Selective Lumbar Spinal Drainage Counters Ischemia After TEVAR

NAPLES, FLA. – Selective lumbar spinal drainage is worthwhile to reduce adverse neurologic outcomes for patients who develop symptoms of spinal cord ischemia after thoracic aortic endograft repair, according to a retrospective study.

Although surgeons who perform open aortic repair commonly employ perioperative lumbar spinal drainage, there is no consensus regarding drain placement for spinal cord ischemia (SCI) that is associated with thoracic endovascular aorta repair (TEVAR), Charles J. Keith said at the annual meeting of the Southern Association for Vascular Surgery.

Mr. Keith, a medical student at the University of Alabama at Birmingham, and his associates reviewed 10 years of experience at their institution to compare outcomes between drained and nondrained patients. Of 266 TEVAR interventions in 239 patients, of whom 167 (70%) were men, between January 2000 and June 2010, 16 (7% of cases) developed SCI within 30 days.

History of stroke, infrarenal pathology, and a longer aortic coverage in centimeters were significant risk factors for SCI in this patient population, Mr. Keith said. There were 147 interventions that involved aneurysms in the study, accounting for just more than half of the aortic pathology treated.

Left subclavian artery stent graft coverage was required in 80 interventions (30%), but it was not significantly associated with SCI.

Study discussant Dr. Peter H. Lin asked about routine or prophylactic drainage for patients with these risk factors. "Use of prophylactic drainage is supported by some, but we would have deployed an extra 105 unnecessary drains in this population," Mr. Keith replied. "There are risks associated with drainage, such as epidural hematoma, as was experienced by one of our patients."

Patients who developed SCI were three times more likely to die within 1 year, compared with non-SCI patients (odds ratio, 3.0).

Focus your efforts on complete symptom recovery after TEVAR and perform frequent neurologic assessments of high-risk patients, Mr. Keith said. These actions will minimize time to drain placement when indicated, improve symptom resolution, and increase 1-year survival.

In all, 10 of the 16 SCI cases were drained. There were no significant differences in terms of risk factors or demographics between drained and nondrained patients. Of the 10 drained cases, three patients experienced complete neurologic symptom resolution, four had partial resolution, and three had no resolution. Of the six patients who were not drained, four experienced complete resolution and two experienced no resolution.

Another aim of the study was to evaluate a drainage protocol adopted at their institution. Since 2007, all patients receive a neurologic evaluation post TEVAR. If they show any symptoms of neurologic deficit, their mean arterial pressure is increased to greater than 110 mm Hg, and the frequency of neurologic exams increases to hourly. Also, a lumbar drain is immediately placed if they have a major deficit and within 3 hours if minor symptoms persist postoperatively.

Although patients who experienced SCI after TEVAR had diminished outcomes, compared with non-SCI patients, the study supports the use of a spinal drainage protocol to improve neurologic outcomes in a select patient population, Mr. Keith said.

There are reports that support the use of steroids to reduce swelling and spinal cord edema, said Dr. Lin of the division of vascular and endovascular therapy at Baylor College of Medicine, Houston.

"Steroids are not included in our protocol, but it’s definitely something to consider," Mr. Keith said.

Dr. Lin asked if the study findings have changed the treatment approach at the University of Alabama. Mr. Keith deferred to Dr. William D. Jordan Jr., a coauthor of the study and moderator of this session at the meeting.

"We seek input from neurologic surgeons and anesthesia to help us place the drains in a more timely fashion," said Dr. Jordan, chief of vascular surgery at the University of Alabama.

A meeting attendee commented that that approach might work at the University of Alabama, but what if feedback from neurosurgery or anesthesia is not available in a timely fashion at another institution?

"In some places, they place a drain the night before in the ICU. If that works at your institution, fine," Dr. Jordan said.

Another attendee asked about the 3-hour window before drain placement. Dr. Jordan replied, "We are basically telling anesthesia: ‘We need these [patients] awake to make sure they are kicking their legs.’ That is why we chose 3 hours for recovery, but we can often tell within 1 hour if the [patient] is moving."

There is no consensus on measures to prevent SCI, Mr. Keith said. In addition to lumbar drainage, others report use of vasopressors to increase mean arterial pressure and predeployment aortic occlusion to detect diminished spinal cord evoked potentials.

Mr. Keith and Dr. Lin said that they had no relevant disclosures. Dr. Jordan had multiple disclosures, including being a consultant, speaker, and advisor for Abbott Vascular; an advisor for LeMaitre Vascular; a speaker and advisor for Medtronic; and a consultant and speaker for W.L. Gore.

