Thoracic endovascular aortic repair (TEVAR) has decreased the morbidity and mortality associated with open surgical repair of descending thoracic aortic diseases, but important complications unique to the procedure remain. Spinal cord ischemia and infarction is a recognized complication caused by endovascular coverage or injury to spinal cord collateral vessels. Stroke is a consequence of thromboembolism or coverage of aortic arch branch vessels with insufficient collateral circulation. Understanding the risk factors and the pathophysiology of neurological complications of TEVAR are important for the successful anesthetic and surgical management and treatment of patients undergoing endovascular procedures involving the thoracic aorta.
MatsumuraJSCambriaRPDakeMDMooreRDSvenssonLGSnyderS. International controlled clinical trial of thoracic endovascular aneurysm repair with the Zenith TX2 endovascular graft: 1-year results. J Vasc Surg. 2008;47:247-257; discussion 57.
2.
FairmanRMCriadoFFarberM. Pivotal results of the Medtronic Vascular Talent Thoracic Stent Graft System: the VALOR trial. J Vasc Surg. 2008;48:546-554.
3.
MakarounMSDillavouEDKeeST. Endovascular treatment of thoracic aortic aneurysms: results of the phase II multicenter trial of the GORE TAG thoracic endoprosthesis. J Vasc Surg. 2005;41:1-9.
4.
JonkerFHVerhagenHJLinPH. Open surgery versus endovascular repair of ruptured thoracic aortic aneurysms. J Vasc Surg. 2011;53:1210-1216.
5.
BortoneASDe CillisED’AgostinoDde Luca Tupputi SchinosaL. Endovascular treatment of thoracic aortic disease: four years of experience. Circulation. 2004;110:II262-II267.
6.
StoneDHBrewsterDCKwolekCJ. Stent-graft versus open-surgical repair of the thoracic aorta: mid-term results. J Vasc Surg. 2006;44:1188-1197.
LeursLJBellRDegrieckYThomasSHoboRLundbomJ. Endovascular treatment of thoracic aortic diseases: combined experience from the EUROSTAR and United Kingdom Thoracic Endograft registries. J Vasc Surg. 2004;40:670-679; discussion 679-680.
9.
JonkerFHTrimarchiSVerhagenHJMollFLSumpioBEMuhsBE. Meta-analysis of open versus endovascular repair for ruptured descending thoracic aortic aneurysm. J Vasc Surg. 2010;51:1026-1032, 1032 e1-1032 e2.
10.
XenosESMinionDJDavenportDL. Endovascular versus open repair for descending thoracic aortic rupture: institutional experience and meta-analysis. Eur J Cardiothorac Surg. 2009;35:282-286.
11.
CheungATWeissSJMcGarveyML. Interventions for reversing delayed-onset postoperative paraplegia after thoracic aortic reconstruction. Ann Thorac Surg. 2002;74:413-419; discussion 420-421.
12.
WeigangEHartertMSiegenthalerMP. Perioperative management to improve neurologic outcome in thoracic or thoracoabdominal aortic stent-grafting. Ann Thorac Surg. 2006;82:1679-1687.
13.
SafiHJWinnerkvistAMillerCCIII. Effect of extended cross-clamp time during thoracoabdominal aortic aneurysm repair. Ann Thorac Surg. 1998;66:1204-1209.
14.
MesseSRBavariaJEMullenM. Neurologic outcomes from high risk descending thoracic and thoracoabdominal aortic operations in the era of endovascular repair. Neurocrit Care. 2008;9:344-351.
15.
EstreraALSheinbaumRMillerCC. Cerebrospinal fluid drainage during thoracic aortic repair: safety and current management. Ann Thorac Surg. 2009;88:9-15.
16.
NaslundTCHollierLHMoneySRFacundusECSkenderisBSII. Protecting the ischemic spinal cord during aortic clamping: the influence of anesthetics and hypothermia. Ann Surg. 1992;215:409-415; discussion 415-416.
17.
