title: Strategies to improve spinal cord ischemia in endovascular thoracic aortic repair: Outcomes of a prospective cerebrospinal fluid drainage protocol.
abstract: OBJECTIVE
  Although endovascular repair of thoracic aortic aneurysm has been shown to reduce the morbidity and mortality rates, spinal cord ischemia remains a persistent problem. We evaluated our experience with spinal cord protective measures using a standardized cerebrospinal fluid (CSF) drainage protocol in patients undergoing endovascular thoracic aortic repair.
  
  
  METHODS
  From 2004 to 2006, 121 patients underwent elective (n = 52, 43%) and emergent (n = 69, 57%) endovascular thoracic aortic stent graft placement for thoracic aortic aneurysm (TAA) (n = 94, 78%), symptomatic penetrating ulceration (n = 11, 9%), pseudoaneurysms (n = 5, 4%) and traumatic aortic transactions (n = 11, 9%). In 2005, routine use of a CSF drainage protocol was established to minimize the risks of spinal cord ischemia. The CSF was actively drained to maintain pressures <15 mm Hg and the mean arterial blood pressures were maintained at >/=90 mm Hg. Data was prospectively collected in our vascular registry for elective and emergent endovascular thoracic aortic repair and the patients were divided into 2 groups (+CSF drainage protocol, -CSF drainage protocol). A chi(2) statistical analysis was performed and significance was assumed for P < .05.
  
  
  RESULTS
  Of the 121 patients with thoracic stent graft placement, the mean age was 72 years, 62 (51%) were male, and 56 (46%) underwent preoperative placement of a CSF drain, while 65 (54%) did not. Both groups had similar comorbidities of coronary artery disease (24 [43%] vs 27 [41%]), hypertension (44 [79%] vs 50 [77%]), chronic obstructive pulmonary disease (18 [32%] vs 22 [34%]), and chronic renal insufficiency (10 [17%] vs 12 [18%]). None of the patients with CSF drainage developed spinal cord ischemia (SCI), and 5 (8%) of the patients without CSF drainage developed SCI within 24 hours of endovascular repair (P< .05). All patients with clinical symptoms of SCI had CSF drain placement and augmentation of systemic blood pressures to >/=90 mm Hg, and 60% (3 of 5 patients) demonstrated marked clinical improvement.
  
  
  CONCLUSIONS
  Perioperative CSF drainage with augmentation of systemic blood pressures may have a beneficial role in reducing the risk of paraplegia in patients undergoing endovascular thoracic aortic stent graft placement. However, selective CSF drainage may offer the same benefit as mandatory drainage.
authors: The Vascular Group and Albany Medical Center Hospital, Albany Medical College, Albany, NY, USA.
authors: Jeffrey C
authors: JC
authors: Hnath
authors: Manish
authors: M
authors: Mehta
authors: John B
authors: JB
authors: Taggert
authors: Yaron
authors: Y
authors: Sternbach
authors: Sean P
authors: SP
authors: Roddy
authors: Paul B
authors: PB
authors: Kreienberg
authors: Kathleen J
authors: KJ
authors: Ozsvath
authors: Benjamin B
authors: BB
authors: Chang
authors: Dhiraj M
authors: DM
authors: Shah
authors: R Clement
authors: RC
authors: Darling
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D002555:Cerebrospinal Fluid; D002985:Clinical Protocols; D004322:Drainage; D005260:Female; D006801:Humans; D008297:Male; D011183:Postoperative Complications / Q000517:prevention & control*; D011446:Prospective Studies; D020760:Spinal Cord Ischemia / Q000517:prevention & control*; D016896:Treatment Outcome