Skip to main content
Log in

Spinal cord injury as a complication of thoracic endovascular aneurysm repair

  • Review Article
  • Published:
Surgery Today Aims and scope Submit manuscript

Abstract

Objective

Spinal cord ischemia (SCI) is a devastating complication of thoracic aortic aneurysm repair in the era of thoracic endovascular aneurysm repair (TEVAR). This review aims to clarify the causes of SCI during TEVAR and to propose ways that it may be prevented.

Methods and results

We performed an extensive literature search of SCI during TEVAR. Based on the existing literature, we examined the anatomy of the anterior spinal cord artery, which supplies blood to the anterior aspect of the spinal cord, and discuss reported effective ways to prevent SCI during TEVAR, including augmentation of arterial blood pressure and drainage of cerebrospinal fluid.

Conclusion

After reviewing the mechanism of SCI during TEVAR, we evaluated promising preventative measures.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Ullery BW, Cheung AT, Fairman RM, Jackson BM, Woo EY, Bavaria J, et al. Risk factors, outcomes, and clinical manifestations of spinal cord ischemia following thoracic endovascular aortic repair. J Vasc Surg. 2011;54:77–84.

    Article  Google Scholar 

  2. Bavaria JE, Appoo JJ, Makarom MS, Verrer J, Yu ZF, Mitchel RS, et al. Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low-risk patients: a multicenter comparative trial. J Thorac Cardiovasc Surg. 2007;133:369–77.

    Article  PubMed  Google Scholar 

  3. Najibi S, Terramani TT, Weiss VI, Donald MT, Lin PH, Redd DC, et al. Endoluminal versus open treatment of descending thoracic aortic aneurysms. J Vas Surg. 2002;36:732–7.

    Article  Google Scholar 

  4. Coselli JS, Bozinovski J, Cheung C. Hypothermic circulatory arrest: safety and efficacy in the operative treatment of descending and thoracoabdominal aortic aneurysms. Ann Thoarc Surg. 2008;85:956–63 (discussion 64).

    Article  Google Scholar 

  5. Svensson LG, Hess KR, Coselli JS, Safi HJ. Influence of segmental arteries, extent, and atriofemoral bypass on postoperative paraplegia after thoracoabdominal aortic operations. J Vasc Surg. 1994;20:255–62.

    Article  CAS  PubMed  Google Scholar 

  6. Griep RB, Ergin MA, Galla JD, Lansman S, Khan N, Quintana C, et al. Lookng for the artery of Adamkiewicz: a quest to minimize paraplegia after operations for aneurysms of the descending thoracic and thoracoabdominal aorta. J Thorac Cardiovasc Surg. 1996;112:1202–12 (discussion 13–5).

    Article  Google Scholar 

  7. Jonker FH, Verhagen HJ, Lin PH, Heijimen RH, Trimarchi S, Lee W, et al. Open surgery versus endovascular repair of ruptured thoracic aortic aneurysms. J Vasc Surg. 2011;53:1210–6.

    Article  PubMed  Google Scholar 

  8. Rizvi AZ, Sullivan TM. Incidence, prevention, and management in spinal cord protection during TEVAR. J Vasc Surg. 2010;52:865–905.

    Article  Google Scholar 

  9. Amabile P, Grisoli D, Giorgi R, Bartoli JM, Piquer P, et al. Incidence and determinants of spinal cord ischemia in stent graft repair of the thoracic aorta. Eur J Vasc Endovasc Surg. 2008;35:455–61.

    Article  CAS  PubMed  Google Scholar 

  10. Acher CW, Heisey DM. Regarding ‘Importance of intercostal artery reattachment during thoracoabdominal aortic aneurysm repair. J Vas Surg. 1998;28:570–1.

    CAS  Google Scholar 

  11. Strauch JT, Lauten A, Zheng N, Wahlers T, Gripp RB. Anatomy of spinal cord blood supply in the pig. Ann Thoarc Surg. 2007;83:2130–4.

    Article  Google Scholar 

  12. Adamkiewicz A. Die Blutegefaesse des mecahnichen Rueckenmarks, SB Heidelberg Akad Wiss. Theil. 1882;I + II:101–30.

    Google Scholar 

  13. Safi HJ, Cambell MP, Ferreira ML, Azizzadeh A, Miller CC. Spinal cord protection in descending thoracic and thoracoabdominal aortic aneurysm repair. Sem Thoarc Cardiovasc Surg. 1998;10:41–4.

    Article  CAS  Google Scholar 

  14. Etz CD, Zoli S, Roder F, Bodian CA, Di Luozzo G, Lazata R, et al. Staged repair significantly reduces paraplegia after extensive thoracoabdominal aortic aneurysm repair. J Thorac Cardiovasc Surg. 2011;139:1464–72.

    Article  Google Scholar 

  15. Acher CW, Wynn MM, Mel MW, Tefera G, Hoch JR. A quantitative assessment of the impact of intercostal artery implantation on paralysis risk in thoracoabdominal aortic aneurysm repair. Ann Surg. 2008;248:529–40.

