MINIMIZING NEUROLOGIC COMPLICATIONS IN THE TREATMENT OF THE - - PDF document

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

MINIMIZING NEUROLOGIC COMPLICATIONS IN THE TREATMENT OF THE THORACIC AORTA

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

DISCLOSURES

➢ None ➢ Not discussing off-label use of anything

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

MECHANISMS OF SCI

➢ Hemodynamic

▪ anatomy ▪ physiology

➢ Embolic

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

MECHANISMS OF SCI

➢ Treated length

Intercostal, lumbar exclusion

➢ Collateral sacrifice

vertebral, hypogastric exclusion

➢ Perioperative instability ➢ Cross clamp duration ➢ Direct blood flow

interruption

➢ Indirect blood flow

interruption

➢ Systemic hypoperfusion

➢ Ischemia / reperfusion

➢ Embolization

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

DETECTION OF SCI

➢ cnNIRS (Near infrared spectroscopy) Monitoring

Etz CD VEITH 2018

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

➢Hemodynamic stability / permissive hypertension

▪ Modify antihypertensive regimen preop ▪ Gradual reintroduction of antihypertensives over several weeks ▪ Use volume before pressors; Hgb ≥ 10

Lowest SBP Recorded During Hospital Stay

96 75 20 40 60 80 100 120 Intact (n = 27) LEW (n = 6) Mean SBP (mm Hg)

p = 0.005

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

➢Hemodynamic stability / permissive hypertension

▪ Reduce or stop antihypertensive medications preop ▪ Gradual reintroduction of antihypertensives over several weeks ▪ Use volume before pressors; Hgb ≥ 10 ▪ Restore lower extremity / pelvic flow

Oderich et al. JEVT 2016; 23(1): 139-49

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

➢ Preservation of collateral spinal cord perfusion

▪ Carotid subclavian bypass ▪ Hypogastric artery revascularization ▪ Simultaneous vs staged (open vs endo, TAA vs TAAA)

Mansukhani NA et al. Ann Vasc Surg 2017; 42:162-68 Bergamini TM et al. J Vasc Surg 202; 34:120-4

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

➢ CSF drainage

▪ reduces SCI from 10-20% to 2.3-10%

Khan NR et al. J Neurosurg Spine 2016; 25:383-93

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

➢ CSF drainage

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

➢ CSF drainage

▪ asymptomatic — low baseline rate (5 – 10 cc/hr) ▪ symptomatic — to effect, not to pressure ▪ < 30 cc in any one hour

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

➢ CSF drainage

▪ asymptomatic — low baseline rate (5 – 10 cc/hr) ▪ symptomatic — to effect, not to pressure ▪ < 30 cc in any one hour ▪ Selective

▪ Endo TAA ▪ Open extent IV TAAA

• Routine

▪ All endo TAAA ▪ Open extent I-III TAAA ▪ Open TAA

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

➢ CSF drainage

▪ asymptomatic — low baseline rate (5 – 10 cc/hr) ▪ symptomatic — to effect, not to pressure ▪ < 30 cc in any one hour ▪ Selective

▪ Endo TAA ▪ Open extent IV TAAA

• Routine

▪ All endo TAAA ▪ Open extent I-III TAAA ▪ Open TAA

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Spinal Cord Ischemic Preconditioning

➢ Incomplete (Staged) repair ➢ Transient aneurysm sac perfusion (TASP) ➢ Intercostal / lumbar artery occlusion 13 14

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Spinal Cord Ischemic Preconditioning ➢ Incomplete (Staged) repair

Etz et al single stage 13% two stage 0% Haulon et al single stage 25% two stage 2.1%

Etz CD et al. J Thor Cardiovasc Surg 2010; 139(6):1464-72 Haulon et al. Eur J Vasc Endovasc Surg 2015; 49:248-54

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Spinal Cord Ischemic Preconditioning

➢ Transient Aneurysm Sac Perfusion

A B C A B C

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Spinal Cord Ischemic Preconditioning

➢ Transient Aneurysm Sac Perfusion

A B

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Spinal Cord Ischemic Preconditioning

➢ Incomplete (Staged) repair ➢ Transient aneurysm sac perfusion (TASP)

Oderich et al. JEVT 2016; 23(1): 139-49

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Spinal Cord Ischemic Preconditioning

➢ Incomplete (Staged) repair ➢ Transient aneurysm sac perfusion (TASP)

Jayia P et al. Aorta 2015;3(2):56-60

Harrison SC et al. J Vasc Surg 2012; 55(4):1202-05

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Spinal Cord Ischemic Preconditioning

➢ Incomplete (Staged) repair ➢ Transient aneurysm sac perfusion (TASP)

Miranda et al. Int Angiol 2018; 37(2): 112-26l

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Spinal Cord Ischemic Preconditioning

