title: The impact of early pelvic and lower limb reperfusion and attentive peri-operative management on the incidence of spinal cord ischemia during thoracoabdominal aortic aneurysm endovascular repair.
abstract: OBJECTIVE
  Spinal cord ischemia (SCI) is a devastating complication following endovascular thoracoabdominal aortic aneurysm (TAAA) repair. In an attempt to reduce its incidence two peri-procedural changes were implemented by the authors in January 2010: (i) all large sheaths are withdrawn from the iliac arteries immediately after deploying the central device and before cannulation and branch extension to the visceral vessels; (ii) the peri-operative protocol has been modified in an attempt to optimize oxygen delivery to the sensitive cells of the cord (aggressive blood and platelet transfusion, median arterial pressure monitoring >85 mmHg, and systematic cerebrospinal fluid drainage).
  
  
  METHODS
  Between October 2004 and December 2013, 204 endovascular TAAA repairs were performed using custom made devices manufactured with branches and fenestrations to maintain visceral vessel perfusion. Data from all of these procedures were prospectively collected in an electronic database. Early post-operative results in patients treated before (group 1, n = 43) and after (group 2, n = 161 patients) implementation of the modified implantation and peri-operative protocols were compared.
  
  
  RESULTS
  Patients in groups 1 and 2 had similar comorbidities (median age at repair 70.9 years [range 65.2-77.0 years]), aneurysm characteristics (median diameter 58.5 mm [range 53-65 mm]), and length of procedure (median 190 minutes [range 150-240 minutes]). The 30 day mortality rate was 11.6% in group 1 versus 5.6% in group 2 (p = .09). The SCI rate was 14.0% versus 1.2% (p < .01). If type IV TAAAs were excluded from this analysis, the SCI rate was 25.0% (6/24 patients) in group 1 versus 2.1% (2/95 patients) in group 2 (p < .01).
  
  
  CONCLUSIONS
  The early restoration of arterial flow to the pelvis and lower limbs, and aggressive peri-operative management significantly reduces SCI following type I-III TAAA endovascular repair. With the use of these modified protocols, extensive TAAA endovascular repairs are associated with low rates of SCI.
authors.affiliation: Aortic Centre, Hôpital Cardiologique, CHRU de Lille, INSERM U1008, Université Lille Nord de France, 59037 Lille Cedex, France.
authors.forename: B
authors.initials: B
authors.lastname: Maurel
authors.affiliation: Aortic Centre, Hôpital Cardiologique, CHRU de Lille, INSERM U1008, Université Lille Nord de France, 59037 Lille Cedex, France.
authors.forename: N
authors.initials: N
authors.lastname: Delclaux
authors.affiliation: Aortic Centre, Hôpital Cardiologique, CHRU de Lille, INSERM U1008, Université Lille Nord de France, 59037 Lille Cedex, France.
authors.forename: J
authors.initials: J
authors.lastname: Sobocinski
authors.affiliation: Aortic Centre, Hôpital Cardiologique, CHRU de Lille, INSERM U1008, Université Lille Nord de France, 59037 Lille Cedex, France.
authors.forename: A
authors.initials: A
authors.lastname: Hertault
authors.affiliation: Aortic Centre, Hôpital Cardiologique, CHRU de Lille, INSERM U1008, Université Lille Nord de France, 59037 Lille Cedex, France.
authors.forename: T
authors.initials: T
authors.lastname: Martin-Gonzalez
authors.affiliation: Aortic Centre, Hôpital Cardiologique, CHRU de Lille, INSERM U1008, Université Lille Nord de France, 59037 Lille Cedex, France.
authors.forename: M
authors.initials: M
authors.lastname: Moussa
authors.affiliation: Aortic Centre, Hôpital Cardiologique, CHRU de Lille, INSERM U1008, Université Lille Nord de France, 59037 Lille Cedex, France.
authors.forename: R
authors.initials: R
authors.lastname: Spear
authors.affiliation: Aortic Centre, Hôpital Cardiologique, CHRU de Lille, INSERM U1008, Université Lille Nord de France, 59037 Lille Cedex, France.
authors.forename: M
authors.initials: M
authors.lastname: Le Roux
authors.affiliation: Aortic Centre, Hôpital Cardiologique, CHRU de Lille, INSERM U1008, Université Lille Nord de France, 59037 Lille Cedex, France.
authors.forename: R
authors.initials: R
authors.lastname: Azzaoui
authors.affiliation: King's Health Partners, London, UK.
authors.forename: M
authors.initials: M
authors.lastname: Tyrrell
authors.affiliation: Aortic Centre, Hôpital Cardiologique, CHRU de Lille, INSERM U1008, Université Lille Nord de France, 59037 Lille Cedex, France. Electronic address: stephan.haulon@chru-lille.fr.
authors.forename: S
authors.initials: S
authors.lastname: Haulon
mesh_terms: D000368:Aged; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D015897:Comorbidity; D016208:Databases, Factual; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods* / Q000401:mortality; D005260:Female; D005602:France / Q000453:epidemiology; D061847:Hospitals, High-Volume; D006801:Humans; D015994:Incidence; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D010388:Pelvis / Q000098:blood supply*; D011474:Prosthesis Design; D012039:Regional Blood Flow; D018570:Risk Assessment; D012307:Risk Factors; D020760:Spinal Cord Ischemia / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000517:prevention & control*; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome
keywords: Endovascular repair; Peri-operative management; Spinal cord ischemia; Thoracoabdominal aortic aneurysm