30 without endograft problems and there were two late aneurysm related deaths. Three patients experienced spinal cord ischaemia and one patient experienced two separate late endoleaks. Six patients had successful endografts and remain alive and well., Discussion: For experienced endovascular surgeons working with a proctor 100% technical success in graft deployment is achievable. Endovascular skills alone do not guarantee long-term success; our results demonstrate the need for careful patient selection, the danger of spinal cord ischaemia and the potential for endoleaks., (© 2013 Royal Australasian College of Surgeons.)

Background: Examination of a large collective combined with individual case analyses may give new insights into mechanisms and prevention of spinal cord ischemia (SCI) after thoracic endovascular repair., Methods: In an 11-year period, stent-grafts were implanted in 406 patients for various aortic pathologic conditions. The mean age was 63 years (15-91 years) and 300 (74%) patients were men; 58 patients underwent staged thoracic stent-graft procedures. The length of aorta covered was between 75 and 584 mm (mean, 204 mm). Thoracoabdominal branched or fenestrated stent-grafts were implanted in 11 patients. The left subclavian artery was occluded in 161 patients (39%); this occurred in half of them (n = 78) after protective revascularization. Prophylactic cerebrospinal fluid (CSF) drainage was used selectively in 4 cases; no neuromonitoring was used., Results: The incidence of SCI was 2.7% (n = 11); 6 patients (1.5%) had major permanent deficits. Conditions that had a potential influence on SCI were analyzed. Statistical correlation was found for previous conventional or endovascular abdominal aortic aneurysm repair (odds ratio [OR], 4.8), coverage of the entire descending thoracic aorta (OR, 3.6), and implantation of thoracoabdominal branched and fenestrated stent-grafts (OR, 9.5). Individual analyses revealed other conditions that might have played a role, such as embolization into the segmental arteries, severe visceral ischemia, profound hemorrhagic shock, and heparin-induced thrombocytopenia., Conclusions: The incidence of SCI is unexpectedly low despite extensive sacrifice of intercostal arteries. Extended coverage of the thoracic and thoracoabdominal aorta seems to have a higher risk, but other factors may contribute to the individual disaster., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The optimal use of lumbar cerebrospinal fluid drainage for the prevention of spinal cord ischemia (SCI) with thoracic endovascular aortic repair (TEVAR) remains unclear. Here, we report our experience with selective preoperative lumbar drain placement with TEVAR., Methods: Between May 2002 and January 12, 381 TEVAR procedures were performed at a single referral institution. Preoperative lumbar drains were placed selectively in patients considered high-risk for SCI due to planned long-segment aortic coverage with a history of prior aortic intervention or planned hybrid Crawford extent I to III thoracoabdominal aortic aneurysm repair., Results: Preoperative lumbar drains were placed in 81 patients (21%); of these, drain placement in 38 (47%) was for procedures involving long-segment descending thoracic aortic coverage in the setting of prior descending thoracic or infrarenal aortic repair, and in 43 (53%) was for hybrid thoracoabdominal aortic aneurysm repair. SCI occurred in 12 patients (14.8%) who received a preoperative lumbar drain, transient in 6 (7.4%) and permanent in 6 (7.4%), whereas SCI occurred in 13 patients (4.3%) who did not receive a preoperative lumbar drain, 12 transient (4.0%) and 1 permanent (0.3%). A lumbar drain complication occurred in 9 drain patients (11.1%), although none resulted in permanent disability. Age, postoperative hypotension, and the number of endografts implanted were independently associated with SCI. Preoperative lumbar drain placement was not associated with reduced SCI., Conclusions: Restricted use of preoperative lumbar drains for patients at high-risk of SCI undergoing TEVAR appears safe and leads to low rates of SCI in nondrained patients. However, the utility of preoperative lumbar drains in preventing SCI with TEVAR remains questionable and should be weighed against the risk of drain complications., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: This study assessed the risk of left subclavian artery (LSA) coverage and the role of revascularization in a large population of patients undergoing thoracic endovascular aortic aneurysm repair., Methods: A retrospective multicenter review of 1189 patient records from 2000 to 2010 was performed. Major adverse events evaluated included cerebrovascular