FeezorRJMartinTDHessPJJr. Extent of aortic coverage and incidence of spinal cord ischemia after thoracic endovascular aneurysm repair. Ann Thorac Surg. 2008;86:1809-1814; discussion 1814.
18.
AmabilePGrisoliDGiorgiRBartoliJMPiquetP. Incidence and determinants of spinal cord ischaemia in stent-graft repair of the thoracic aorta. Eur J Vasc Endovasc Surg. 2008;35:455-461.
19.
GreenbergRKLuQRoselliEE. Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques. Circulation. 2008;118:808-817.
20.
DossMBalzerJMartensS. Emergent endovascular stent grafting for perforated acute type B dissections and ruptured thoracic aortic aneurysms. Ann Thorac Surg. 2003;76:493-498; discussion 497-498.
21.
UlleryBWCheungATFairmanRM. Risk factors, outcomes, and clinical manifestations of spinal cord ischemia following thoracic endovascular aortic repair. J Vasc Surg. 2011;54:677-684.
22.
FeezorRJMartinTDHessPJ. Risk factors for perioperative stroke during thoracic endovascular aortic repairs (TEVAR). J Endovasc Ther. 2007;14:568-573.
23.
ChangCKChuterTAReillyLM. Spinal arterial anatomy and risk factors for lower extremity weakness following endovascular thoracoabdominal aortic aneurysm repair with branched stent-grafts. J Endovasc Ther. 2008;15: 356-362.
24.
DunningJMartinJEShennibHChengDC. Is it safe to cover the left subclavian artery when placing an endovascular stent in the descending thoracic aorta?Interact Cardiovasc Thorac Surg. 2008;7:690-697.
25.
LeeWAMartinTDGravensteinN. Partial right atrial inflow occlusion for controlled systemic hypotension during thoracic endovascular aortic repair. J Vasc Surg. 2008;48:494-498.
26.
SvenssonLGKleppPHinderRA. Spinal cord anatomy of the baboon–comparison with man and implications for spinal cord blood flow during thoracic aortic cross-clamping. S Afr J Surg. 1986;24:32-34.
27.
SliwaJAMacleanIC. Ischemic myelopathy: a review of spinal vasculature and related clinical syndromes. Arch Phys Med Rehabil. 1992;73:365-372.
28.
ShamjiMFMaziakDEShamjiFMGinsbergRJPonR. Circulation of the spinal cord: an important consideration for thoracic surgeons. Ann Thorac Surg. 2003;76:315-321.
29.
GharagozlooFLarsonJDausmannMJNevilleRFJrGomesMN. Spinal cord protection during surgical procedures on the descending thoracic and thoracoabdominal aorta: review of current techniques. Chest. 1996;109:799-809.
30.
CheshireWPSantosCCMasseyEWHowardJFJr. Spinal cord infarction: etiology and outcome. Neurology. 1996;47:321-330.
31.
DommisseGF. The blood supply of the spinal cord: a critical vascular zone in spinal surgery. J Bone Joint Surg Br. 1974;56:225-235.
32.
BiglioliPRobertoMCannataA. Upper and lower spinal cord blood supply: the continuity of the anterior spinal artery and the relevance of the lumbar arteries. J Thorac Cardiovasc Surg. 2004;127:1188-1192.
33.
BollDTBulowHBlackhamKAAschoffAJSchmitzBL. MDCT angiography of the spinal vasculature and the artery of Adamkiewicz. AJR Am J Roentgenol. 2006;187: 1054-1060.
34.
StrauchJTLautenASpielvogelD. Mild hypothermia protects the spinal cord from ischemic injury in a chronic porcine model. Eur J Cardiothorac Surg. 2004;25:708-715.
35.
MiyairiTKotsukaYMorotaT. Paraplegia after open surgery using endovascular stent graft for aortic arch aneurysm. J Thorac Cardiovasc Surg. 2001;122:1240-1243.
36.
GillilanLA. Veins of the spinal cord: anatomic details; suggested clinical applications. Neurology. 1970;20:860-868.
37.
