Medullar protection in endovascular surgery of toracoabdominal aorta

Viader Barraca, I., Vallejo Tarrats, A., Artigas Soler, A., Rosas, M., Hernández, C., Masó, A.
Corporació Sanitària Parc Taulí de Sabadell

Background:
The drainage of CSF as a protective medullar measure in the aortic vascular surgery has shown a reduction in the incidence of medullar ischemia increasing the medullar perfusion by decreasing intrathecal pressure. Even though its practice is widely accepted in open Aortic surgery, there is still no consensus on its prophylactic insertion in endovascular surgery.

Case Report:
This involved a 68-year-old patient, with an asymptomatic thoracoabdominal aneurism, programmed for endovascular repair by a fenestrated endograft with visceral involment (2 renals / 1 AMS / Celiac trunk). No intraoperative incidents. At the end of the surgery there were no focal neurological deficiencies. In the recovery room the patient complained of a motor weakness in lower extremities. Under suspicion of medullar ischemia, we decided to place an intradural catheter to drain CSF. This resulted in a total resolution of the neurological symptoms. Four days later, after the patient had been discharged, he reported a progessive interescapular pain. Angio-TC was performed, and this showed an aortic dissection type B with extension until the proximal end of the aortic endograft. Labetalol was used to maintain a strict tensional control. 
The patient was proposed for a differed stent-graft placement. Before the surgery a lumbar catheter to drain CSF was placed without any incidence. Intraoperative hemodynamical control was performed with transesophageal endocardio. The postoperative period continued without complications, and the catheter was removed 2 days later.

Discussion:
Spinal chord injury is uncommon after FEVAR. According to the available literature, the role of prophylactic CSF drainage is difficult to establish. The indications of CSF drainage according to the protocol of our center includes: patients with previous aortic endovascular surgery, subclavia oclusion, hypogastric oclusion and long endograft extension. Our patient had no criteria to place a prophylactic catheter in the first surgery but, due to the neurological complications, it was used as a rescue mesure.

Learning points:
Although the role of CSF drainage as a medullar protection has not been established as a gold standard in thoracoabdominal endovascular surgery, its application in selected cases can be very useful, since it is one of the fundamental pillars in the prevention and treatment of medullar ischaemia.

References:

	Rev. Hosp. Ital. B.Aires Vol. 27 Nº 1, marzo 2007. Rostagno R. et al. Endoprótesis fenestrada para el tratamiento del aneurisma de la aorta abdominal
	2010 Guidelines on Thoracic Aortic Disease, Hiratzka et al, pags 336-342.
	Rev. Esp. Anestesiol. Reanim. 2008; 55: 263-265
	Journal of Clinical Anesthesia. 2003 Feb;15(1):59-63. Fuchs RJ, Lee WA, Seubert CN, Gelman S. Transient paraplegia after stent grafting of a descending thoracic aortic aneurysm treated with cerebrospinal fluid drainage.
	Carmona P et al. Proteccion medular en la cirugia abierta y endovascular de las enfermedades de la aorta toracica y toracoabdominal. Rev Esp AnestesiolReanim. 2011; 58: 110-118
	Eur J Vasc Endovasc Surg. 2015 Nov;50(5):599-607. Neuroprotective Strategies Can Prevent Permanent Paraplegia in the Majority of Patients Who Develop Spinal Cord Ischaemia After Endovascular Repair of Thoracoabdominal Aortic Aneurysms. Rossi SH et al.
	Keith Ch J et al. Protocol implementation of selective postoperativelumbasr spinal drainage after thoracic aortic endograft. J Vasc Surg 2012;55:1-9)


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