title: Spinal cord ischemia after thoracic stent-grafting: causes apart from intercostal artery coverage.
abstract: BACKGROUND
  Examination of a large collective combined with individual case analyses may give new insights into mechanisms and prevention of spinal cord ischemia (SCI) after thoracic endovascular repair.
  
  
  METHODS
  In an 11-year period, stent-grafts were implanted in 406 patients for various aortic pathologic conditions. The mean age was 63 years (15-91 years) and 300 (74%) patients were men; 58 patients underwent staged thoracic stent-graft procedures. The length of aorta covered was between 75 and 584 mm (mean, 204 mm). Thoracoabdominal branched or fenestrated stent-grafts were implanted in 11 patients. The left subclavian artery was occluded in 161 patients (39%); this occurred in half of them (n = 78) after protective revascularization. Prophylactic cerebrospinal fluid (CSF) drainage was used selectively in 4 cases; no neuromonitoring was used.
  
  
  RESULTS
  The incidence of SCI was 2.7% (n = 11); 6 patients (1.5%) had major permanent deficits. Conditions that had a potential influence on SCI were analyzed. Statistical correlation was found for previous conventional or endovascular abdominal aortic aneurysm repair (odds ratio [OR], 4.8), coverage of the entire descending thoracic aorta (OR, 3.6), and implantation of thoracoabdominal branched and fenestrated stent-grafts (OR, 9.5). Individual analyses revealed other conditions that might have played a role, such as embolization into the segmental arteries, severe visceral ischemia, profound hemorrhagic shock, and heparin-induced thrombocytopenia.
  
  
  CONCLUSIONS
  The incidence of SCI is unexpectedly low despite extensive sacrifice of intercostal arteries. Extended coverage of the thoracic and thoracoabdominal aorta seems to have a higher risk, but other factors may contribute to the individual disaster.
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany. zipfel@dhzb.de
authors.forename: Burkhart
authors.initials: B
authors.lastname: Zipfel
authors.forename: Semih
authors.initials: S
authors.lastname: Buz
authors.forename: Mathias
authors.initials: M
authors.lastname: Redlin
authors.forename: Dietrich
authors.initials: D
authors.lastname: Hullmeine
authors.forename: Robert
authors.initials: R
authors.lastname: Hammerschmidt
authors.forename: Roland
authors.initials: R
authors.lastname: Hetzer
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001013:Aorta, Thoracic / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D005260:Female; D005500:Follow-Up Studies; D005858:Germany / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012189:Retrospective Studies; D020760:Spinal Cord Ischemia / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology*; D015607:Stents; D013895:Thoracic Arteries / Q000601:surgery*; D055815:Young Adult