Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Sci

spinal cord ischemia after aortic intervention

  • Login to see the comments

Sci

  1. 1. SPINAL CORD ISCHEMIA IN AORTIC INTERVENTION F2 Parach Sirisriro 30th Oct 2018
  2. 2. OUTLINE • Introduction • Anatomy and spinal cord collateral network • Pathophysiology of spinal cord injury • Prevention of spinal cord injury Minimize spinal cord ischemia time Increase tolerance to ischemia Augmentation of spinal cord perfusion Early detection of spinal cord ischemia • Management of Spinal cord ischemia • Conclusion
  3. 3. REFERENCE
  4. 4. JOURNAL • Uchino, G., et al. (2017). "Spinal cord protection during thoracoabdominal aortic replacement: spinal cord perfusion maintenance." Interactive cardiovascular and thoracic surgery 24(5): 708- 713. • Drinkwater, S., et al. (2010). "The incidence of spinal cord ischaemia following thoracic and thoracoabdominal aortic endovascular intervention." European Journal of Vascular and Endovascular Surgery 40(6): 729-735. • Etz, C. D., et al. (2015). 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, Oxford University Press. • Bisdas, T., et al. (2015). "Risk factors for spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms." Journal of vascular surgery 61(6): 1408-1416.
  5. 5. • Scott, D. and M. Denton (2016). "Spinal cord protection in aortic endovascular surgery." BJA: British Journal of Anaesthesia 117(suppl_2): ii26-ii31. • Ullery, B. W., et al. (2011). "Risk factors, outcomes, and clinical manifestations of spinal cord ischemia following thoracic endovascular aortic repair." Journal of vascular surgery 54(3): 677-684. • Scali, S. T., et al. (2018). "Implementation of a bundled protocol significantly reduces risk of spinal cord ischemia after branched or fenestrated endovascular aortic repair." Journal of vascular surgery 67(2): 409- 423. e404. • Fedorow, C. A., Moon, M. C., Mutch, W. A. C., & Grocott, H. P. (2010). Lumbar cerebrospinal fluid drainage for thoracoabdominal aortic surgery: Rationale and practical considerations for management. Anesthesia and Analgesia, 111(1), 46. 10.1213/ANE.0b013e3181ddddd • Youngblood, S. C., et al. (2013). "Complications of cerebrospinal fluid drainage after thoracic aortic surgery: a review of 504 patients over 5 years. " The Journal of thoracic and cardiovascular surgery 146(1): 166-171. • Rong, L., et al. (2018). "Cerebrospinal-fluid drain-related complications in patients undergoing open and endovascular repairs of thoracic and thoraco-abdominal aortic pathologies: a systematic review and meta- analysis." British journal of anaesthesia JOURNAL
  6. 6. ANATOMY OF SPINAL CORD BLOOD SUPPLY The spinal cord receives blood from spinal arteries derived from branches of larger arteries These major arteries include the following: • Vertebral arteries: arising from the subclavian arteries in the neck. • Ascending cervical arteries: arising from a branch of the subclavian arteries. • Posterior intercostal arteries: arising from the thoracic aorta. • Lumbar arteries: arising from the abdominal aorta. • Lateral sacral arteries: arising from pelvic internal iliac arteries. Gustavo S.(2017). Endovascular Aortic Repair [electronic resource] : Current Techniques with Fenestrated, Branched and Parallel Stent-Grafts. Chapter 47
  7. 7. ANATOMY OF SPINAL CORD BLOOD SUPPLY The cervicothoracic region (C1–T3) : supplied by the vertebral arteries and the cervical ascending arteries The mid‐thoracic region (T3–T7) : receives branches from the intercostal arteries at T7 The thoracolumbar region (below T8) : derives its blood supply from the major radiculo‐medullary artery, called the great radicular artery of Adamkiewicz : its origin varies but usually branches off the aorta in the T9 to T12 region. Djindjian R: Arteriography of the spinal cord, Am J Roentgenol Radium Ther Nucl Med 107:461-478, 1969.
