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Gomes et al. Vessel Plus 2023;7:24 https://dx.doi.org/10.20517/2574-1209.2023.60 Page 5 of 16

Table 3. SVS Practice Guidelines (2010) [52] : recommendations of LSA revascularization for TEVAR patients with LSA coverage
(GRADE 1, level C)
[51]
Left vertebral dominance (absent, atretic, or occluded right vertebral artery, absence of communication between the left VA and the circle of
Willis with termination of the left VA artery into the posterior inferior cerebellar artery)
Compromised collateral spinal cord perfusion
Prior ligation of lumbar and middle sacral arteries during infrarenal aortic surgery
Planned coverage of the descending thoracic aorta longer than 200 mm
Hypogastric artery occlusion
Prior left internal mammary-to-coronary artery bypass

bifurcation . Simonte et al. reported no occurrence of spinal cord ischemia in a study including 157
[56]
[57]
consecutive cases in which iliac branch devices were utilized . Schneider et al., in a study on long-term
outcomes of iliac branch endografts, reported primary patency of 95.1% of the internal iliac artery limb and
freedom of secondary intervention of 90.5% at the 5-year landmark, demonstrating that the iliac branch
grafts are a valuable tool in the preservation of the hypogastric artery flow .
[58]

The importance of the repair extension and intercostal/lumbar arteries coverage
Covering an extensive segment of the thoracoabdominal aorta could compromise intercostal and lumbar
contribution to the spinal cord, and increase the risk of SCI. Feezor et al., in a study including 326 TEVAR
patients, observed an incidence of 10% of SCI and concluded that patients who developed permanent
deficits had a higher length of aortic coverage . Flores et al., in a study including 25 patients undergoing
[59]
TAA repair with the stented elephant trunk technique, reported that the combination of a distal landing
zone below T7 and a history of prior AAA repair was the strongest predictor for the occurrence of SCI, with
an odds ratio of 5.46 (P = 0.0047) . Czerny et al. observed that simultaneous obliteration of at least two
[60]
independent vascular territories associated with intraoperative hypotension is a significant risk factor for
[61]
SCI . In a study including 1096 TAA and TAAA cases submitted to open repair, Afifi et al. reported that
ligation of intercostal arteries between the T8 and T12 significantly increased the risk of paraplegia . The
[62]
authors report that reimplantation of intercostal arteries only minimally increases the procedure duration.
Therefore, this would potentially reduce the risk of SCI without significantly impacting the overall
procedure risk. Lastly, it has been reported that total aortic coverage longer than 205 mm is associated with
the development of SCI [63,64] .

Staged strategy
Especially for complex TAA and TAAA that would require an extended coverage of the thoracic and
abdominal aorta, the staged strategy is an essential tool in preventing SCI, either for open or endovascular
repairs. The rationale behind this approach consists of dividing the repair into two shorter and less morbid
interventions, so the collateral network has enough time to compensate for the reduction of blood flow,
potentially diminishing the risk of postoperative SCI. Etz et al., in a study including 90 TAAA patients
submitted to open procedures, observed a significantly lower rate of paraparesis and paraplegia after staged
[65]
TAAA repair compared to non-staged patients . Interestingly, this result was observed despite a
significantly higher number of intercostal and lumbar arteries being sacrificed in the staged group. In a
study including 87 TAAA patients submitted to endovascular repair, O’Callaghan et al. observed a
significantly lower incidence of SCI in patients undergoing staged repair compared to patients who
underwent non-staged repair, even though the length of aortic coverage was significantly greater in the
staged group . Moreover, all the SCI symptoms in the staged group were temporary. A recent publication
[66]
by Dias-Neto et al., including 1,947 patients from the International Aortic Research Consortium,
demonstrated that the staged strategy significantly reduced the risk of permanent paraplegia after
fenestrated/branched repair of extension I-III TAAA . This body of evidence highlights the potential for
[67]