NAPLES, FLA. – Selective lumbar spinal drainage is worthwhile to reduce adverse neurologic outcomes for patients who develop symptoms of spinal cord ischemia after thoracic aortic endograft repair, according to a retrospective study.

Although surgeons who perform open aortic repair commonly employ perioperative lumbar spinal drainage, there is no consensus regarding drain placement for spinal cord ischemia (SCI) that is associated with thoracic endovascular aorta repair (TEVAR), Charles J. Keith said at the annual meeting of the Southern Association for Vascular Surgery.

Mr. Keith, a medical student at the University of Alabama at Birmingham, and his associates reviewed 10 years of experience at their institution to compare outcomes between drained and nondrained patients. Of 266 TEVAR interventions in 239 patients, of whom 167 (70%) were men, between January 2000 and June 2010, 16 (7% of cases) developed SCI within 30 days.

History of stroke, infrarenal pathology, and a longer aortic coverage in centimeters were significant risk factors for SCI in this patient population, Mr. Keith said. There were 147 interventions that involved aneurysms in the study, accounting for just more than half of the aortic pathology treated.

Left subclavian artery stent graft coverage was required in 80 interventions (30%), but it was not significantly associated with SCI.

Study discussant Dr. Peter H. Lin asked about routine or prophylactic drainage for patients with these risk factors. "Use of prophylactic drainage is supported by some, but we would have deployed an extra 105 unnecessary drains in this population," Mr. Keith replied. "There are risks associated with drainage, such as epidural hematoma, as was experienced by one of our patients."

Patients who developed SCI were three times more likely to die within 1 year, compared with non-SCI patients (odds ratio, 3.0).

Focus your efforts on complete symptom recovery after TEVAR and perform frequent neurologic assessments of high-risk patients, Mr. Keith said. These actions will minimize time to drain placement when indicated, improve symptom resolution, and increase 1-year survival.

In all, 10 of the 16 SCI cases were drained. There were no significant differences in terms of risk factors or demographics between drained and nondrained patients. Of the 10 drained cases, three patients experienced complete neurologic symptom resolution, four had partial resolution, and three had no resolution. Of the six patients who were not drained, four experienced complete resolution and two experienced no resolution.

Another aim of the study was to evaluate a drainage protocol adopted at their institution. Since 2007, all patients receive a neurologic evaluation post TEVAR. If they show any symptoms of neurologic deficit, their mean arterial pressure is increased to greater than 110 mm Hg, and the frequency of neurologic exams increases to hourly. Also, a lumbar drain is immediately placed if they have a major deficit and within 3 hours if minor symptoms persist postoperatively.

Although patients who experienced SCI after TEVAR had diminished outcomes, compared with non-SCI patients, the study supports the use of a spinal drainage protocol to improve neurologic outcomes in a select patient population, Mr. Keith said.

There are reports that support the use of steroids to reduce swelling and spinal cord edema, said Dr. Lin of the division of vascular and endovascular therapy at Baylor College of Medicine, Houston.

"Steroids are not included in our protocol, but it’s definitely something to consider," Mr. Keith said.

Dr. Lin asked if the study findings have changed the treatment approach at the University of Alabama. Mr. Keith deferred to Dr. William D. Jordan Jr., a coauthor of the study and moderator of this session at the meeting.

"We seek input from neurologic surgeons and anesthesia to help us place the drains in a more timely fashion," said Dr. Jordan, chief of vascular surgery at the University of Alabama.

A meeting attendee commented that that approach might work at the University of Alabama, but what if feedback from neurosurgery or anesthesia is not available in a timely fashion at another institution?

"In some places, they place a drain the night before in the ICU. If that works at your institution, fine," Dr. Jordan said.

Another attendee asked about the 3-hour window before drain placement. Dr. Jordan replied, "We are basically telling anesthesia: ‘We need these [patients] awake to make sure they are kicking their legs.’ That is why we chose 3 hours for recovery, but we can often tell within 1 hour if the [patient] is moving."

There is no consensus on measures to prevent SCI, Mr. Keith said. In addition to lumbar drainage, others report use of vasopressors to increase mean arterial pressure and predeployment aortic occlusion to detect diminished spinal cord evoked potentials.

Mr. Keith and Dr. Lin said that they had no relevant disclosures. Dr. Jordan had multiple disclosures, including being a consultant, speaker, and advisor for Abbott Vascular; an advisor for LeMaitre Vascular; a speaker and advisor for Medtronic; and a consultant and speaker for W.L. Gore.