    PubMed  Google Scholar 

  16. Safi HJ, Miller CC III, Carr C. LLiopoulos DC, Doray DA, Baldwin JC. Importance of intercostal artery reattachment during thoracoabdominal aortic aneurysm repair. J Vasc Surg. 1998;27:58–66 (discussion 8).

    Article  CAS  PubMed  Google Scholar 

  17. Cosseli JS, Conklin LD, LeMaire SA. Thoracoabdominal aortic aneurysm repair: review and update of current strategies. Ann Thoarc Surg. 2002;74:ST881–4 (discussion 592–8).

    Google Scholar 

  18. Svensson LG, Louchoukos NT, Miller DC, Bavaria JE, Coselli JS, Curi MA, et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thoarc Surg. 2008;85:S1–41.

    Article  Google Scholar 

  19. Heinemann MK, Brassel F, Herzog T, Dresler C, Becker H, Borst HG. The role of spinal angiography in operation on the thoracic aorta. Myth of reality? Ann Thoarac Surg. 1998;65:346–51.

    Article  CAS  Google Scholar 

  20. Williams GM, Roseborough GS, Webb TH, Perler BA, Krosnick T. Preoperative selective intercostal angiography in patients undergoing thoracoabdominal aneurysm repair. J Vasc Surg. 2004;39:314–21.

    Article  PubMed  Google Scholar 

  21. Nojiri J, Matsumoto K, Kato A, Miho T, Furukawa K, Ohtsubo S, et al. The Adamkiewics artery: demonstration by intra-arterial computed tomographic angiography. Eur J Cardiothorac Surg. 2007;255:873–81.

    Google Scholar 

  22. Nijenhuis RJ, Muli M, Wilmink JT, Thoron AK, Backers WH. MR angiography of the great anterior radiculomedullary artery (Adamkiewicz artery) validated by digital sub: raction angiography. AJNR Am J Neuroradiol. 2006;27:1565–72.

    CAS  PubMed  Google Scholar 

  23. Etz CD, Zoli S, Bischolf MS, Bodian C, Di Luozzo G, Griepp RB. Measuring the collateral network pressure to minimize paraplegia risk in thoracoabdominal aneurysm resection. J Thorac Cardiovasc Surg. 2010;140(6 Suppl):S125–30. doi:10.1016/j.jtcvs.2010.07.040 (discussion S142–6).

    Article  PubMed  Google Scholar 

  24. Etz CD, Di Luozzo G, Zoli S, Lazaia R, Plestis KA, Bodian CA, et al. Direct spinal cord ferfusion pressure monitoring in extensive distal aortic aneurysm repair. Ann Thorac Surg. 2009;87:1764–73 (discussion 73–4).

    Article  PubMed  Google Scholar 

  25. Safi HJ, Estrera AL, Miller CC, Huynh TT, Porat EE, Azizzadeh A, et al. Evolution of risk for neurologic deficit after descending and thoracoabdominal aortic repair. Ann Thoarc Sur. 2005;80:2173–9 (discussion 9).

    Article  Google Scholar 

  26. Kron IL. On ‘onlay patch for complete intercostals artery preservation during thoracic and thoracoabdominal aortic neurysm repair. J Card Surg. 2005;20:582.

    Article  Google Scholar 

  27. Okita Y, Takamoto S, Ando M, Morota T, Yamaki F, Matsukawa R, et al. Repair for aneurysms of the entire descending thoracic aorta or thoracoabdominal aorta using a deep hypothermia. Eur J Cardiothorac Surg. 1997;12:120–6.

    Article  CAS  PubMed  Google Scholar 

  28. Etz CD, Luehr M, Kari FA, Bodian CA, Smego D, Plestis KA, et al. Paraplegia after extensive thoracic and thoracoabdominal aortic aneurysm repair. Does critical spinal cord ischemia occur postoperativey? J Thorac Cardiovasc Surg. 2008;135:324–30.

    Article  PubMed  Google Scholar 

  29. Sundt TM, Flemming MD, Oderich GS, Torres NE, Li Z, Lenoch J, et al. Spinal cord protection during open repair of thoracic and thoracoabdominal aortic aneurysms using hypothermia and circulatory arrest. J Am Coll Surg. 2011;12:678–83 (discussion 84–5).

    Article  Google Scholar 

  30. Maniar HS, Sundt TM III, Prasad SM, Chu CM, Camillo CJ, Moon MR, et al. Delayed paraplegia after thoracic and thoracoabdominal aneurysm repair: a continuing risk. Ann Thoarc Surg. 2003;75:113–9 (discussion 9–20).

    Article  Google Scholar 

  31. Cosseli JS, Bozeinovski J, LeMaire SA. Open surgical repair of 2286 thoracoabdominal aortic aneurysms. Ann Thorac Surg. 2007;83:5862–4 (discussion 590–2).

    Google Scholar 

  32. Greenberg RK, Lu Q, Roselli EE, Svensson LG, Moon MC, Hermandez AV, et al. Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniquues. Circulation. 2008;118:808–17.