accident (CVA) and spinal cord ischemia (SCI). Subgroup analysis was performed for noncovered LSA (group A), covered LSA (group B), and covered/revascularized LSA (group C)., Results: Of 1189 patients, 394 had LSA coverage (33.1%), and 180 of these patients (46%) underwent LSA revascularization. In all patients, emergency operations (9.5% vs 4.3%; P=.001), renal failure (12.7% vs 5.3%; P=.001), hypertension (7% vs 2.3%; P=.01), and number of stents placed (1=3.7%, 2=7.4%, ≥3=10%; P=.005) were predictors of SCI. History of cerebrovascular disease (9.6% vs 3.5%; P=.002), chronic obstructive pulmonary disease (9.5% vs 5.4%; P=.01), coronary artery disease (8.5% vs 5.3%; P=.03), smoking (8.9% vs 4.2%) and female gender (5.3% men vs 8.2% women; P=.05) were predictors of CVA. Subgroup analysis showed no significant difference between groups B and C (SCI, 6.3% vs 6.1%; CVA, 6.7% vs 6.1%). LSA revascularization was not protective for SCI (7.5% vs 4.1%; P=.3) or CVA (6.1% vs 6.4%; P=.9). Women who underwent revascularization had an increased incidence of CVA event compared with all other subgroups (group A: 5.6% men, 8.4% women, P=.16; group B: 6.6% men, 5.3% women, P=.9; group C: 2.8% men, 11.9% women, P=.03)., Conclusions: LSA coverage does not appear to result in an increased incidence of SCI or CVA event when a strategy of selective revascularization is adopted. Selective LSA revascularization results in similar outcomes among the three cohorts studied. Revascularization in women carries an increased risk of a CVA event and should be reserved for select cases., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: To analyse the incidence of stroke after thoracic endovascular aortic repair (TEVAR) for aortic arch disease., Methods: In the last decade, 393 patients received TEVAR at our Institution; in 143 cases the aortic arch was involved (32 zones '0', 35 zones '1' and 76 zone '2'). The left subclavian artery (LSA) was revascularised selectively in 75 cases; the proximal LSA was ligated or occluded with a plug in 55 cases before endograft (EG) deployment., Results: Initial clinical success, perioperative mortality, spinal cord ischaemia and stroke in TEVAR patients with or without arch involvement were, respectively, 86.7% vs. 94.4%, 4.2% vs. 2.4%, 2.1% vs. 3.6% and 2.8% vs. 1.2%. The stroke rate was 9.4% (P < 0.02) in 'zone 0', 0% in 'zone 1' and 1.3% in 'zone 2' with scans showing severe atheroma and/or thrombus in all cases. Stroke was observed in patients with 2.6% or without 2.9% LSA revascularisation; however, it was never observed in patients in whom the LSA was occluded before EG deployment and in 4.5% of patients in whom it was patent at the time of EG deployment., Conclusions: Stroke after TEVAR is not infrequent especially when the arch is involved. Careful patient selection together with a strategy to reduce embolisation such as occlusion of supra-aortic trunks before EG deployment may play a beneficial role., (Copyright © 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Many authors using a hybrid debranching strategy for the treatment of thoracoabdominal pathologies have reported disappointing results and the initial enthusiasm for the technique has given way to criticism and ambiguity. The aim of the present meta-analysis study was to assess the safety and efficacy of the technique in patients with thoracoabdominal aortic aneurysms or other aortic pathologies., Methods and Results: A multiple electronic search was performed on all articles describing hybrid open endovascular repair. Separate meta-analyses were conducted for technical success, visceral graft patency, spinal cord ischemia symptoms, renal insufficiency, and other complications as well as 30-day/in-hospital mortality. Nineteen publications with a total of 507 patients were analyzed. The pooled estimates for primary technical success and visceral graft patency were 96.2% (95% CI, 93.5%-98.2%) and 96.5% (95% CI, 95.2%-97.8%) respectively. A pooled rate of 7.5% (95% CI, 5.0%-11.0%) for overall spinal cord ischemia symptoms was observed; whereas for irreversible paraplegia the pooled rate was 4.5% (95% CI, 2.5%-7.0%). The pooled estimate for renal failure was 8.8% (95% CI, 3.9%-15.5%). The pooled 30-day/in-hospital mortality rate was 12.8% (95% CI, 8.6%-17.0%). During the mean follow-up period of 34.5 (95% CI, 31.5-37.5) months, a total of 119 endoleaks were identified in 111 patients (22.7%)., Conclusions: The repair of thoracoabdominal pathologies by means of hybrid procedures in patients who are poor surgical candidates is still associated with significant morbidity and mortality rates. Future studies may substantiate whether the technique is amenable to amelioration and improvement.

