Mechanisms of symptomatic spinal cord ischemia after TEVAR: insights from the European Registry of Endovascular Aortic Repair Complications (EuREC).
OBJECTIVE
To test the hypothesis that simultaneous closure of at least 2 independent vascular territories supplying the spinal cord and/or prolonged hypotension may be associated with symptomatic spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR).


METHODS
A pattern matching algorithm was used to develop a risk model for symptomatic SCI using a prospective 63-patient single-center cohort to test the positive predictive value (PPV) of prolonged intraoperative hypotension and/or simultaneous closure of at least 2 of 4 the vascular territories supplying the spinal cord (left subclavian, intercostal, lumbar, and hypogastric arteries). This risk model was then applied to data extracted from the multicenter European Registry on Endovascular Aortic Repair Complications (EuREC). Between 2002 and 2010, the 19 centers participating in EuREC reported 38 (1.7%) cases of symptomatic spinal cord ischemia among the 2235 patients in the database.


RESULTS
In the single-center cohort, direct correlations were seen between the occurrence of symptomatic SCI and both prolonged intraoperative hypotension (PPV 1.00, 95% CI 0.22 to 1.00, p=0.04) and simultaneous closure of at least 2 independent spinal cord vascular territories (PPV 0.67, 95% CI 0.24 to 0.91, p=0.005). Previous closure of a single vascular territory was not associated with an increased risk of symptomatic spinal cord ischemia (PPV 0.07, 95% CI 0.01 to 0.16, p=0.56). The combination of prolonged hypotension and simultaneous closure of at least 2 territories exhibited the strongest association (PPV 0.75, 95% CI 0.38 to 0.75, p<0.0001). Applying the model to the entire EuREC cohort found an almost perfect agreement between the predicted and observed risk factors (kappa 0.77, 95% CI 0.65 to 0.90).


CONCLUSIONS
Extensive coverage of intercostal arteries alone by a thoracic stent-graft is not associated with symptomatic SCI; however, simultaneous closure of at least 2 vascular territories supplying the spinal cord is highly relevant, especially in combination with prolonged intraoperative hypotension. As such, these results further emphasize the need to preserve the left subclavian artery during TEVAR.
Department of Cardiovascular Surgery, Inselspital, University Hospital Berne, Switzerland. martin.czerny@insel.ch
Martin
M
Czerny
Holger
H
Eggebrecht
Gottfried
G
Sodeck
Fabio
F
Verzini
Piergiorgio
P
Cao
Gabriele
G
Maritati
Vicente
V
Riambau
Friedhelm
F
Beyersdorf
Bartosz
B
Rylski
Martin
M
Funovics
Christian
C
Loewe
Jürg
J
Schmidli
Piergiorgio
P
Tozzi
Ernst
E
Weigang
Toru
T
Kuratani
Ugolino
U
Livi
Giampiero
G
Esposito
Santi
S
Trimarchi
Jos C
JC
van den Berg
Weiguo
W
Fu
Roberto
R
Chiesa
Germano
G
Melissano
Luca
L
Bertoglio
Lars
L
Lonn
Ingrid
I
Schuster
Michael
M
Grimm
D000368:Aged; D000465:Algorithms; D001013:Aorta, Thoracic / Q000503:physiopathology / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000503:physiopathology / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects*; D057225:Data Mining; D057510:Endovascular Procedures / Q000009:adverse effects*; D005060:Europe; D005260:Female; D006801:Humans; D007022:Hypotension / Q000150:complications; D008297:Male; D008875:Middle Aged; D010363:Pattern Recognition, Automated; D011446:Prospective Studies; D012039:Regional Blood Flow; D012042:Registries; D015203:Reproducibility of Results; D018570:Risk Assessment; D012307:Risk Factors; D020760:Spinal Cord Ischemia / Q000209:etiology* / Q000503:physiopathology; D013348:Subclavian Artery / Q000503:physiopathology; D016896:Treatment Outcome