➢ Incomplete (Staged) repair ➢ Transient aneurysm sac perfusion YES NO Kasprzak 12 (2) / 40 11 (9) / 43 0.03 Youssef 0 / 10 3 (?) / 20 0.28 Orrico 2 (1) / 32 Javia 9 (1) / 25 O’Callaghan 3 (0) / 27 12 (7) / 32 0.03 ( ) = permanent deficit

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Spinal Cord Ischemic Preconditioning

➢ Intercostal / lumbar artery occlusion—selective

Branzen et al. EuroIntervention 2018

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Spinal Cord Ischemic Preconditioning

➢ Intercostal / lumbar artery occlusion—selective

Branzen et al. EuroIntervention 2018

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Spinal Cord Ischemic Preconditioning

➢ Intercostal / lumbar artery occlusion—selective

Branzen et al. EuroIntervention 2018

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Spinal Cord Ischemic Preconditioning

➢ Intercostal / lumbar artery occlusion—selective

Branzen et al. EuroIntervention 2018

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Spinal Cord Ischemic Preconditioning

➢ Intercostal / lumbar artery occlusion—selective

Etz et al. VEITH 2018

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Spinal Cord Ischemic Preconditioning

➢ Intercostal / lumbar artery occlusion—selective

Etz et al. VEITH 2018

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Spinal Cord Ischemic Preconditioning

➢ Intercostal / lumbar artery occlusion—selective

Etz et al. VEITH 2018

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Spinal Cord Ischemic Preconditioning

➢ Intercostal / lumbar artery occlusion—selective

Etz et al. VEITH 2018

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Spinal Cord Ischemic Preconditioning

➢ Intercostal / lumbar artery occlusion—selective

Etz et al. VEITH 2018

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Spinal Cord Ischemic Preconditioning

➢ Intercostal / lumbar artery occlusion—non-selective

Sonesson VEITH 2018

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Hyperglycemia ➢ Associated with worse clinical outcomes

▪ Acute ischemic stroke ▪ Severe head injury ▪ Subarachnoid hemorrhage

➢ Animal studies may be harmful in setting of spinal cord ischemic injury

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Hyperglycemia

➢ Elevated blood and CSF glucose significantly associated with

postoperative LEW in patients undergoing MBEVAR

➢ Elevated glucose levels preceed onset of LEW Hiramoto JS et al; JVS 2017. 65(2): 311-317

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

GROUP A BEFORE IIP

▪

N=22

▪

7 / 22 (38%) LEW within 48 hours

▪

Transient 5 / 22 (23%)

▪

Permanent 2 / 22 (9%)

GROUP B AFTER IIP

▪

N=31

▪

0 / 31 (0%) LEW within 48 hours

▪

1 / 31 (3%) one leg sensory deficit

▪

1 / 31 (3%) paraplegia POD # 4, 2 days after insulin stopped

Rate of LEW <48 hours significantly lower after IIP started p=0.009

Hyperglycemia

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Group A1, n=7 BEFORE IIP LEW + Group A2, n=15 BEFORE IIP LEW - P-value Group B, n=21 AFTER IIIP Blood Glucose (mg/dL) Pre-operative 117 ± 20 108 ± 24 0.44 112 ± 28 Immediately Postoperative 162 ± 53 142 ± 31 0.27 134 ± 37 Postoperative Day 1 140 ± 27 117 ± 16 0.02 114 ± 22 CSF Glucose (mg/dL) Pre-operative 67 ± 13 58 ± 13 0.14 60 ± 14 Immediately Postoperative 80 ± 15 66 ± 14 0.03 69 ± 18 Postoperative Day 1 102 ± 15 77 ± 15 0.001 72 ± 19

Blood and CSF glucose levels in endo TAAA patients

Hyperglycemia

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Insulin resistance

Hyperglycemia

Phospho-Serine type 1 Insulin receptor P-Ser312-IRS1 Abnormally phosphorylated insulin receptor Inhibits insulin signaling Pan-tyrosine-phospho-insulin receptor P-panTyr-IRS1 Normal phosphorylated insulin receptor Facilitates insulin signaling Insulin resistance: Ratio of P-Ser312-IRS1 / P-panTyr-IRS1

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

Insulin resistance

Hyperglycemia

*p<.001

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

TREATMENT OF SCI

Hyperbaric Oxygen ➢ 1 – 30 hours post deficit ➢ After other treatment attempts failed

Lindsay TF VEITH 2018

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UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF

PREVENTION OF SCI

➢ Create stability

▪ Volume, hemoglobin, restore leg perfusion

➢ Preserve all spinal perfusion collateral pathways ➢ Stage whenever feasible

▪ Preservation of collateral perfusion ▪ Gradual exclusion of intercostal and lumbar branches

➢ CSF drain use guided by risk and local resources ➢ Keep glucose normal ➢ Watch for further info regarding the impact of

intercostal artery occlusion

➢ Be aggressive — it’s not hopeless (unless emboli)

UCSF Vascular & Endovascular Symposium 2019

Preventing SCI in Thoracic Aortic Procedures

UCSF 39 40