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Gomes et al. Vessel Plus 2023;7:24 https://dx.doi.org/10.20517/2574-1209.2023.60 Page 11 of 16

presenting this adverse event. NIRS can be maintained in the intensive care unit for monitoring high-risk
patients, although there is no consensus recommending its use and no sufficient evidence available for a
precise cutoff that would be concerning for SCI.

The maneuvers described above should also be implemented for the cases with postoperative SCI. MAP
above 90 mmHg and hemoglobin above 10 mg/dL are goals that should be pursued in these cases. If a
prophylactic spinal drain was inserted, a therapeutic drain should be placed with the purpose of keeping
CSFP below 10 mmHg. If the neurologic deficits do not improve as expected, lower CSFP values can be
attempted as a heroic maneuver up to the discretion of the surgical team assisting the patient. However, in
addition to the high risk of intracranial bleeding from aggressive CSF drainage, there is no consensus
recommending this practice to date.

The use of therapeutic CSF drainage can also be indicated even in those cases presenting delayed-onset SCI
[108]
symptoms, with satisfactory results reported in the literature . Weissler et al. suggest that permissive
hypertension (systolic blood pressure up to 150 mmHg) during the first month after TEVAR could also aid
in the protection against SCI .
[109]
Finally, the use of high-dose steroids as part of a rescue protocol is described in the literature, even in cases
with a delayed presentation of SCI , but there is no consensus recommending this practice.
[110]

CONCLUSION
Spinal cord ischemia prevention in the context of TAA or TAAA repair requires meticulous surgical
planning including a thorough analysis of the contributions to spinal cord perfusion and repair extension,
always evaluating the need for a staged approach. Careful perioperative strategies including hypotension
avoidance and neuromonitoring, weighing the advantages and disadvantages of preoperative lumbar drain
implantation are paramount in these cases. The strategies for preventing SCI discussed in this review can be
applied in a combined fashion, depending on the patient’s anatomy and the planned repair. Vascular and
cardiothoracic surgeons dedicated to the treatment of TAA and TAAA should be comfortable with all the
SCI protective and rescue strategies in order to reduce the risk of this adverse event in this patient
population.

DECLARATIONS
Authors’ contributions
Literature review; data interpretation; manuscript preparation; critical revision of the manuscript; approval
of the manuscript: all authors.

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
Vivian Carla Gomes: no disclosures; Federico Ezequiel Parodi: Stock options from Centerline Biomedical;
Mark A Farber: WL Gore - Consulting, Clinical Trial Support; Getinge - Consulting; Cook - Research
support, Clinical Trial support; ViTTA - Consulting, Clinical Trial support; Centerline Biomedical - Stock
options, Clinical Trial support.