  8. 8. ARTERY OF ADAMKIEWICZ • Watershed region- Thoraco lumbar segment. Blood supply derived from large radicular arteries called ARM (Artery of Adamkiewicz) Origin T9-T12 – in 75% T8-L3 – in 15% L1-L2 – in 10% of patients. Gustavo S.(2017). Endovascular Aortic Repair [electronic resource] : Current Techniques with Fenestrated, Branched and Parallel Stent-Grafts. Chapter 47
  9. 9. THE COLLATERAL NETWORK CONCEPT Etz et al. The Collateral Network Concept: A Reassessment of the Anatomy of Spinal Cord Perfusion Thorac Cardiovasc Surg. April 2012
  10. 10. SPINAL CORD ISCHEMIA Gustavo S.(2017). Endovascular Aortic Repair [electronic resource] : Current Techniques with Fenestrated, Branched and Parallel Stent-Grafts. Chapter 47
  11. 11. SPINAL CORD ISCHEMIA • Uncommon condition • Sudden onset of paralysis, sensory loss, urinary and bowel dysfunction •Monophasic attack •Severe prognosis with permanent and disabling sequelae Salvador de la Barrera et al. Spinal Cord 2001 Bisdas T et al. J Vasc Surg 2015
  12. 12. SPINAL CORD ISCHEMIA ‐ ETIOLOGY 36% idiopathic 25% aortic surgery 19% systemic arteriosclerosis 11% acute perfusion deficit Salvador de la Barrera et al. Spinal Cord 2001 Bisdas T et al. J Vasc Surg 2015
  13. 13. SPINAL CORD ISCHEMIA IN AORTIC INTERVENTION • Spinal Cord Ischemia SCI remains the most devastating complication after thoracic or thoracoabdominal repair. • Its rate has not declined with the use of endovascular technology and ranges from 2% to 10% after TEVAR (3.89% in a review of 4936 patients) Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74, 3183-3221.e
  14. 14. • Immediate-direct result of hypo-perfusion and secondary hypoxic damage. • Delayed complications can develop between 1 & 21 days following surgery. • Results from reperfusion hyperemia and free radical generation – edema of the cord –regional hypoperfusion SPINAL CORD ISCHEMIA Wan IYP, Angelini GD, Bryan AJ, Ryder I, Underwood MJ. prevention of spinal cord ischemia during descending thoracic and thoracoabdominal surgery. Eur J Cardio-thorac Surg 2001;19:203-13.
  15. 15. SPINAL CORD ISCHEMIA IN AORTIC INTERVENTION
  16. 16. • Risk Factors for ischemia - Longer extent of aneurysm (greatest risk in Crawford type II, least in type IV) - Perioperative hypotension - Emergency operation (16.7 vs 3.9%) - Open operative repair - Acute aortic rupture/dissection PREDISPOSING FACTOR Etz, C. D., et al. (2015). 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, Oxford University Press.
  17. 17. • Risk Factors for ischemia - Longer duration of aortic cross-clamp - Failure to re-implant segmental arteries - Prior distal aortic surgery - Severe peripheral vascular disease - Anemia (impairing oxygen supply) - Systemic vasodilatation with vascular steal (for control of hypertension associated with aortic clamping ) PREDISPOSING FACTOR Etz, C. D., et al. (2015). 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, Oxford University Press.
  18. 18. PREDISPOSING FACTOR → Risk of ischemia greatest in open repair: 8-28% vs 4-7% Open Endovascular
  19. 19. CRAWFORD CLASSIFICATION Drinkwater, S., et al. (2010). "The incidence of spinal cord ischaemia following thoracic and thoracoabdominal aortic endovascular intervention. " European Journal of Vascular and Endovascular Surgery 40(6): 729-735. Incidence of spinal cord ischemia according to Crawford extend of aneurysm Endovascular repair 10% 19% 5% 3% Open surgical repair 14% 22% 10% 2%
  20. 20. SPINAL CORD ISCHEMIA IN AORTIC INTERVENTION Scott DJ, Denton MJ. Spinal cord protection in aortic endovascular surgery. Br J Anaesth 2016;117:26-31.