CrawfordESSvenssonLGHessKR. A prospective randomized study of cerebrospinal fluid drainage to prevent paraplegia after high-risk surgery on the thoracoabdominal aorta. J Vasc Surg. 1991;13:36-45; discussion 46.
38.
ChiesaRMelissanoGMarrocco-TrischittaMMCiviliniESetacciF. Spinal cord ischemia after elective stent-graft repair of the thoracic aorta. J Vasc Surg. 2005;42:11-17.
39.
EstreraALMillerCCIIIHuynhTT. Preoperative and operative predictors of delayed neurologic deficit following repair of thoracoabdominal aortic aneurysm. J Thorac Cardiovasc Surg. 2003;126:1288-1294.
CheungATPochettinoAMcGarveyML. Strategies to manage paraplegia risk after endovascular stent repair of descending thoracic aortic aneurysms. Ann Thorac Surg. 2005;80:1280-1288; discussion 1288-1289.
42.
GravereauxECFariesPLBurksJA. Risk of spinal cord ischemia after endograft repair of thoracic aortic aneurysms. J Vasc Surg. 2001;34:997-1003.
43.
TiesenhausenKHessingerMTomkaMPortugallerHSwanidzeSOberwalderP. Endovascular treatment of mycotic aortic pseudoaneurysms with stent-grafts. Cardiovasc Intervent Radiol. 2008;31:509-513.
44.
HellerLBChaneyMA. Paraplegia immediately following removal of a cerebrospinal fluid drainage catheter in a patient after thoracoabdominal aortic aneurysm surgery. Anesthesiology. 2001;95:1285-1287.
45.
KasirajanKDolmatchBOurielKClairD. Delayed onset of ascending paralysis after thoracic aortic stent graft deployment. J Vasc Surg. 2000;31:196-199.
46.
ButhJHarrisPLHoboR. Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) registry. J Vasc Surg. 2007;46:1103-1110; discussion 1110-1111.
47.
MartinDJMartinTDHessPJDanielsMJFeezorRJLeeWA. Spinal cord ischemia after TEVAR in patients with abdominal aortic aneurysms. J Vasc Surg. 2009;49:302-306; discussion 306-307.
48.
SchlosserFJVerhagenHJLinPH. TEVAR following prior abdominal aortic aneurysm surgery: increased risk of neurological deficit. J Vasc Surg. 2009;49:308-314; discussion 314.
49.
BarilDTCarroccioAEllozySH. Endovascular thoracic aortic repair and previous or concomitant abdominal aortic repair: is the increased risk of spinal cord ischemia real?Ann Vasc Surg. 2006;20:188-194.
50.
KhoynezhadADonayreCEBuiHKopchokGEWalotIWhiteRA. Risk factors of neurologic deficit after thoracic aortic endografting. Ann Thorac Surg. 2007;83:S882-S889; discussion S90-S92.
51.
AcherCWWynnMMHochJRPopicPArchibaldJTurnipseedWD. Combined use of cerebral spinal fluid drainage and naloxone reduces the risk of paraplegia in thoracoabdominal aneurysm repair. J Vasc Surg. 1994;19:236-246; discussion 47-48.
52.
WynnMMMellMWTeferaGHochJRAcherCW. Complications of spinal fluid drainage in thoracoabdominal aortic aneurysm repair: a report of 486 patients treated from 1987 to 2008. J Vasc Surg. 2009;49:29-34; discussion 35.
53.
McCulloughJLHollierLHNugentM. Paraplegia after thoracic aortic occlusion: influence of cerebrospinal fluid drainage: experimental and early clinical results. J Vasc Surg. 1988;7:153-160.
54.
FedorowCAMoonMCMutchWAGrocottHP. Lumbar cerebrospinal fluid drainage for thoracoabdominal aortic surgery: rationale and practical considerations for management. Anesth Analg. 2010;111:46-58.
55.
DasmahapatraHKColesJGWilsonGJ. Relationship between cerebrospinal fluid dynamics and reversible spinal cord ischemia during experimental thoracic aortic occlusion. J Thorac Cardiovasc Surg. 1988;95:920-923.
