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Sufali et al. Vessel Plus 2024;8:16 https://dx.doi.org/10.20517/2574-1209.2023.139 Page 11 of 14

Although 50 mL seemed to be an unrealistic threshold already in 2021 when these findings were published,
our group focused on strict and careful CSFD management.

[28]
Permissive endoleak was first described by Reilly and Chuter in 2010 , when they successfully reversed the
symptoms of SCI in a patient who received an endovascular repair of a type II Crawford’s extent TAAA.
The authors obtained a Ib endoleak by placing a balloon-expandable stent between the distal portion of the
infrarenal endograft and the aortic wall. Three months later, a Palmaz stent was used to solve the endoleak
and complete the procedure. Thereafter, this idea was developed to leave an interstep intentional
[29]
endoleak, and to avoid abrupt cessation of spinal cord perfusion through intercostal and lumbar arteries,
while enhancing collateral circuit formation. The main techniques to stage a TAAA endovascular repair are
[30]
three: a first isolated thoracic endograft placement , a minimally invasive segmental artery coil
[20]
embolization [31,32] , and a TASP . Depending on aneurysm anatomical characteristics, in our series, a multi-
staged TAAA repair was realized whenever possible. Not-staged cases were usually patients with a higher
anesthesiological risk or with larger aneurysmal diameters. Among the preventive measures introduced by
the present multidisciplinary protocol, treatment staging reached a statistical significance, in accordance
with previous reports in the literature [33,34] . Given the positive effect of staging in preventing SCI, the absence
of TAAA rupture between the two steps in the presented series, and also considering that the second stage
can often be performed under local anesthesia, further prospective studies about this preventive strategy
should be performed, in order to validate these conclusions.

In their 2021 systematic review and meta-analysis on the occurrence of SCI after TAAA endovascular
repair, Pini et al. reported a lower pooled SCI rate after staged compared with non-staged repair (9% vs.
18%, respectively; P = 0.02), independently from the method and timing of staging . More recently, Dias-
[5]
Neto et al. published an analysis of the data from 24 centers of the ARC, with 1947 extent I-III TAAA
electively treated with a staged approach from 2006 to 2021 . The staging strategies (proximal thoracic
[35]
endografting, TASP, MISACE, and combinations of these) allow lower rates of mortality and/or permanent
paraplegia at 30 days or within hospital stay, and higher 1- and 3-year survival.

Recent studies focused on the results of different anesthesiological choices in the endovascular repair of
TAAA give us several insights into the different available possibilities [35-36] . A detailed discussion of every
aspect of a SCI prevention protocol together with the anesthesiology team for each patient is fundamental
[36]
for clinical success .
In 2022, Monaco et al. compared first the short-term results of F/B-EVAR performed under general
anesthesia with sedation with those performed under monitored anesthesia care (MAC) in addition to local
anesthesia, finding that the type of anesthesia seemed to have no effect on procedure success, perioperative
morbidity, or mortality in patients undergoing F/BEVAR, despite a higher need of inotropes/vasopressors
to treat intraoperative hypotension with general anesthesia . In 2023, Monaco et al. compared the results
[37]
of F/B-EVAR under MAC with remifentanil-based sedation with those using dexmedetomidine instead,
finding a worse patient satisfaction with the latter. Moreover, remifentanil was associated with less
hemodynamic effect than dexmedetomidine .
[38]

Considering the high complexity of F/BEVARprocedures and their potential long surgical time, general
anesthesia was used in all cases reported in the present study.

Concerning intraoperative SSEPs/MEPs monitoring, no large randomized controlled trials are currently
available, at the best of our knowledge. In a retrospective review of 1,214 thoracic and TAAA treated
[16]