Introduction: A paucity of literature exists regarding spinal cord ischemia and atherosclerosis. Therefore, the present study aimed to review this literature in hopes of better understanding this pathology., Methods: Various search engines and databases were accessed using the following terms "atherosclerosis and spinal cord ischemia", "atherosclerosis and vascular myelopathy", "spinal cord ischemia" and "arteriosclerosis of spinal arteries"., Results: Twenty publications were found to be relevant to the present review. However, very few studies were identified that dealt specifically with atherosclerosis and spinal cord ischemia. The more valid cross-sectional studies indicated that local atherosclerosis in the spinal arterial network is minimal in comparison with the rest of the body. The anterior spinal artery appears to be one of the few arteries affected by atherosclerotic plaque formation. A greater propensity to affect the lower cervical spinal cord and a correlation with advancing age appears to exist. Systemic atherosclerosis may or may not have an effect on ischemia of the spinal cord., Conclusions: Much of the current literature regarding atherosclerosis and spinal cord ischemia is vague and conflicting. Future studies aimed at, for example, imaging of the spinal cord in patients with ischemic-like symptoms are warranted.

Objectives: To synthesize the available evidence regarding the outcomes associated with nonoperative management, open repair, and endovascular repair of thoracic aortic transection., Methods: We searched electronic databases (MEDLINE, EMBASE Cochrane, Web of Science, and Scopus) for studies that enrolled patients with aortic transection and measured the outcomes of interest. Two reviewers determined study eligibility and extracted data. We estimated the event rate associated with the different approaches from case series and the relative risk from comparative studies. Estimates from each study were pooled using the random effects model., Results: We found 139 studies that fulfilled the inclusion criteria, the majority of which were noncomparative surgical case series, retrospective, and none were randomized. Studies included 7768 patients, the majority of which were males. The mortality rate was significantly lower in patients who underwent endovascular repair, followed by open repair and nonoperative management (9%, 19%, and 46%, respectively, P < .01). No significant difference in event rate across the three groups was noted for the outcomes of anterior stroke, posterior stroke, or any stroke. The risk of spinal cord ischemia and end-stage renal disease were higher in open repair compared with the other 2 groups (9% vs 3% and 3%, P = .01 for spinal cord ischemia and 8% vs 5% and 3%, P = .01 for end-stage renal disease). Compared with endovascular repair, open repair was associated with an increased risk of graft infection and systemic infections. Meta-analyses of comparative studies demonstrated that compared with open repair, endovascular repair is associated with reduced mortality and spinal cord ischemia (relative risk, 0.61; 95% confidence interval, 0.46-0.80; and relative risk, 0.34; 95% confidence interval, 0.16-0.74; respectively). Inferences are limited by methodological quality, survival, and publication biases., Conclusions: Very low-quality evidence suggests that, compared with open repair or nonoperative management, endovascular repair of thoracic aortic transection is associated with better survival and decreased risk of spinal cord ischemia, renal injury, and graft and systemic infections. Nonoperative management is associated with the least favorable outcomes., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: Spinal cord ischemia after open surgical repair for rAAA is a rare event. We estimated the current incidence and tried to identify risk factors. We also report a new case., Methods: Group A consisted of 10 reports on open repair for rAAA from 1980 until 2009. Only series of ≥100 patients were considered to estimate the incidence. Thirty three case reports from 1956 until 2009 were identified (group B). Case reports from group B were not encountered in group A. Group B patients were stratified according to the type of neurological deficit as described by Gloviczki (type I complete infarction and type II infarction of the anterior two third)., Results: Group A consisted of 1438 patients. In group A 86% were male with a mean age of 72.1 years. The incidence of post-operative paraplegia was 1.2% (range 0-2.8%). In-hospital mortality was 46.9%. Of the 33 patients of group B were 86% male with a mean age of 68.0 years. Most patients developed a type I (42%) or type II (33%) deficit. In-hospital mortality was 51.6%. No significant differences between different types were encountered., Conclusion: Spinal cord ischemia after ruptured AAA is a rare complication with an incidence of 1.2% (range 0-2.8%)., (Copyright © 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)