Page 245 - Read Online

Page 10 of 14 Sufali et al. Vessel Plus 2024;8:16 https://dx.doi.org/10.20517/2574-1209.2023.139

In 2018, Dijkstra et al. published a review of preventive strategies for SCI after thoracic and thoraco-
[12]
abdominal aortic repair . They included 43 studies for a total of 7,168 patients, all retrospective cohort
studies, mainly non-comparative, based on very heterogeneous populations of thoracic or
thoracoabdominal aneurysms, dissections, penetrating aortic ulcers, and traumatic injuries. Overall, a
specific SCI prevention protocol was used in about 77% of the studies included in the review. Generally, SCI
is more often transient than permanent (5.7% vs. 2.2%, respectively), with the transient SCI rate ranging
from 0.3% to 31% and the permanent SCI rate from 0.3% to 21%, without a time trend . Permanent SCI
[12]
was 3.6% in the thoracoabdominal aneurysm subgroup at pooled analyses. The more counterintuitive result
reported by this study was the high rate (8%) of SCI affecting TAAA repairs with CSFD. The Authors
suggest that this may be related to a subgroup of patients at very high risk for SCI. Also counterintuitive was
the finding of an association between a permissive endoleak and a rather high (5%) transient SCI rate. The
final suggestion was to selectively use CSFD only in high-risk patients and to promote international
multicenter prospective and high-quality studies to define a universally accepted preventive protocol for
SCI.

To assess risks and benefits related to the use of selective CSFD in F/B-EVAR for Crawford’s extent I-IV
TAAA, Kitpanit et al. analyzed 106 consecutive patients treated from 2014 to 2019 in a prospective
physician-sponsored investigational device exemption study . Despite an overall low rate of SCI (3.8%), the
[8]
authors found a high incidence of CSFD-related major complications, including spinal hematoma,
subarachnoid and cerebellar hemorrhage, and a spinal drain fracture. There was a significant increase in
intensive unit care and hospital length of stay for patients with CSFD. The authors concluded by
discouraging a routine use of prophylactic CSFD and instead emphasized the need for prospective
randomized trials on the use of CSFD in the endovascular treatment of TAAA.

Recently, the US Aortic Research Consortium (US-ARC) published the results of a 65-question survey on
[26]
the methods and protocols to prevent SCI in high-risk patients. These high-risk patients were identified in
the presence of Crawford’s extent I-III, a shaggy aorta, a previous EVAR or open infra-renal aortic repair, or
an abnormal pelvic or vertebral perfusion. The 8 principal investigators differed in the answers principally
on the timing of the resumption of antihypertensive medications, on the duration of the hemoglobin goals,
and on the management of CSFD. Particularly, the investigators using prophylactic CSFD in high-risk
patients for SCI were 6 of 8 (75%), with one of the 6 changing the practice during the study to only CSFD
placement as a rescue maneuver for SCI onset. The US-ARC concluded with a consensus on the beneficial
role of the CSFD for the prevention of SCI, although underlying the need for clinical trials to obtain
rigorous scientific data on its preoperative prophylactic use.

On this point, Aucoin et al. reported worse neurologic outcomes and lower survival with the therapeutic
CSFD for SCI symptoms onset compared with prophylactic CSFD . These findings again highlight the
[26]
necessity of randomized controlled trials to compare prophylactic and therapeutic CSFD. Conversely, in the
systematic review of Pini et al., the pooled SCI rate was 13% for symptomatic CSFD and 14% for
prophylactic CSFD (P:0.87) .
[5]

Among major complications, intracranial hemorrhage affected 5 patients in our series (2 also presenting
SCI). Previous research conducted by our group already indicated that ICH after F/B-EVAR does occur
[27]
mainly in patients with CSFD, and that a platelet count reduction greater than 60%, chronic kidney disease,
and a liquor drainage higher than 50 mL are strongly associated with ICH, independently from the urgent
or selective setting. Statistical analysis failed to show a difference between manual or auto-draining, which
have always been selected according to anesthesiologists’ preference and availability of the devices.