UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures MINIMIZING NEUROLOGIC COMPLICATIONS IN THE TREATMENT OF THE THORACIC AORTA 1 UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures DISCLOSURES ➢ None ➢ Not discussing off-label use of anything 2 1
UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures MECHANISMS OF SCI ➢ Hemodynamic ▪ anatomy ▪ physiology ➢ Embolic 3 UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures MECHANISMS OF SCI ➢ Direct blood flow ➢ Treated length interruption Intercostal, lumbar exclusion ➢ Collateral sacrifice ➢ Indirect blood flow interruption vertebral, hypogastric exclusion ➢ Perioperative instability ➢ Systemic hypoperfusion ➢ Cross clamp duration ➢ Ischemia / reperfusion ➢ Embolization 4 2
UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures DETECTION OF SCI ➢ cnNIRS (Near infrared spectroscopy) Monitoring Etz CD VEITH 2018 5 UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI ➢ Hemodynamic stability / permissive hypertension ▪ Modify antihypertensive regimen preop ▪ Gradual reintroduction of antihypertensives over several weeks ▪ Use volume before pressors; Hgb ≥ 10 Lowest SBP Recorded During Hospital Stay 120 100 Mean SBP (mm Hg) 80 p = 0.005 60 96 40 75 20 0 Intact (n = 27) LEW (n = 6) 6 3
UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI ➢ Hemodynamic stability / permissive hypertension ▪ Reduce or stop antihypertensive medications preop ▪ Gradual reintroduction of antihypertensives over several weeks ▪ Use volume before pressors; Hgb ≥ 10 ▪ Restore lower extremity / pelvic flow Oderich et al. JEVT 2016; 23(1): 139-49 7 UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI ➢ Preservation of collateral spinal cord perfusion ▪ Carotid subclavian bypass ▪ Hypogastric artery revascularization ▪ Simultaneous vs staged (open vs endo, TAA vs TAAA) Bergamini TM et al. J Mansukhani NA et al. Ann Vasc Surg 202; 34:120-4 Vasc Surg 2017; 42:162-68 8 4
UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI ➢ CSF drainage ▪ reduces SCI from 10-20% to 2.3-10% Khan NR et al. J Neurosurg Spine 2016; 25:383-93 9 UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI ➢ CSF drainage 10 5
UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI ➢ CSF drainage ▪ asymptomatic — low baseline rate (5 – 10 cc/hr) ▪ symptomatic — to effect, not to pressure ▪ < 30 cc in any one hour 11 UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI ➢ CSF drainage ▪ asymptomatic — low baseline rate (5 – 10 cc/hr) ▪ symptomatic — to effect, not to pressure ▪ < 30 cc in any one hour ▪ Selective ▪ Endo TAA ▪ Open extent IV TAAA • Routine ▪ All endo TAAA ▪ Open extent I-III TAAA ▪ Open TAA 12 6
UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI ➢ CSF drainage ▪ asymptomatic — low baseline rate (5 – 10 cc/hr) ▪ symptomatic — to effect, not to pressure ▪ < 30 cc in any one hour ▪ Selective ▪ Endo TAA ▪ Open extent IV TAAA • Routine ▪ All endo TAAA ▪ Open extent I-III TAAA ▪ Open TAA 13 UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI Spinal Cord Ischemic Preconditioning ➢ Incomplete (Staged) repair ➢ Transient aneurysm sac perfusion (TASP) ➢ Intercostal / lumbar artery occlusion 14 7
UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI Spinal Cord Ischemic Preconditioning ➢ Incomplete (Staged) repair Etz et al single stage 13% two stage 0% Haulon et al single stage 25% two stage 2.1% Etz CD et al. J Thor Cardiovasc Haulon et al. Eur J Vasc Endovasc Surg 2015; 49:248-54 Surg 2010; 139(6):1464-72 15 UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI Spinal Cord Ischemic Preconditioning ➢ Transient Aneurysm Sac Perfusion C A B A B C 16 8
UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI Spinal Cord Ischemic Preconditioning ➢ Transient Aneurysm Sac Perfusion B A 17 UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI Spinal Cord Ischemic Preconditioning ➢ Incomplete (Staged) repair ➢ Transient aneurysm sac perfusion (TASP) Oderich et al. JEVT 2016; 23(1): 139-49 18 9
UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI Spinal Cord Ischemic Preconditioning ➢ Incomplete (Staged) repair ➢ Transient aneurysm sac perfusion (TASP) Harrison SC et al. J Vasc Jayia P et al. Aorta Surg 2012; 55(4):1202-05 2015;3(2):56-60 19 UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI Spinal Cord Ischemic Preconditioning ➢ Incomplete (Staged) repair ➢ Transient aneurysm sac perfusion (TASP) Miranda et al. Int Angiol 2018; 37(2): 112-26l 20 10
UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI Spinal Cord Ischemic Preconditioning ➢ Incomplete (Staged) repair ➢ Transient aneurysm sac perfusion YES NO Kasprzak 12 (2) / 40 11 (9) / 43 0.03 Youssef 0 / 10 3 (?) / 20 0.28 ( ) = permanent Orrico 2 (1) / 32 deficit Javia 9 (1) / 25 O’Callaghan 3 (0) / 27 12 (7) / 32 0.03 21 UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI Spinal Cord Ischemic Preconditioning ➢ Intercostal / lumbar artery occlusion — selective Branzen et al. EuroIntervention 2018 22 11
UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI Spinal Cord Ischemic Preconditioning ➢ Intercostal / lumbar artery occlusion — selective Branzen et al. EuroIntervention 2018 23 UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI Spinal Cord Ischemic Preconditioning ➢ Intercostal / lumbar artery occlusion — selective Branzen et al. EuroIntervention 2018 24 12
UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI Spinal Cord Ischemic Preconditioning ➢ Intercostal / lumbar artery occlusion — selective Branzen et al. EuroIntervention 2018 25 UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI Spinal Cord Ischemic Preconditioning ➢ Intercostal / lumbar artery occlusion — selective Etz et al. VEITH 2018 26 13
UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI Spinal Cord Ischemic Preconditioning ➢ Intercostal / lumbar artery occlusion — selective Etz et al. VEITH 2018 27 UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI Spinal Cord Ischemic Preconditioning ➢ Intercostal / lumbar artery occlusion — selective Etz et al. VEITH 2018 28 14
UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI Spinal Cord Ischemic Preconditioning ➢ Intercostal / lumbar artery occlusion — selective Etz et al. VEITH 2018 29 UCSF Vascular & Endovascular Symposium 2019 UC SF Preventing SCI in Thoracic Aortic Procedures PREVENTION OF SCI Spinal Cord Ischemic Preconditioning ➢ Intercostal / lumbar artery occlusion — selective Etz et al. VEITH 2018 30 15
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