title: Staged endovascular repair of thoracoabdominal aortic aneurysms limits incidence and severity of spinal cord ischemia.
abstract: OBJECTIVE
  Neurologic dysfunction remains a persistent complication of extensive aortic repair owing to disruption of the spinal collateral network. We hypothesized that staged repair might mitigate the incidence and severity of this spinal cord ischemia (SCI).
  
  
  METHODS
  We conducted a retrospective cohort study of patients undergoing a Crawford type II repair of a thoracoabdominal aortic aneurysm between January 2008 and July 2013. Baseline demographics, incidence of prior aortic surgery, comorbidities, and outcomes were prospectively recorded. Staged repair was defined as intentional completion of the endovascular repair as two temporally separate procedures, referred to as a two-stage repair. Extent of aortic cover was calculated by three-dimensional imaging and reported as the proportion of the aorta covered between the left subclavian artery and the aortic bifurcation. Primary outcome measures were incidence and severity of SCI and mortality.
  
  
  RESULTS
  The study included 87 patients, divided into the following subgroups: single-stage repair (n = 32; repair in a single procedure, without prior aortic surgery), two-stage repair (n = 27; repair in two separate procedures, without prior aortic surgery), and unintentionally staged repair (n = 28; those with prior aortic surgery, without an intention to stage). Median time between stages was 5 months (range, 1-60 months). All groups were equivalent in terms of demographics and risk factors; however, the staged group had significantly greater proximal aortic cover (P = .001). The overall rates of SCI in the nonstaged and staged groups were 37.5% (12 of 32) and 11.1% (3 of 27), respectively (P = .03). Furthermore, all neurologic injuries in the staged group were temporary. The 30-day survival in the single-stage, two-stage, and unintentionally staged repairs was 18.8%, 0%, and 10.7%, respectively (P = .52).
  
  
  CONCLUSIONS
  Staged repair appears both to protect against SCI and to enhance overall survival in extensive aortic repair.
authors.affiliation: Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Adrian
authors.initials: A
authors.lastname: O'Callaghan
authors.affiliation: Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Tara M
authors.initials: TM
authors.lastname: Mastracci
authors.affiliation: Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio. Electronic address: eagletm@ccf.org.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Eagleton
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D057510:Endovascular Procedures / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009820:Ohio / Q000453:epidemiology; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D020760:Spinal Cord Ischemia / Q000175:diagnosis / Q000401:mortality / Q000517:prevention & control*; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome