title: Lower extremity weakness after endovascular aneurysm repair with multibranched thoracoabdominal stent grafts.
abstract: OBJECTIVE
  We conducted our study to describe the incidence, presentation, management, risk factors, and outcomes of lower extremity weakness (LEW) after elective endovascular aneurysm repair with multibranched thoracoabdominal stent grafts.
  
  
  METHODS
  Excluding symptomatic patients and those with aortic dissection, between July 2005 and October 2013, 116 patients with aortic aneurysms were treated in a prospective, single-center trial of multibranched endovascular aneurysm repair. LEW that resolved within 30 days of operation was classified as transient. Persistent LEW was defined as inability to walk or stand 30 days after surgery. Perioperative spinal cord protection measures included bypass as needed to maintain flow to the subclavian and internal iliac arteries, cerebrospinal fluid drainage, and permissive hypertension.
  
  
  RESULTS
  Postoperative LEW occurred in 24 of 116 patients (20.6%). In 15 (12.9%), LEW was transient with full recovery. Nine patients (7.7%) had persistent LEW, three with paraparesis and six with paraplegia. Five of 24 patients (21%) awoke from anesthesia with LEW. Symptoms of LEW developed within 72 hours of operation in 14 of 24 (58%). Late-onset LEW (≥72 hours postoperatively) always occurred in the presence of a precipitating hypotensive event (5 of 24; 21%). Univariate analysis showed no association between LEW and Crawford type, staged repair, aneurysm extent, or postoperative endoleak. Baseline glomerular filtration rate <30 mL/min/1.73 m(2) (odds ratio [OR], 4.2; 95% confidence interval [CI], 1.2-14.6; P = .03), fluoroscopy time >190 minutes (OR, 3.6; 95% CI, 1.0-12.7; P = .04), and sustained hypotension (OR, 2.9; 95% CI, 1.1-7.7; P = .04) were identified as independent risk factors for LEW in multivariate analysis.
  
  
  CONCLUSIONS
  Most episodes of LEW after multibranched endovascular aneurysm repair are transient and do not occur in the operating room. Adjunctive strategies to maintain spinal perfusion, including cerebrospinal fluid drainage and permissive hypertension, may help prevent permanent LEW.
authors.affiliation: Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif. Electronic address: julia.sobel@ucsfmedctr.org.
authors.forename: Julia D
authors.initials: JD
authors.lastname: Sobel
authors.affiliation: Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
authors.forename: Shant M
authors.initials: SM
authors.lastname: Vartanian
authors.affiliation: Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
authors.forename: Warren J
authors.initials: WJ
authors.lastname: Gasper
authors.affiliation: Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
authors.forename: Jade S
authors.initials: JS
authors.lastname: Hiramoto
authors.affiliation: Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
authors.forename: Timothy A M
authors.initials: TA
authors.lastname: Chuter
authors.affiliation: Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
authors.forename: Linda M
authors.initials: LM
authors.lastname: Reilly
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation; D016009:Chi-Square Distribution; D017558:Elective Surgical Procedures; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation; D005260:Female; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D035002:Lower Extremity; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D018908:Muscle Weakness / Q000453:epidemiology* / Q000503:physiopathology / Q000628:therapy; D018482:Muscle, Skeletal / Q000294:innervation*; D016017:Odds Ratio; D020335:Paraparesis / Q000453:epidemiology; D010264:Paraplegia / Q000453:epidemiology; D011446:Prospective Studies; D011474:Prosthesis Design; D012307:Risk Factors; D012495:San Francisco / Q000453:epidemiology; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome