Alexander J Gregory MD FRCPC Department of Anesthesia University of Calgary Calgary Alberta Canada May 30 2014 Thoracic Aortic Rounds aortaca OBJECTIVES Cervical Plexus Vertebrals ID: 909096
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Slide1
Aortic Intervention & Spinal Cord Ischemia
Alexander J Gregory MD, FRCPCDepartment of Anesthesia, University of CalgaryCalgary, Alberta, CanadaMay 30, 2014
Thoracic Aortic Rounds
aorta.ca
Slide2OBJECTIVES
Slide3Slide4Cervical Plexus
(
Vertebrals
)
Hypogastric
Plexus
(
Iliacs
)
Lumbar
Segmentals
Intercostal
Segmentals
Slide5Slide6Risk
Slide7SCI incidenceTAAA= 8-28%TAA= 2-3%
TEVAR = 2-3%HAR = 0-4%
Slide8Risk Factors> 1 territory of blood supply lost
Peri-operative hypotensionChronic renal failureStent coverageArtery of Adamkiewicz sacrificeAtherosclerotic aortaSmokingComplicated Type-B, HAR & aortic transection
Age
Slide9Risk Factors> 1 territory of blood supply lost
Peri-operative hypotensionChronic renal failure? Stent coverage? Artery of Adamkiewicz sacrifice?? Atherosclerotic aorta
?? Smoking?? Complicated Type-B, HAR & aortic transection?? Age
Slide10Slide11LSCA
Bypass
Slide12Semin
Thorac Cardiovasc Surg 2009; 21:347-354 Ishimaru
Classification
Slide13Arm Ischemia
Slide14Vertebrobasilar
Ischemia
Slide15SCI
Slide16Recommendation 1: In patients who need elective TEVAR where achievement of a proximal seal necessitates coverage of the left subclavian artery, we suggest routine preoperative revascularization, despite the very low-quality evidence (GRADE 2, level C).
J Vasc Surg 2009;50:1155-8
Slide17Semin Vasc Surg 2012; 25:232-237
Slide18Semin Vasc Surg 2012; 25:232-237
Slide19Routine revascularization is unnecessary in the majority of patients requiring zone II coverage during thoracic endovascular aortic repair: A longitudinal outcomes study using United States Medicare population data.
Wilson JE, Galiñanes EL, Hu P, Dombrovskiy Vym and Vogel TR. Vascular. 2013 Sep 3. [Epub ahead of print]
Medicare & Medicaid Services- Inpatient claims 2006-07n= 2676 TEVAR, 869 LSCA covered, 49 LSCA bypassedTEVAR + LSCA w/out bypass = 1.9% bypassed in 1st yearTEVAR + LSCA + bypass = 12.8% vs
3.8% stroke & higher mortality
Slide20LSCA bypassProphylactic LSCA bypass:
LIMA AV fistula L hand dominance Supra-aortic or COW abnormalitiesLSCA bypass for clinically relevant malperfusion
SCI does not appear to be substantially increased in most patients
Slide21Slide22Collateral
Network
Slide23Slide24Slide25J
Thorac Cardiovasc Surg 2011;141:1020-8
= ASA
= DP
T
L
Slide26J
Thorac Cardiovasc Surg 2011;141:1020-8
Slide27J
Thorac Cardiovasc Surg 2011;141:1020-8
Slide28J
Thorac Cardiovasc Surg 2011;141:1029-36
Slide29J Thorac Cardiovasc Surg
2011;141:1029-36
Slide30J
Thorac Cardiovasc Surg 2011;141:1029-36
Slide31J Thorac Cardiovasc Surg
2011;141:1029-36
Nat
24h
120h
Slide32J
Thorac Cardiovasc Surg 2011;141:1029-36
Slide33J Thorac Cardiovasc Surg
2010;140:S125-30
Slide34J
Thorac Cardiovasc Surg 2010;140:S125-30
T & L SA sacrifice
Slide35J
Thorac Cardiovasc Surg 2010;140:S125-30
T & L SA sacrifice
L only SA sacrifice
Slide36J
Thorac Cardiovasc Surg 2010;140:S125-30
T & L SA sacrifice
L only SA sacrifice
T SA sacrifice 7d later
Slide37Slide38CSF
Drains
Slide39Slide40Hanna et al 20132002-2012, TEVAR, n=381Prev aortic surgery + >75% + below T6 or Hybrid repair Crawford I-III
Pre-op CSFd= 21% (81/381)Post-op CSFd for SCI= 1% (3/300)Group SCI= 6.6% (25/381), 1.8% (7/381) permanentPre-op CSFd SCI= 14.8% (12/81), 7.4% (6/81) permanentNo CSFd
SCI= 4.3% (13/300), 0.3% (1/300) permanentCSFd complications= 11.1% (9/81), HA 5, leak 2, minor SDH 2No CSF drained 32% (26/81)Keith et al 20122000-2010, TEVAR, n=266Pre-op CSFd excluded, post-op SCI protocolSCI= 6% (16/266), 3.4% (9/266) permanentCSFd req’d= 3.8% (10/266)CSFd
reversed SCI= 30% (3/10)CSFd complications= 10% (1/10), SDH 1Time of SCI onset to CSFd= 8.2 +/- 10.5 hrs
Slide41Hanna et al 20132002-2012, TEVAR, n=381Prev aortic surgery + >75% + below T6 or Hybrid repair Crawford I-III
Pre-op CSFd= 21% (81/381)Post-op CSFd for SCI= 1% (3/300)Group SCI= 6.6% (25/381), 1.8% (7/381) permanentPre-op CSFd SCI= 14.8% (12/81), 7.4% (6/81) permanentNo CSFd
SCI= 4.3% (13/300), 0.3% (1/300) permanentCSFd complications= 11.1% (9/81), HA 5, leak 2, minor SDH 2No CSF drained 32% (26/81)Keith et al 20122000-2010, TEVAR, n=266Pre-op CSFd excluded, post-op SCI protocolSCI= 6% (16/266), 3.4% (9/266) permanentCSFd
req’d= 3.8% (10/266)CSFd reversed SCI= 30% (3/10)CSFd complications= 10% (1/10), SDH 1
Time of SCI onset to CSFd= 8.2 +/- 10.5 hrs
Slide42Hanna et al 20132002-2012, TEVAR, n=381Prev aortic surgery + >75% + below T6 or Hybrid repair Crawford I-III
Pre-op CSFd= 21% (81/381)Post-op CSFd for SCI= 1% (3/300)Group SCI= 6.6% (25/381), 1.8% (7/381) permanentPre-op CSFd SCI= 14.8% (12/81), 7.4% (6/81) permanentNo CSFd
SCI= 4.3% (13/300), 0.3% (1/300) permanentCSFd complications= 11.1% (9/81), HA 5, leak 2, minor SDH 2No CSF drained 32% (26/81)Keith et al 20122000-2010, TEVAR, n=266Pre-op CSFd excluded, post-op SCI protocolSCI= 6% (16/266), 3.4% (9/266) permanentCSFd req’d= 3.8% (10/266)
CSFd reversed SCI= 30% (3/10)CSFd complications= 10% (1/10), SDH 1Time of SCI onset to
CSFd= 8.2 +/- 10.5 hrs
Slide43Hanna et al 20132002-2012, TEVAR, n=381Prev aortic surgery + >75% + below T6 or Hybrid repair Crawford I-III
Pre-op CSFd= 21% (81/381)Post-op CSFd for SCI= 1% (3/300)Group SCI= 6.6% (25/381), 1.8% (7/381) permanentPre-op CSFd SCI= 14.8% (12/81), 7.4% (6/81) permanentNo CSFd
SCI= 4.3% (13/300), 0.3% (1/300) permanentCSFd complications= 11.1% (9/81), HA 5, leak 2, minor SDH 2No CSF drained 32% (26/81)Keith et al 20122000-2010, TEVAR, n=266Pre-op CSFd excluded, post-op SCI protocolSCI= 6% (16/266), 3.4% (9/266) permanentCSFd req’d= 3.8% (10/266)CSFd
reversed SCI= 30% (3/10)CSFd complications= 10% (1/10), SDH 1Time of SCI onset to CSFd= 8.2 +/- 10.5 hrs
Slide44Hanna et al 20132002-2012, TEVAR, n=381Prev aortic surgery + >75% + below T6 or Hybrid repair Crawford I-III
Pre-op CSFd= 21% (81/381)Post-op CSFd for SCI= 1% (3/300)Group SCI= 6.6% (25/381), 1.8% (7/381) permanentPre-op CSFd SCI= 14.8% (12/81), 7.4% (6/81) permanent
No CSFd SCI= 4.3% (13/300), 0.3% (1/300) permanentCSFd complications= 11.1% (9/81), HA 5, leak 2, minor SDH 2No CSF drained 32% (26/81)Keith et al 20122000-2010, TEVAR, n=266Pre-op CSFd excluded, post-op SCI protocolSCI= 6% (16/266), 3.4% (9/266) permanentCSFd
req’d= 3.8% (10/266)CSFd reversed SCI= 30% (3/10)CSFd
complications= 10% (1/10), SDH 1Time of SCI onset to CSFd= 8.2 +/- 10.5 hrs
Slide45Hanna et al 20132002-2012, TEVAR, n=381Prev aortic surgery + >75% + below T6 or Hybrid repair Crawford I-III
Pre-op CSFd= 21% (81/381)Post-op CSFd for SCI= 1% (3/300)Group SCI= 6.6% (25/381), 1.8% (7/381) permanentPre-op CSFd SCI= 14.8% (12/81), 7.4% (6/81) permanentNo CSFd
SCI= 4.3% (13/300), 0.3% (1/300) permanentCSFd complications= 11.1% (9/81), HA 5, leak 2, minor SDH 2No CSF drained 32% (26/81)Keith et al 20122000-2010, TEVAR, n=266Pre-op CSFd excluded, post-op SCI protocolSCI= 6% (16/266), 3.4% (9/266) permanentCSFd
req’d= 3.8% (10/266)CSFd reversed SCI= 30% (3/10)CSFd
complications= 10% (1/10), SDH 1Time of SCI onset to CSFd= 8.2 +/- 10.5 hrs
Slide46CSFd Current FMC StrategySelective use
Intra-op CSF pressure < 10 mmHg SCPP > 70 mmHgCSF drainage < 10 mL/hrSSEPFast-track general anesthesiaPost-op q1h neuro vitalsNeuro normal= CSF pressure < 15 mmHg & SCPP > 65 mmHg
SCI protocol
Slide47