spinal cord ischemia after TEVAR Endovascular surgery

1. T.Ruangpratyakul
Spinal Cord Ischemia
after TEVAR

2. Spinal cord ischemia
13%
87%
0
25
50
75
100
Incident 3.9% (0-13.3%)
Length of hospital stay
Post-op pulmonary complication
Post-op renal complication
Global mortality
Immediately (early)
Late up to 72 hr (delayed)

3. Anatomy
Artery of Adamkiewicz T8-T12

4. Spinal perfusion
Mean aortic
pressure
Spinal
perfusion
CSF
pressure
= -
spinal cord
vascular
auto-regulation
CSF pressureCVP
Systemic arterial
pressure

5. Clinical Manifestation

6. Risk factor
1.extension of aortic coverage >205 mm
2.coverage of Adamkiewicz artery origin
3.compromise of collateral arteries
Dias-Neto M, Reis PV, Rolim D, Ramos JF, Teixeira JF, Sampaio S. Strategies to prevent TEVAR-related spinal cord ischemia. Vascular. 2017 Jun;25(3):307–15.

7. Risk factor

8. • Needle progression: nerve damage, epidural hematoma
• Catheter: fracture, infection
• Drainage: intracranial hemorrhage, headache
• Excessive drainage: headache, photophobia, diplopia
CSF drainage
COMPLICATION

9. Prevention SCI
Strategies

10. Preoperative
• Optimize patient’s cardiovascular status
• Decreasing dose of antihypertensives preoperatively
• Assess the collateral bed and consider revascularization
if possible

11. Intraoperative
• Maintain spinal pressure <8-12 mmHg
• Exclude minimal of intercostal arteries
• Avoid occlusion of collateral arteries
• Stage operation: 3 month
• Intraoperative neurophysiologic monitoring: SEP, tcMEP
• Hemodynamic monitoring: MAP > 75-85, avoid hypotension

13. Postoperative
• Continued lumbar drain for 48-72 hr
• Hemodynamic monitor: avoid hypotension and elevated
CVP
• Slow resumption of Antihypertensive

14. If SCI is detected
• Dainage spinal pressure: <5 mmHg, 5 days
• Oxygen delivery: Hb > 10 g/dL, O2, CI >2.5 L/min/BSA
• Hemodynamic: MAP >90, SCPP >80
• Neuroprotective drug: manitol, corticosteroid, naloxone
• Assess for other underlying contributing factor: GIB,
infection, cardiac arrhythmia

15. Take home message
• Prevention is the BEST
• spinal drainage
• length of stent < 205 mm
• Lt. subclavian bypass, avoid hypogastric occlusion
• hemodynamic monitoring, avoid hypotension

16. THANK
YOU