56.
MurrayMJBowerTCOliverWCJrWernerEGloviczkiP. Effects of cerebrospinal fluid drainage in patients undergoing thoracic and thoracoabdominal aortic surgery. J Cardiothorac Vasc Anesth. 1993;7:266-272.
57.
CinaCSAbouzahrLArenaGOLaganaADevereauxPJFarrokhyarF. Cerebrospinal fluid drainage to prevent paraplegia during thoracic and thoracoabdominal aortic aneurysm surgery: a systematic review and meta-analysis. J Vasc Surg. 2004;40:36-44.
58.
KhanSNStansbyG. Cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery. Cochrane Database Syst Rev. 2004;(1):CD003635.
59.
EllozySHCarroccioAMinorM. Challenges of endovascular tube graft repair of thoracic aortic aneurysm: midterm follow-up and lessons learned. J Vasc Surg. 2003;38:676-683.
60.
HnathJCMehtaMTaggertJB. Strategies to improve spinal cord ischemia in endovascular thoracic aortic repair: outcomes of a prospective cerebrospinal fluid drainage protocol. J Vasc Surg. 2008;48:836-840.
FleckTHutschalaDWeisslMWolnerEGrabenwogerM. Cerebrospinal fluid drainage as a useful treatment option to relieve paraplegia after stent-graft implantation for acute aortic dissection type B. J Thorac Cardiovasc Surg. 2002;123:1003-1005.
63.
Ortiz-GomezJRGonzalez-SolisFJFernandez-AlonsoLBilbaoJI. Reversal of acute paraplegia with cerebrospinal fluid drainage after endovascular thoracic aortic aneurysm repair. Anesthesiology. 2001;95:1288-1289.
64.
FuchsRJLeeWASeubertCNGelmanS. Transient paraplegia after stent grafting of a descending thoracic aortic aneurysm treated with cerebrospinal fluid drainage. J Clin Anesth. 2003;15:59-63.
65.
HiratzkaLFBakrisGLBeckmanJA. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010;121:e266-e369.
66.
UlleryBWQuatromoniJJacksonBM. Impact of intercostal artery occlusion on spinal cord ischemia following thoracic endovascular aortic repair. Vasc Endovascular Surg. 2011;45:519-523.
67.
McGarveyMLMullenMTWooEY. The treatment of spinal cord ischemia following thoracic endovascular aortic repair. Neurocrit Care. 2007;6:35-39.
CinaCSSafarHALaganaAArenaGClaseCM. Subclavian carotid transposition and bypass grafting: consecutive cohort study and systematic review. J Vasc Surg. 2002;35:422-429.
71.
RizviAZMuradMHFairmanRMErwinPJMontoriVM. The effect of left subclavian artery coverage on morbidity and mortality in patients undergoing endovascular thoracic aortic interventions: a systematic review and meta-analysis. J Vasc Surg. 2009;50:1159-1169.
72.
ter WolbeekCHartertMConzelmannLO. Value and pitfalls of neurophysiological monitoring in thoracic and thoracoabdominal aortic replacement and endovascular repair. Thorac Cardiovasc Surg. 2010;58:260-264.
KeyhaniKMillerCCIIIEstreraALWegrynTSheinbaumRSafiHJ. Analysis of motor and somatosensory evoked potentials during thoracic and thoracoabdominal aortic aneurysm repair. J Vasc Surg. 2009;49:36-41.
75.
ShineTSHarrisonBADe RuyterML. Motor and somatosensory evoked potentials: their role in predicting spinal cord ischemia in patients undergoing thoracoabdominal aortic aneurysm repair with regional lumbar epidural cooling. Anesthesiology. 2008;108:580-587.
76.
SundtTMFlemmingMDOderichGS. Spinal cord protection during open repair of thoracic and thoracoabdominal aortic aneurysms using profound hypothermia and circulatory arrest. J Am Coll Surg. 2010;212:678-683; discussion 84-85.
