title: TEVAR following prior abdominal aortic aneurysm surgery: increased risk of neurological deficit.
abstract: OBJECTIVE
  Evidence regarding the impact of prior abdominal aortic aneurysm (AAA) repair on the risk of neurological deficit after thoracic endovascular aortic aneurysm repair (TEVAR) is lacking. The purpose of this study was to characterize the risk of TEVAR-related neurological deficit in patients who previously underwent infrarenal AAA surgery.
  
  
  METHODS
  Prospective maintained databases of patients undergoing TEVAR in the participating institutions were searched for patients with a history of prior AAA surgery before TEVAR. Patient and procedural characteristics and postoperative mortality and morbidity were subsequently centrally collected and systematically entered in a database. Univariate and multivariate logistic regression were performed associating variables with postoperative spinal cord ischemia (SCI).
  
  
  RESULTS
  Seventy-two patients were identified that underwent TEVAR after prior AAA repair. The risk of SCI was 12.5% (n = 9) and significantly higher than the 1.7% risk of SCI in patients without prior AAA repair (relative risk [RR] 7.2, 95% confidence interval [CI] 2.6 to 19.6, P < .0001). Symptoms of SCI completely resolved in 4 patients with prior AAA repair. Univariate analysis demonstrated that the following variables were significant predictors of SCI in patients with prior AAA repair: preoperative renal insufficiency (odds ratio [OR] 29.5; 95% CI 5.3-164, P < .001), increased length of aorta coverage by TEVAR (OR 1.1; 95% CI 1.0-1.2, P .039) and a lengthened time interval between prior AAA repair and TEVAR (OR 1.2; 95% CI 1.0-1.4, P .026). Preoperative renal insufficiency was also significantly associated with the risk of SCI in multivariate analysis (P .011).
  
  
  CONCLUSIONS
  Prior infrarenal AAA repair is associated with dramatic increased risk of SCI after TEVAR compared to patients without prior AAA surgery. Preoperative renal insufficiency appears to be an important predictor of SCI after TEVAR in patients with prior AAA repair. A thorough understanding of the risk profile in patients requiring TEVAR following prior AAA surgery is essential when determining appropriate surgical recommendations. If the diameter and rupture risk are large and TEVAR is indicated, the best available care should be offered for maximal protection of the spinal cord in these patients.
authors.affiliation: Section of Vascular Surgery, Yale University, New Haven, Connecticut 06510, USA.
authors.forename: Felix J V
authors.initials: FJ
authors.lastname: Schlösser
authors.forename: Hence J M
authors.initials: HJ
authors.lastname: Verhagen
authors.forename: Peter H
authors.initials: PH
authors.lastname: Lin
authors.forename: Eric L G
authors.initials: EL
authors.lastname: Verhoeven
authors.forename: Joost A
authors.initials: JA
authors.lastname: van Herwaarden
authors.forename: Frans L
authors.initials: FL
authors.lastname: Moll
authors.forename: Bart E
authors.initials: BE
authors.lastname: Muhs
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000150:complications* / Q000000981:diagnostic imaging / Q000601:surgery; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000601:surgery*; D001027:Aortography / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects*; D019992:Databases as Topic; D005260:Female; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D016017:Odds Ratio; D051437:Renal Insufficiency / Q000150:complications; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D020760:Spinal Cord Ischemia / Q000209:etiology*; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014481:United States