NAPLES, FLA. – Selective lumbar spinal drainage is worthwhile to reduce adverse neurologic outcomes for patients who develop symptoms of spinal cord ischemia after thoracic aortic endograft repair, according to a retrospective study.

Although surgeons who perform open aortic repair commonly employ perioperative lumbar spinal drainage, there is no consensus regarding drain placement for spinal cord ischemia (SCI) that is associated with thoracic endovascular aorta repair (TEVAR), Charles J. Keith said at the annual meeting of the Southern Association for Vascular Surgery.

Mr. Keith, a medical student at the University of Alabama at Birmingham, and his associates reviewed 10 years of experience at their institution to compare outcomes between drained and nondrained patients. Of 266 TEVAR interventions in 239 patients, of whom 167 (70%) were men, between January 2000 and June 2010, 16 (7% of cases) developed SCI within 30 days.

History of stroke, infrarenal pathology, and a longer aortic coverage in centimeters were significant risk factors for SCI in this patient population, Mr. Keith said. There were 147 interventions that involved aneurysms in the study, accounting for just more than half of the aortic pathology treated.

Left subclavian artery stent graft coverage was required in 80 interventions (30%), but it was not significantly associated with SCI.

Study discussant Dr. Peter H. Lin asked about routine or prophylactic drainage for patients with these risk factors. "Use of prophylactic drainage is supported by some, but we would have deployed an extra 105 unnecessary drains in this population," Mr. Keith replied. "There are risks associated with drainage, such as epidural hematoma, as was experienced by one of our patients."

Patients who developed SCI were three times more likely to die within 1 year, compared with non-SCI patients (odds ratio, 3.0).

Focus your efforts on complete symptom recovery after TEVAR and perform frequent neurologic assessments of high-risk patients, Mr. Keith said. These actions will minimize time to drain placement when indicated, improve symptom resolution, and increase 1-year survival.

In all, 10 of the 16 SCI cases were drained. There were no significant differences in terms of risk factors or demographics between drained and nondrained patients. Of the 10 drained cases, three patients experienced complete neurologic symptom resolution, four had partial resolution, and three had no resolution. Of the six patients who were not drained, four experienced complete resolution and two experienced no resolution.

Another aim of the study was to evaluate a drainage protocol adopted at their institution. Since 2007, all patients receive a neurologic evaluation post TEVAR. If they show any symptoms of neurologic deficit, their mean arterial pressure is increased to greater than 110 mm Hg, and the frequency of neurologic exams increases to hourly. Also, a lumbar drain is immediately placed if they have a major deficit and within 3 hours if minor symptoms persist postoperatively.

Although patients who experienced SCI after TEVAR had diminished outcomes, compared with non-SCI patients, the study supports the use of a spinal drainage protocol to improve neurologic outcomes in a select patient population, Mr. Keith said.

There are reports that support the use of steroids to reduce swelling and spinal cord edema, said Dr. Lin of the division of vascular and endovascular therapy at Baylor College of Medicine, Houston.

"Steroids are not included in our protocol, but it’s definitely something to consider," Mr. Keith said.

Dr. Lin asked if the study findings have changed the treatment approach at the University of Alabama. Mr. Keith deferred to Dr. William D. Jordan Jr., a coauthor of the study and moderator of this session at the meeting.

"We seek input from neurologic surgeons and anesthesia to help us place the drains in a more timely fashion," said Dr. Jordan, chief of vascular surgery at the University of Alabama.

A meeting attendee commented that that approach might work at the University of Alabama, but what if feedback from neurosurgery or anesthesia is not available in a timely fashion at another institution?

"In some places, they place a drain the night before in the ICU. If that works at your institution, fine," Dr. Jordan said.

Another attendee asked about the 3-hour window before drain placement. Dr. Jordan replied, "We are basically telling anesthesia: ‘We need these [patients] awake to make sure they are kicking their legs.’ That is why we chose 3 hours for recovery, but we can often tell within 1 hour if the [patient] is moving."

There is no consensus on measures to prevent SCI, Mr. Keith said. In addition to lumbar drainage, others report use of vasopressors to increase mean arterial pressure and predeployment aortic occlusion to detect diminished spinal cord evoked potentials.

Mr. Keith and Dr. Lin said that they had no relevant disclosures. Dr. Jordan had multiple disclosures, including being a consultant, speaker, and advisor for Abbott Vascular; an advisor for LeMaitre Vascular; a speaker and advisor for Medtronic; and a consultant and speaker for W.L. Gore.