  21. 21. MECHANISM IN SPINAL CORD ISCHEMIA Etz, C. D., et al. (2015). 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, Oxford University Press.
  22. 22. TEVAR - Large profile femoral sheath - The use of femoral conduits For sheath access Gustavo S.(2017). Endovascular Aortic Repair [electronic resource] : Current Techniques with Fenestrated, Branched and Parallel Stent-Grafts. Chapter 47
  23. 23. PATHOPHYSIOLOGY OF SPINAL CORD INJURY Etz, C. D., et al. (2015). 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, Oxford University Press.
  24. 24. PATHOPHYSIOLOGY OF SPINAL CORD INJURY Etz, C. D., et al. (2015). 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, Oxford University Press.
  25. 25. AUTOREGULATION • Spinal cord blood flow is constant Between 10 - 50 mmHg CO2 Between 50 - 135 mmHg MABP Mechanism: Sympathetic ganglia Sensory control center caudal to the medulla Further research needed Uchino, G., et al. (2017). "Spinal cord protection during thoracoabdominal aortic replacement: spinal cord perfusion maintenance." Interactive cardiovascular and thoracic surgery 24(5): 708-713.
  26. 26. SPINAL BLOOD FLOW AFTER THORACIC AORTIC OCCLUSION (AORTIC CROSS CLAMPING) Spinal cord perfusion pressure (SCPP )= MABP – CSF pressure > 50 – 60 mmHg to protect spinal cord from ischemia Normal CSF pressure = 13 – 15 mmHg Temporary aortic cross-clamping decreases SCBF and distal organ perfusion Distal hypotension Proximal hypertension Increase in left ventricle afterload Gustavo S.(2017). Endovascular Aortic Repair [electronic resource] : Current Techniques with Fenestrated, Branched and Parallel Stent-Grafts. Chapter 47
  27. 27. SPINAL BLOOD FLOW AFTER THORACIC AORTIC OCCLUSION (AORTIC CROSS CLAMPING) AoX Proximal hypertension + intracranial pressure ↑ Autoregulation: CSF pressure ↑ SCPP ↓ Spinal cord injury hypotension Interrupting sympathetic fibers Direct myocardial dysfunction Increase in CSF pressure (21-25 mmHg) Increase in central venous pressure Elevation in intracranial pressure Release of aortic cross-clamping: CSFP remains elevated for 5 minutes CSFP returns to normal after 25 minutes Hyperemia is observed Uchino, G., et al. (2017). "Spinal cord protection during thoracoabdominal aortic replacement: spinal cord perfusion maintenance." Interactive cardiovascular and thoracic surgery 24(5): 708-713.
  28. 28. SPINAL CORD PROTECTION
  29. 29. PREVENTION OF SPINAL CORD INJURY Minimize spinal cord ischemia time Increase tolerance to ischemia Augmentation of spinal cord perfusion Early detection of spinal cord ischemia
  30. 30. STRATEGIE TO PREVENT Uchino, G., et al. (2017). "Spinal cord protection during thoracoabdominal aortic replacement: spinal cord perfusion maintenance." Interactive cardiovascular and thoracic surgery 24(5): 708-713.
  31. 31. MINIMIZE SPINAL CORD ISCHEMIA TIME - Decrease duration of surgery - Preservation of subclavian artery flow - Distal aortic perfusion Passive shunt (Gott shunt) Left heart bypass = Atrial- femoral bypass - Thoracic endovascular aortic repair - Staged repair Gott shuntLeft heart bypass Uchino, G., et al. (2017). "Spinal cord protection during thoracoabdominal aortic replacement: spinal cord perfusion maintenance. " Interactive cardiovascular and thoracic surgery 24(5): 708-713.
