Safety of cerebrospinal fluid drainage for spinal cord ischemia prevention in thoracic endovascular aortic repair

John R Spratt; Kristen L Walker; Tyler J Wallen; Dan Neal; Yury Zasimovich; George J Arnaoutakis; Tomas D Martin; Martin R Back; Salvatore T Scali; Thomas M Beaver

doi:10.1016/j.xjtc.2022.05.001

Safety of cerebrospinal fluid drainage for spinal cord ischemia prevention in thoracic endovascular aortic repair

JTCVS Tech. 2022 May 11:14:9-28. doi: 10.1016/j.xjtc.2022.05.001. eCollection 2022 Aug.

Affiliations

¹ Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla.
² Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, Fla.
³ Acute and Perioperative Pain Medicine Division, Department of Anesthesia, University of Florida, Gainesville, Fla.

Abstract

Objective: Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) is associated with permanent neurologic deficit and decreased survival. Prophylactic cerebrospinal fluid (CSF) drainage (CSFD) in TEVAR is controversial. We evaluated the usage of CSFD in TEVAR at our tertiary aortic center.

Methods: Our institutional TEVAR database was reviewed to determine the frequency of CSFD usage/complications. Complications were categorized as mild (headache/CSF leak not requiring intervention, urinary retention), moderate (headache/CSF leak requiring intervention, drain malfunction requiring replacement), or severe (intrathecal hemorrhage, CSFD-attributable neurologic deficit). The relationships between CSFD complications and patient/procedural characteristics, CSFD placement timing, and survival were analyzed.

Results: Nine hundred thirty-six TEVAR procedures were performed in 869 patients from 2011 to 2020. Three hundred ninety CSFD drains were placed in 373 (41.7%) TEVAR patients. Most CSFD drains (89.5%) were pre-TEVAR. Most post-TEVAR drains were placed for new SCI symptoms (n = 21). Twenty-five patients (6.4%) suffered 32 CSFD complications. Most (n = 17) were mild in severity. Severe CSFD complications occurred in 5/432 (1.1% CSF drains) patients. No patient/procedural characteristics were predictive of CSFD complications. Post implant CSFD placement for new SCI symptoms conferred an increased risk of CSFD complication (odds ratio, 6.9; 95% CI, 2.42-19.6; P < .01). The long-term survival of the CSFD complication cohort did not differ from the overall population.

Conclusions: Post-TEVAR CSFD placement for new SCI symptoms was associated with substantially greater risk of CSFD complications. Avoidance of post-implant therapeutic drain placement might be the key to prevention of CSFD complications, favoring a strategy of selective pre-implant drain placement in patients at higher risk for SCI.

Keywords: APS, acute pain service; B/FEVAR, branched/fenestrated endovascular aortic repair; CSF, cerebrospinal fluid; CSFD, cerebrospinal fluid drainage; CT, computed tomography; EDH, epidural hematoma; ICH, intracranial hemorrhage; PDPH, post dural puncture headache; SCI, spinal cord ischemia; TAA, thoracic aortic aneurysm; TEVAR, thoracic endovascular aortic repair; aortic aneurysm; cerebrospinal fluid drain; perioperative management; spinal cord ischemia; thoracic endovascular aortic repair.