    Article  PubMed  Google Scholar 

  33. Feezor RJ, Martin TD, Hess PJ Jr, Daniels MJ, Beaver TM, Klodell CT, et al. Extent of aortic coverage and incidence of spinal cord ischemia after thoracic endovascular aneurysm repair. Ann Thoarc Surg. 2008;86:1809–14 (discussion 14).

    Article  Google Scholar 

  34. Stone DH, Brewster DC, Kwolek CJ, Lamuraglia GM, Conrad MF, Chung TK, et al. Stent-garft versus open-surgical repair of the thoracic aorta: mid-term results. J Vasc Surg. 2006;44:188–97.

    Google Scholar 

  35. Patterson BO, Holt PJ, Nienaber C, Fairman RM, Heijimen RH, Thompson MM. Management of the left subclavian artery and neurologic complication after thoracic endovascular repair. J Vasc Surg. 2014;60:1491–8.

    Article  PubMed  Google Scholar 

  36. Conrad MF, Ye JV, Chung TK, Davison JK, Cambria RP. Spinal cord complications after thoracic aortic surgery: long-term survival and functional status varies with deficit severity. J Vasc Surg. 2008;48:47–53.

    Article  PubMed  Google Scholar 

  37. Czerny M, Eggebrecht H, Sodeck G, Verzini F, Cao P, Mantati G, et al. Mechanism of symptomatic spinal cord ischemia after TEVAR: insights from the European Registry of Endovascular Aortic epair Complications (EuREC). J Endovasc Ther. 2012;19:37–43.

    Article  PubMed  Google Scholar 

  38. Weigang E, Hartert M, Sircar R, Von Samson P, Siegenthaler M, Luehr M, et al. Neurophysiological monitoring during thoracoabdominal endovascular stent graft implantation. Eur J Cardiothorac Surg. 2006;2:392–6.

    Article  Google Scholar 

  39. Eagleton MJ, Shah S, Petkosevek D, Greenberg RK. Hypogastric and subclavian artey patency affects onset and recovery of spinal cord ischemia associated with aortic endografting. J Vasc Surg. 2014;59:89–94.

    Article  PubMed  Google Scholar 

  40. Wong CS, Healy D, Canning C, Coffey JC, Boyle JR. Walsh SR.A systematic review of spinal cord injury and cerevrospinal fluid drainage after thoracic aortic endografting. J Vasc Surg. 2012;56:1438–47.

    Article  PubMed  Google Scholar 

  41. Wynn MM, Mell MW, Tefera G, Hoch JR, Acher CW. Complications of spinal fluid drainage in thoracoabdominal aortic aneurysm repair: a report of 486 patients treated from 1987 to 2008. J Vasc Surg. 2009;49:29–34 (discussion 34–5).

    Article  PubMed  Google Scholar 

  42. Bobadilla JL, Wynn M, Tefera G, Acher CW. Low incidence of paraplegia after thoracic endovascular aneurysm repair with proactive spinal cord protective protocols. J Vas Surg. 2013;57:1537–42.

    Article  Google Scholar 

  43. Leurs LT, Bell R, Degrieck Y, Thomas S, Hobo R, Lundbom J, et al. Endovascular treatment of thoracic aortic disease: combined experience from the EUROSTAR and United Kingdom Thoracic Endograft registries. J Vasc Surg. 2004;40:670–9 (discussion 679–80).

    Article  PubMed  Google Scholar 

  44. Jacob MJ, Meylaerts SA, de Haan P, de Mol RA, Kalman CJ. Assessment of spinal cord ischemia by means of evoked spinal cord monitoring during thoracoabdominal aortic surgery. Semin Vasc Surg. 2000;13:299–307.

    Google Scholar 

  45. Van Dongen EP, Schepens MA, Morshus WJ, ter Beek HT, Aarts LP, de Boer A, et al. Thoracic and thoracoabdominal aortic aneurysm repair use of evoked potential monitoring in 118 patients. J Vasc Surg. 2001;34:1035–40.

    Article  PubMed  Google Scholar 

  46. Luehr M, Salameh A, Haunschmid J, Hoyer A, Girmach FF, von Asperm K, et al. Minimally invasive segmental artery coil embolization for preconditioning of the spinal cord collateral network before one-stage descending and thoracoadominal aneurysm repair. (Phila). 2014;9:60–5.

    Article  Google Scholar 

  47. Katayama H, Kurokawa Y, Nakamura K, Ito H, Kanemitsu Y, Matsuda N, et al. Extended Clavien-Dindo classification of surgical complications: Japan Clinical Oncology Group postoperative complications criteria. Surg Today. 2016;46:668–85.

    Article  PubMed  Google Scholar 

  48. Etz CD, Weigang E, Hartert M, Mestres CA, Bartolomeo RD, Bachet JE, et al. Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery. Eur J Cardiothorac Surg. 2015;47:943–57.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Taijiro Sueda.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sueda, T., Takahashi, S. Spinal cord injury as a complication of thoracic endovascular aneurysm repair. Surg Today 48, 473–477 (2018). https://doi.org/10.1007/s00595-017-1588-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00595-017-1588-5

Keywords

Navigation