  32. 32. • Staged repair Principle based on “dynamic collateral vascular network” - Endovascular repair in different stages - Dividing extensive aneurysm repair into multiple steps may mitigate the impact of diminished blood flow to the collateral network - Allowing new blood vessels to grow - Reduce chance of ischemia - Less/no neurologic deficit postoperatively MINIMIZE SPINAL CORD ISCHEMIA TIME Uchino, G., et al. (2017). "Spinal cord protection during thoracoabdominal aortic replacement: spinal cord perfusion maintenance." Interactive cardiovascular and thoracic surgery 24(5): 708-713.
  33. 33. INCREASE TOLERANCE TO ISCHEMIA - Deliberate mild systemic hypothermia - Deep hypothermic circulatory arrest - Selective spinal cord hypothermia by epidural cooling Pharmacologic neuroprotection CSF drainage Uchino, G., et al. (2017). "Spinal cord protection during thoracoabdominal aortic replacement: spinal cord perfusion maintenance. " Interactive cardiovascular and thoracic surgery 24(5): 708-713.
  34. 34. • Deliberate mild systemic hypothermia = 32-34°C : * Hypothermia is the only intervention in humans has been proven consistently to be effective for protecting the CNS Disadvantage : arrythmias, coagulation abnormalities * Allowing body core temperature to decrease after induction → Re-warming after reperfusion: gradually, avoid systemic hyperthermia INCREASE TOLERANCE TO ISCHEMIA Uchino, G., et al. (2017). "Spinal cord protection during thoracoabdominal aortic replacement: spinal cord perfusion maintenance. " Interactive cardiovascular and thoracic surgery 24(5): 708-713.
  35. 35. • Deep hypothermic circulatory arrest = 10-18°C → requires Cardiopulmonary bypass * For TAAA that extends into the aortic branch requiring temporary temporary interruption of cerebral blood flow * Risks associated : → stroke caused by cerebral atheroembolism → postoperative encephalopathy → cerebral hyperthermia during re-warming INCREASE TOLERANCE TO ISCHEMIA Uchino, G., et al. (2017). "Spinal cord protection during thoracoabdominal aortic replacement: spinal cord perfusion maintenance. " Interactive cardiovascular and thoracic surgery 24(5): 708-713.
  36. 36. INCREASE TOLERANCE TO ISCHEMIA Gustavo S.(2017). Endovascular Aortic Repair [electronic resource] : Current Techniques with Fenestrated, Branched and Parallel Stent-Grafts. Chapter 47
  37. 37. AUGMENTATION OF SPINAL CORD PERFUSION • Deliberate hypertension - MAP 80-100 mmHg - CVD < CSF pressure - For at least 24h-48h postoperatively • Lumbar cerebrospinal fluid (CSF) drainage - CSF pressure < 10 -15mmHg - CSF drainage < 25 ml/hr to avoid complications (intracranial/subdural hematoma) • Re-implantation of intercostals and lumbar segmental arteries Uchino, G., et al. (2017). "Spinal cord protection during thoracoabdominal aortic replacement: spinal cord perfusion maintenance. " Interactive cardiovascular and thoracic surgery 24(5): 708-713.
  38. 38. LUMBAR CEREBROSPINAL FLUID (CSF) DRAINAGE Gustavo S.(2017). Endovascular Aortic Repair [electronic resource] : Current Techniques with Fenestrated, Branched and Parallel Stent-Grafts. Chapter 47
  39. 39. Draining cerebrospinal fluid(CSF) can reduce pressure in the spinal cord or brain. Increased Pressure = Reduce blood flow Lumbar cerebrospinal fluid (CSF) drainage AUGMENTATION OF SPINAL CORD PERFUSION Fedorow, C. A., Moon, M. C., Mutch, W. A. C., & Grocott, H. P. (2010). Lumbar cerebrospinal fluid drainage for thoracoabdominal aortic surgery: Rationale and practical considerations for management. Anesthesia and Analgesia, 111(1), 46. 10.1213/ANE.0b013e3181ddddd
  40. 40. LUMBAR CEREBROSPINAL FLUID (CSF) DRAINAGE Rong, L., et al. (2018). "Cerebrospinal-fluid drain-related complications in patients undergoing open and endovascular repairs of thoracic and thoraco-abdominal aortic pathologies: a systematic review and meta-analysis." British journal of anaesthesia.