77.
KulikACastnerCFKouchoukosNT. Replacement of the descending thoracic aorta: contemporary outcomes using hypothermic circulatory arrest. J Thorac Cardiovasc Surg. 2010;139:249-55.
78.
CoselliJSBozinovskiJCheungC. Hypothermic circulatory arrest: safety and efficacy in the operative treatment of descending and thoracoabdominal aortic aneurysms. Ann Thorac Surg. 2008;85:956-963; discussion 964.
79.
MichenfelderJDMildeJH. The relationship among canine brain temperature, metabolism, and function during hypothermia. Anesthesiology. 1991;75:130-136.
80.
AllenBTDavisCGOsborneDKarlI. Spinal cord ischemia and reperfusion metabolism: the effect of hypothermia. J Vasc Surg. 1994;19:332-339; discussion 339-340.
81.
RokkasCKCroninCSNittaT. Profound systemic hypothermia inhibits the release of neurotransmitter amino acids in spinal cord ischemia. J Thorac Cardiovasc Surg. 1995;110:27-35.
82.
MotoyoshiNTakahashiGSakuraiMTabayashiK. Safety and efficacy of epidural cooling for regional spinal cord hypothermia during thoracoabdominal aneurysm repair. Eur J Cardiothorac Surg. 2004;25:139-141.
83.
TabayashiKMotoyoshiNSaikiY. Efficacy of perfusion cooling of the epidural space and cerebrospinal fluid drainage during repair of extent I and II thoracoabdominal aneurysm. J Cardiovasc Surg (Torino). 2008;49:749-755.
84.
DavisonJKCambriaRPVierraDJColumbiaMAKoustasG. Epidural cooling for regional spinal cord hypothermia during thoracoabdominal aneurysm repair. J Vasc Surg. 1994;20:304-310.
85.
BlackJHDavisonJKCambriaRP. Regional hypothermia with epidural cooling for prevention of spinal cord ischemic complications after thoracoabdominal aortic surgery. Semin Thorac Cardiovasc Surg. 2003;15:345-352.
86.
LaschingerJCCunninghamJNJrCooperMMKriegerKNathanIMSpencerFC. Prevention of ischemic spinal cord injury following aortic cross-clamping: use of corticosteroids. Ann Thorac Surg. 1984;38:500-507.
87.
NylanderWAJrPlunkettRJHammonJWJrOldfieldEHMeachamWF. Thiopental modification of ischemic spinal cord injury in the dog. Ann Thorac Surg. 1982;33: 64-68.
88.
KuniharaTMatsuzakiKShiiyaNSaijoYYasudaK. Naloxone lowers cerebrospinal fluid levels of excitatory amino acids after thoracoabdominal aortic surgery. J Vasc Surg. 2004;40:681-690.
89.
ReeceTBKernJATribbleCGCassadaDC. The role of pharmacology in spinal cord protection during thoracic aortic reconstruction. Semin Thorac Cardiovasc Surg. 2003;15:365-377.
90.
KohnoHIshidaAImamakiMShimuraHMiyazakiM. Efficacy and vasodilatory benefit of magnesium prophylaxis for protection against spinal cord ischemia. Ann Vasc Surg. 2007;21:352-359.
91.
GutscheJTCheungATMcGarveyML. Risk factors for perioperative stroke after thoracic endovascular aortic repair. Ann Thorac Surg. 2007;84:1195-1200; discussion 1200.
92.
HoltPJJohnsonCHinchliffeRJ. Outcomes of the endovascular management of aortic arch aneurysm: implications for management of the left subclavian artery. J Vasc Surg. 2010;51:1329-1338.
93.
CloughREModaraiBToppleJA. Predictors of stroke and paraplegia in thoracic aortic endovascular intervention. Eur J Vasc Endovasc Surg. 2010;41:303-310.
94.
WheatleyGHIIIGurbuzATRodriguez-LopezJA. Midterm outcome in 158 consecutive Gore TAG thoracic endoprostheses: single center experience. Ann Thorac Surg. 2006;81:1570-1577; discussion 1577.
