1. Spinal Cord Ischemia during TEVAR
John J Ricotta MD FACS
Professor of Surgery Georgetown University
Chair of Surgery Washington Hospital Center
CRT February 2012

2. I have no real or apparent conflicts of interest to report.
John J. Ricotta, MD
I have no real or apparent conflicts of interest to report.

3. Objectives To define the Incidence of SCI after TEVAR
To Identify Factors associated with SCI
To Delineate Strategies to reduce/treat SCI
To discuss potential new diagnostic methods for early detection of SCI

4. SCI after TEVAR SCI occurs in 5-20% of Open TAA
SCI occurs in 3-8% of TEVAR
Incidence of SCI is related to the indication for intervention and the extent of TAA
Results from decreased SC perfusion from inadequate collateral perfusion or I/R injury
Presentation and Prevention of SCI differs somewhat from Open Surgery.

5. Vascular Anatomy SC

6. Factors associated with SCI in TEVAR
Length of Operation
Hypotension
Extent of TA coverage
Indication for Intervention
Female Gender
Adequacy Collateral Circulation
- Left SCA Coverage prior AAA repair

7. Differences in SCI: OPEN vs. EV
OPEN – poor collateral flow during X clamp is a factor, as is prolonged hypotension RX: retrograde perfusion, cooling, CSF drainage, intercostal reimplantation, delayed deficits less common
TEVAR – no X clamp, limited hypotension, reimplantation is impossible
RX: limit coverage of important arteries, maintain SPP, delayed deficit is more common than with Open repair

8. Prevention of SCI Early Diagnosis is Critical!!
Increase SPPF – reduce CSFP to < 10 mm increase MAP to >90mm
Identify and avoid covering important Spinal Arteries - CTA
Create Type I or Type IV endoleak
Treat Reperfusion Injury
- naloxone , scavengers

9. Effect of Intervention on Paparplegia Rate (Acher C
Effect of Intervention on Paparplegia Rate (Acher C. JTCV Surg 140 (Suppl 6) S142-6,2010)

10. CTA to Identify Spinal Arteries (Furukawa et al Ann Thor Surg 2010;90:1840-6)

11. Distribution of Artery of Adamkewicz (Furukawa et al Ann Thoracic Surg 2010;90:1840-6)

12. Creation of Type 1 Endoleak (Reilly LM, Chuter TAM, JEVT 2010;17:21-9)

13. TEVAR Modification (Ilic N et al , JTCVS 2011;141:604-6)

14. Monitoring to Guide Therapy
Evoked Potentials
Systemic Markers I/R – not useful, delayed, non specific
CSF Markers of I/R lactate SC O2 tension Heat Shock Proteins HSP 70, HSP 27

15. Summary
SCI remains a major morbidity after TEVAR, although the incidence in less than after OSR
High risk patients include females, those with long areas of TA coverage, extensive aneurysmal disease, Prior AAA repair, Left SCA coverage
Careful Preoperative planning with identification of critical arteries is important
Prevention: Limit length of Coverage, keep MAP>90, employ CSF drains and keep CSFP<10, elective revascularization of LSCA

16. Summary
SCI is often delayed in TEVAR as compared to OSR – postoperative monitoring is critical
CSF drain and mild hypertension must continue postoperatively in high risk groups
Monitoring using Clinical exam , EP and perhaps in the future biomarkers will be critical to early detection and treatment
Creating “endoleaks” for later closure may be of use in some complex cases.