Cerebrospinal fluid drainage during thoracic aortic repair: safety and current management.
BACKGROUND
The benefit of cerebrospinal fluid (CSF) drainage during thoracic aortic repair has been established. Few studies, however, report management and safety of CSF drainage.


METHODS
Between September 1992 and August 2007, 1,353 repairs of the thoracic aorta were performed, with 82% using CSF drainage. The CSF drainage was not used in cases of rupture, acute trauma, infection, or prior paraplegia. Thirty-one percent (76 of 246) of patients without CSF drainage were repaired prior to standardized use. All drains were inserted by cardiovascular anesthesia staff. Repairs were performed using distal aortic perfusion with heparinization. Early management involved free drainage to maintain CSF pressure less than 10 mm Hg, but was later modified to limit CSF drainage unless neurologic deficit occurred.


RESULTS
Cerebrospinal fluid drainage was technically achieved in 99.8% (1,105 of 1,107) of cases. The CSF catheter-related complications occurred in 1.5% (17 of 1,107) of patients. No spinal hematomas were observed. The CSF leaks with spinal headache, CSF leak without spinal headache, spinal headache, intracranial hemorrhage, catheter fracture, and meningitis occurred in 6 (0.54%), 1 (0.1%), 2 (0.2%), 5 (0.45%), 1 (0.1%), and 2 (0.2%) cases, respectively. Mortality from subdural hematoma was 40% (2 of 5), and from meningitis was 50% (1 of 2). Spinal headaches resolved with conservative management. All CSF leaks resolved, but 71% (5/7) required blood patches. Since implementation of a limited CSF drainage protocol, no subdural hematomas have been observed.


CONCLUSIONS
Cerebrospinal fluid drainage for thoracic aortic repairs can be performed safely with excellent technical success. Perioperative management of CSF drains requires diligent monitoring and judicious drainage. Standardizing CSF management may be beneficial.
Estrera
Anthony L
AL
Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School Houston, Houston, Texas, USA. anthony.l.estrera@uth.tmc.edu
Sheinbaum
Roy
R
Miller
Charles C
CC
Azizzadeh
Ali
A
Walkes
Jon-Cecil
JC
Lee
Taek-Yeon
TY
Kaiser
Larry
L
Safi
Hazim J
HJ
D000328:Adult; D000368:Aged; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D002315:Cardiopulmonary Bypass / Q000379:methods; D002555:Cerebrospinal Fluid; D015331:Cohort Studies; D003131:Combined Modality Therapy; D004322:Drainage; D004502:Education, Medical, Continuing; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007430:Intraoperative Care / Q000379:methods*; D008297:Male; D008875:Middle Aged; D010264:Paraplegia / Q000517:prevention & control; D011183:Postoperative Complications / Q000517:prevention & control; D011859:Radiography; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000379:methods*