95.
PatelHJWilliamsDMUpchurchGRJr. Long-term results from a 12-year experience with endovascular therapy for thoracic aortic disease. Ann Thorac Surg. 2006;82: 2147-2153.
96.
IyerVSMackenzieKSTseLW. Early outcomes after elective and emergent endovascular repair of the thoracic aorta. J Vasc Surg. 2006;43:677-683.
97.
FattoriRNienaberCARousseauH. Results of endovascular repair of the thoracic aorta with the Talent Thoracic stent graft: the Talent Thoracic Retrospective Registry. J Thorac Cardiovasc Surg. 2006;132:332-339.
98.
GutscheJTSzetoWCheungAT. Endovascular stenting of thoracic aortic aneurysm. Anesthesiol Clin. 2008;26:481-499.
99.
KatzESTunickPARusinekHRibakoveGSpencerFCKronzonI. Protruding aortic atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: experience with intraoperative transesophageal echocardiography. J Am Coll Cardiol. 1992;20:70-77.
100.
van der LindenJHadjinikolaouLBergmanPLindblomD. Postoperative stroke in cardiac surgery is related to the location and extent of atherosclerotic disease in the ascending aorta. J Am Coll Cardiol. 2001;38:131-135.
101.
MelissanoGCiviliniEBertoglioL. Results of endografting of the aortic arch in different landing zones. Eur J Vasc Endovasc Surg. 2007;33:561-566.
102.
CooperDGWalshSRSadatUNooraniAHayesPDBoyleJR. Neurological complications after left subclavian artery coverage during thoracic endovascular aortic repair: a systematic review and meta-analysis. J Vasc Surg. 2009;49:1594-1601.
103.
GorichJAsquanYSeifarthH. Initial experience with intentional stent-graft coverage of the subclavian artery during endovascular thoracic aortic repairs. J Endovasc Ther. 2002;9(suppl 2):II39-II43.
104.
RehdersTCPetzschMInceH. Intentional occlusion of the left subclavian artery during stent-graft implantation in the thoracic aorta: risk and relevance. J Endovasc Ther. 2004;11:659-666.
105.
BergeronPMangialardiNCostaP. Great vessel management for endovascular exclusion of aortic arch aneurysms and dissections. Eur J Vasc Endovasc Surg. 2006;32:38-45.
106.
PetersonBGEskandariMKGleasonTGMoraschMD. Utility of left subclavian artery revascularization in association with endoluminal repair of acute and chronic thoracic aortic pathology. J Vasc Surg. 2006;43:433-439.
107.
OrendKHZarbisNSchelzigHHalterGLangGSunder-PlassmannL. Endovascular treatment (EVT) of acute traumatic lesions of the descending thoracic aorta: 7 years’ experience. Eur J Vasc Endovasc Surg. 2007;34: 666-672.
108.
MatsumuraJSLeeWAMitchellRS. The Society for Vascular Surgery Practice Guidelines: management of the left subclavian artery with thoracic endovascular aortic repair. J Vasc Surg. 2009;50:1155-1158.
109.
MariscalcoGPiffarettiGTozziM. Predictive factors for cerebrovascular accidents after thoracic endovascular aortic repair. Ann Thorac Surg. 2009;88:1877-1881.
110.
OzatikMAGolMKFansaI. Risk factors for stroke following coronary artery bypass operations. J Card Surg. 2005;20:52-57.
111.
ParlaniGVerziniFZannettiS. Does gender influence outcome of AAA endoluminal repair?Eur J Vasc Endovasc Surg. 2003;26:69-73.
112.
RiesenmanPJFarberMAMendesRRMarstonWAFultonJJKeagyBA. Coverage of the left subclavian artery during thoracic endovascular aortic repair. J Vasc Surg. 2007;45:90-94; discussion 94-95.
113.
AdamsHPJrdel ZoppoGAlbertsMJ. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007;38:1655-711.