  41. 41. • Monitor : Neuro Vital Signs / Neuromuscular/ Neurovascular Checks q1h • Maintain Lumbar Drain - 72 hours for open repair -24-48 hours for endovascular repair • Monitor for Pink/Bloody CSF • Maintain Hemoglobin >9mg/dl • Maintain SBP >140 mmHg LUMBAR CEREBROSPINAL FLUID (CSF) DRAINAGE Fedorow, C. A., Moon, M. C., Mutch, W. A. C., & Grocott, H. P. (2010). Lumbar cerebrospinal fluid drainage for thoracoabdominal aortic surgery: Rationale and practical considerations for management. Anesthesia and Analgesia, 111(1), 46. 10.1213/ANE.0b013e3181ddddd
  42. 42. LUMBAR CEREBROSPINAL FLUID (CSF) DRAINAGE Rong, L., et al. (2018). "Cerebrospinal-fluid drain-related complications in patients undergoing open and endovascular repairs of thoracic and thoraco-abdominal aortic pathologies: a systematic review and meta-analysis." British journal of anaesthesia.
  43. 43. LUMBAR CEREBROSPINAL FLUID (CSF) DRAINAGE Rong, L., et al. (2018). "Cerebrospinal-fluid drain-related complications in patients undergoing open and endovascular repairs of thoracic and thoraco-abdominal aortic pathologies: a systematic review and meta-analysis." British journal of anaesthesia.
  44. 44. COMPLICATION OF SPINAL DRAINAGE • In a review of 504 patients who underwent TEVAR with preoperative CSF : Youngblood et al. reported a 12.7% complication rate and associated with a mortality rate of 14.3% including - headache (9.7%) - catheter fracture (0.2%) - intracranial bleeding (2.8%) - subdural hematoma (1.9%) * The clinical presentation of an intracranial hemorrhage after CSF drainage varies from severe headache and confusion to coma, motor deficit, or respiratory arrest Youngblood, S. C., et al. (2013). "Complications of cerebrospinal fluid drainage after thoracic aortic surgery: a review of 504 patients over 5 years. " The Journal of thoracic and cardiovascular surgery 146(1): 166-171.
  45. 45. EARLY DETECTION OF SPINAL CORD ISCHEMIA • Early detection of spinal cord ischemia = monitoring function of the spinal cord - Intraoperative MEP - Intraoperative SSEP - Serial postoperative neurologic examination - Biochemic measurements Uchino, G., et al. (2017). "Spinal cord protection during thoracoabdominal aortic replacement: spinal cord perfusion maintenance. " Interactive cardiovascular and thoracic surgery 24(5): 708-713.
  46. 46. EARLY DETECTION OF SPINAL CORD ISCHEMIA
  47. 47. SPINAL CORD ISCHEMIA AFTER AORTIC SURGERY • Overall 30-day and 36-month survivals in those developing SCI were 92 % and 45%, respectively. • In those patients that did not have resolution of their symptoms, 3-month survival was reduced from 92 to 36 %. • This highlights the devastating long-term outcomes of patients suffering from profound SCI with paraplegia Gustavo S.(2017). Endovascular Aortic Repair [electronic resource] : Current Techniques with Fenestrated, Branched and Parallel Stent-Grafts. Chapter 47
  48. 48. STRATEGIE TO PREVENT
  49. 49. BENEFIT OF CSF DRAINAGE • CSF drainage is the only method aimed at mitigating SCI during TAAA/DTA repair supported by randomised evidence. • Class IB indication in the US guidelines • Strong recommendation in high-risk patients in the European guidelines. • Spinal perfusion pressure = MAP - CSF pressure : a reduction in CSF pressure should increasespinal blood flow Gustavo S.(2017). Endovascular Aortic Repair [electronic resource] : Current Techniques with Fenestrated, Branched and Parallel Stent-Grafts. Chapter 47
  50. 50. THANK YOU

×