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Page 2 of 14 Sufali et al. Vessel Plus 2024;8:16 https://dx.doi.org/10.20517/2574-1209.2023.139

morbidities, postoperative hemodialysis, and 30-day/in-hospital mortality were assessed as early outcomes.
Survival was evaluated during follow-up.

Results: Out of 104 patients, there were 6 (6%), 51 (49%), and 47 (45%) Crawford’s extent I, II, and III TAAAs,
respectively. A staged TAAA repair, according to endograft design, anatomical and clinical characteristics, was
performed in 83 (80%) cases. The mean hospital stay was 25 ± 22 days. Eight (8%) patients developed SCI, 2
(2%) transitory, and 6 (6%) permanent. Among those with permanent deficits, only 3 (3%) patients had
permanent paraplegia with inability to walk. Out of 104 patients, 5 (5%) had cerebral hemorrhage, two among SCI
patients. Postoperative cardiac and pulmonary morbidity was reported in 6 (6%) and 6 (6%) cases, respectively.
Hemodialysis was necessary in 3 (3%) patients. Three patients died within 30 postoperative days and other 4
during a prolonged/complicated hospitalization, for an overall in-hospital mortality of 7%. The mean follow-up was
30 ± 18 months. The overall estimated 3-year survival was 62%, with a significant difference in survival at 2 years
between patients with and without postoperative SCI (SCI: 18% vs. no-SCI: 69%; P < 0.001).

Conclusions: A dedicated multidisciplinary SCI prevention protocol in elective F/B-EVAR for Crawford’s I-III
TAAAs is feasible and safe, with encouraging rates of SCI (8% overall SCI, 6% permanent impairment, and 3%
paraplegia). The 30-day mortality (3%), cardiopulmonary morbidities (6%), and dialysis rate (3%) were
satisfactory, as well as the estimated survival at 3 years (62%). Patients with SCI had a significantly lower survival
(18% vs. 69%) at 2 years.

Keywords: Thoracoabdominal aortic aneurysm, endovascular repair, spinal cord ischemia, paraplegia, prevention
protocol, cerebrospinal fluid drainage, motor-evoked potentials, somatosensory-evoked potentials

INTRODUCTION
Fenestrated and branched endografting (F/B-EVAR) is an established technique to treat thoracoabdominal
aortic aneurysms (TAAAs) in patients at high surgical risk with specific anatomical characteristics .
[1,2]
Satisfactory results in terms of technical and clinical success have been reported in the literature at mid-term
follow-up, even in very challenging scenarios, such as urgent situations or in cases with previous aortic
[3]
repair .
Despite the progress in overall postoperative results, spinal cord ischemia/infarction (SCI) remains a
possible catastrophic complication after F/B-EVAR for TAAAs, leading to a significant reduction in quality
[4]
of life and survival . In a recent systematic review and meta-analysis, the pooled incidence of SCI after F/B-
EVAR was found to be 13% . Previous studies reported an incidence of SCI up to 35% , with a higher risk
[6]
[5]
related to factors such as urgent/emergent repair, previous aortic surgery, Crawford’s extent I-III TAAAs,
and loss of subclavian/hypogastric arteries .
[7-9]
In the last decades, a number of preoperative, intraoperative and postoperative strategies including surgical,
anesthesiological and medical adjuncts have been proposed in order to reduce the incidence of SCI after
[15]
F/B-EVAR in TAAAs [10-14] . CSFD and intraoperative neuromonitoring with SSEPs/MEPs [1,16-17] have also
been extensively investigated, but their efficacy is still debated in the literature.

The aim of the present study was to report the results of a dedicated multidisciplinary SCI prevention
protocol, consisting of surgical, anesthesiological and neurological measures, for elective endovascular
repair of Crawford’s extent I-III TAAAs by F/B-EVAR.