Perioperative management to improve neurologic outcome in thoracic or thoracoabdominal aortic stent-grafting.
BACKGROUND
Thoracic or thoracoabdominal aortic stent-graft repair has shown a reduction in morbidity and mortality rates due to the procedure's advantages (no aortic cross-clamping, continuous distal aortic perfusion, no reperfusion injury). However, 3% to 12% of the patients are at risk of spinal cord ischemia. We investigated spinal cord protective measures with evoked potentials, cerebrospinal fluid drainage, and prevention of hypotension to minimize postoperative neurologic deficit.


METHODS
Between November 2000 and July 2005, vital parameters and spinal cord function were monitored, including cerebrospinal fluid pressure and transcranial motor-evoked and somatosensory-evoked potentials in 36 stent-graft procedures (31 patients) on the thoracic or thoracoabdominal aorta.


RESULTS
Stent-graft placement was technically successful in all patients. We achieved a survival rate of 100% without neurologic deficit after fast-track extubation. Eleven of 31 patients exhibited changes in evoked potentials during stent-graft deployment. In 12 of 31 patients (including the 11 with evoked potential alterations), cerebrospinal fluid pressure exceeded 15 mm Hg. Cerebrospinal fluid drainage and vital parameter adjustment were executed in those instances. We observed intraoperative evoked potential total recovery in 10 of 11 patients after these interventions.


CONCLUSIONS
Interventions to improve spinal cord perfusion led to total recovery of spinal function in most patients (10/11). Therefore, spinal cord protective measures with motor- and somatosensory-evoked potential monitoring, cerebrospinal fluid drainage, and prevention of hypotension can reduce the incidence of spinal cord ischemia and improve the neurologic outcome of patients undergoing endovascular thoracic or thoracoabdominal aortic repair.
Weigang
Ernst
E
Department of Cardiovascular Surgery, University Hospital Freiburg, Freiburg, Germany. ernst.weigang@web.de
Hartert
Marc
M
Siegenthaler
Michael P
MP
Beckmann
Nicholas A
NA
Sircar
Ronen
R
Szabò
Gàbor
G
Etz
Christian D
CD
Luehr
Maximilian
M
von Samson
Patrick
P
Beyersdorf
Friedhelm
F
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects; D002555:Cerebrospinal Fluid; D004322:Drainage; D005071:Evoked Potentials; D006801:Humans; D007022:Hypotension / Q000517:prevention & control; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D010264:Paraplegia / Q000209:etiology; D013116:Spinal Cord / Q000098:blood supply / Q000502:physiology; D015607:Stents