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Page 10 of 16 Gomes et al. Vessel Plus 2023;7:24 https://dx.doi.org/10.20517/2574-1209.2023.60

Table 4. Rescue strategies
Intraoperative strategies Keep MAP > 90 mmHg through careful infusion of volume and use of vasopressors
Keep hemoglobin ≥ 10 mg/dL
If prophylactic spinal drain is in place, keep CSFP < 10 mmHg
Reimplantation of intercostal arteries (if open repair) open repair
TASP (in endovascular repair)
Modification of the sequence of implantation of components during endovascular repair
Postoperative strategies Keep MAP > 90 mmHg through careful infusion of volume and use of vasopressors
Keep hemoglobin ≥ 10 mg/dL
Therapeutic spinal drain (goal: CSFP < 10 mmHg)
Possible use of high-dose steroids
CSFP: Cerebrospinal fluid pressure; TASP: temporary aneurysm sac perfusion.

During open cases, the reimplantation of intercostal arteries has been demonstrated to be an effective tool in
reducing the risk of SCI, without significantly increasing the duration of the procedure .
[62]
As for the rescue maneuvers during endovascular procedures, the rationale behind TASP is the prevention
of the complete aneurysm sac thrombosis and maintenance of blood inflow to the spinal cord through
intercostal and lumbar arteries achieved by intentionally leaving at least one target vessel non-scented.
Kasprzak et al., in a study with 83 patients submitted to BEVAR for TAAA treatment , reported that the
[104]
cases submitted to TASP had a significantly lower incidence of severe SCI or paraplegia compared to those
that did not undergo this technique. These authors observed a median of 48 days (range 1-370 days)
between the index procedure and completion of repair. Harrison et al. described an interval of 7-10 days
between the TAAA repair and the complete exclusion of the aneurysm. TASP can also be obtained by
leaving the contralateral limb of a bifurcated device incomplete [84,105] .

Another intraoperative option to improve spinal cord perfusion during F/BEVAR for TAAA is the
modification of the implantation sequence of the components during the repair. This maneuver aims to
provide early pelvic and limb reperfusion by deploying the bifurcated component and iliac limbs and
removing the large caliber sheaths from the iliac system before deploying the target vessel stents through an
axillary access. Maurel et al., analyzed 204 TAAA patients submitted to endovascular repair and observed a
significantly lower rate of SCI in patients who were submitted to early pelvic reperfusion using this
[106]
technique .

Finally, in those cases presenting intraoperative SCI that did not have a spinal drain placed preoperatively, a
therapeutic drain can also be indicated by the time the surgical intervention ends. According to the
recommendations reported by Aucoin et al. on behalf of the US-ARC, keeping hemoglobin ≥ 10 mg/dL,
MAP ≥ 90 mmHg, and obtaining an immediate image of the spine to rule out hematomas are also essential
rescue maneuvers in this context .
[75]

The use of high-dose steroids has also been documented in this scenario in conjunction with the
[107]
aforementioned techniques, but there is no consensus recommending this practice .
SCI with postoperative onset
The multidisciplinary team must be attentive to the hemodynamic and neurologic status during the whole
postoperative period of TAA and TAAA patients. A low threshold to trigger rescue strategies intended to
prevent permanent neurologic deficits is recommended to reduce the recovery time from SCI in those