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Page 4 of 14 Sufali et al. Vessel Plus 2024;8:16 https://dx.doi.org/10.20517/2574-1209.2023.139

Table 1. Dedicated multidisciplinary SCI prevention protocol
Multidisciplinary SCI prevention protocol
Surgical measures Staged TAAAs repair
Patency of subclavian and hypogastric arteries (revascularization, if needed)
Early pelvic and limbs reperfusion
Anesthesiological measures Routine use of cerebrospinal fluid drainage
(within 72 postoperative h ) Maintenance of a mean arterial pressure > 80 mmHg
Maintenance of a hemoglobin concentration > 10 g/dL
Neurological measures Preoperative clinical evaluation
Intraoperative motor and somatosensory evoked potential monitoring*
Postoperative clinical evaluation
*Since 2019.

(3) Early limbs reperfusion

Despite the introduction of low-profile devices, sheaths needed to perform complex aortic procedures still
have large calibers (18-20 Fr), which may be occlusive, especially in the narrowest anatomies. Femoral
sheaths were always withdrawn as soon as possible during the procedure, for pelvic and lower limb
restoration of blood flow.

Anesthesiological measures
CSFD is obtained by the insertion of a catheter in the lumbar subarachnoid space. The deliquoration aims
to reduce the compression on spinal cord, which may present post-ischemic edema, and facilitate its
perfusion thanks to the lowering of the positive pressure inside the canal. A key point of this protocol
consisted of the routine use of CSFD (Liquogard, Moller Medical GmbH, Fulda, Germany) in all Crawford’s
extent I-III TAAAs patients. The only cases excluded from the use of CSFD were urgent settings (not
included in the presented study), patients under non-suspendable ADP-inhibitors or dual antiplatelet
therapy (DAPT) or with excessive prolonged activated partial thromboplastin time (aPTT > 1.5 s), or even
the presence of prohibitive spine diseases. Acetylsalicylic acid was introduced for every patient submitted to
F/B-EVAR if no contraindications were present, while oral anticoagulants and new oral anticoagulants were
shifted to low-molecular-weight heparin (LMWH) dosed on patient’s weight. LMWH was suspended 24 h
prior to the surgery to permit CSFD insertion, which was always performed in operating room the day of
the procedure, just before starting surgery. It was inserted by an anesthesiologist and without fluoroscopic
guidance. Cerebrospinal fluid pressure was maintained through CSFD deliquoration of no more than
20 mL/h, < 10 mm Hg during operation and for at least 72 postoperative hours. CSFD was kept on site for a
longer time in case of SCI symptoms onset, increased cerebrospinal fluid pressure, or aPTT > 1.5 s. For
staged F/B-EVAR, CSFD was maintained or repositioned for every step, whenever possible. Additionally, a
CSFD was also positioned emergently in case of SCI symptoms onset at any time. In case of SCI onset in
patients already under DAPT/ADP-inhibitors or anticoagulants, the insertion of a CSFD is discussed
depending on the grade of SCI and the response to the optimization of all the other hemodynamic factors,
mainly hemoglobin level and mean systolic pressure. If an urgent CSFD positioning is needed, the
optimization of the patient’s coagulation condition is attempted.

Finally, the CSFD was always removed only after a “clamping test” of 24 h negative for SCI symptoms onset.
It was removed with an aPTT < 1.5. At discharge, or at least 72 h after the CSFD removal, dual antiplatelet
therapy was introduced and continued for at least 3 months. For patients under oral anticoagulants or new
oral anticoagulant therapy, only acetylsalicylic acid was added (or Clopidogrel, in case of acetylsalicylic acid
contraindications).