PARAPLEGIA: HOW TO AVOID THE PROBLEM THAT WONT DISAPPEAR ? Geert - - PowerPoint PPT Presentation

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PARAPLEGIA: HOW TO AVOID THE PROBLEM THAT WONT DISAPPEAR ? Geert - - PowerPoint PPT Presentation

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PARAPLEGIA: HOW TO AVOID THE PROBLEM THAT WONT DISAPPEAR ? Geert Willem Schurink Barend Mees Michiel de Haan Michael Jacobs Maastricht University Medical Center, the Netherlands European Vascular Center Aachen-Maastricht, Germany and the

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SLIDE 1

PARAPLEGIA: HOW TO AVOID THE PROBLEM THAT WON’T DISAPPEAR?

Geert Willem Schurink Barend Mees Michiel de Haan Michael Jacobs

Maastricht University Medical Center, the Netherlands European Vascular Center Aachen-Maastricht, Germany and the Netherlands

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SLIDE 2

PARAPLEGIA: HOW TO AVOID THE PROBLEM THAT WON’T DISAPPEAR?

Geert Willem Schurink Barend Mees Michiel de Haan Michael Jacobs

Maastricht University Medical Center, the Netherlands European Vascular Center Aachen-Maastricht, Germany and the Netherlands

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SLIDE 3

Disclosures

  • Consultant for COOK Medical
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SLIDE 4

Strategies to prevent SCI

Open repair

– CSF drainage – Preserve LSA and HA perfusion – Spinal cord function monitoring – BP management – Staged repair

  • Endovasc. repair

– CSF drainage – Preserve LSA and HA perfusion – Spinal cord function monitoring – BP management – Staged repair

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SLIDE 5

Bisdas T et al. (2015) Dias NV et al. (2015) Guillou M et al. (2012) Harrison C et al. (2012) Jayia P et al. (2015) Kasprzak PM et al. (2014) Kato M et al.(2015) Kitagawa A et al. (2013) Maurel B et al. (2015) Rossi SH et al. (2015) Sobel JD et al. (2015)

Only endovascular repair of TAAA:

  • 11 publications
  • 873 patients
  • Permanent SCI: 3,6%
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SLIDE 6

2 4 6 8 10 12 14

>2 preventive measures ≤2 preventive measures Profylactic spinal fluid drain Selective spinal fluid drain Avoidance of hypotension Staged procedures Selective LSA revascularization Permissive temporary endoleak Neuromonitoring All studies

4 2,1 8 2,2 3,6 3,1 5 4,9 12,8 3,6

>2 preventive measures ≤2 preventive measures Profylactic spinal fluid drain Selective spinal fluid drain Avoidance of hypotension Staged procedures Selective LSA revascularization Permissive temporary endoleak Neuromonitoring All studies

Permanent paraplegia in endoTAAA

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SLIDE 7

2 4 6 8 10 12 14

>2 preventive measures ≤2 preventive measures Profylactic spinal fluid drain Selective spinal fluid drain Avoidance of hypotension Staged procedures Selective LSA revascularization Permissive temporary endoleak Neuromonitoring All studies

4 2,1 8 2,2 3,6 3,1 5 4,9 12,8 3,6

>2 preventive measures ≤2 preventive measures Profylactic spinal fluid drain Selective spinal fluid drain Avoidance of hypotension Staged procedures Selective LSA revascularization Permissive temporary endoleak Neuromonitoring All studies

Permanent paraplegia in endoTAAA

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SLIDE 8

2 4 6 8 10 12 14

>2 preventive measures ≤2 preventive measures Profylactic spinal fluid drain Selective spinal fluid drain Avoidance of hypotension Staged procedures Selective LSA revascularization Permissive temporary endoleak Neuromonitoring All studies

4 2,1 8 2,2 3,6 3,1 5 4,9 12,8 3,6

>2 preventive measures ≤2 preventive measures Profylactic spinal fluid drain Selective spinal fluid drain Avoidance of hypotension Staged procedures Selective LSA revascularization Permissive temporary endoleak Neuromonitoring All studies

Permanent paraplegia in endoTAAA

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SLIDE 9

2 4 6 8 10 12 14

>2 preventive measures ≤2 preventive measures Profylactic spinal fluid drain Selective spinal fluid drain Avoidance of hypotension Staged procedures Selective LSA revascularization Permissive temporary endoleak Neuromonitoring All studies

4 2,1 8 2,2 3,6 3,1 5 4,9 12,8 3,6

>2 preventive measures ≤2 preventive measures Profylactic spinal fluid drain Selective spinal fluid drain Avoidance of hypotension Staged procedures Selective LSA revascularization Permissive temporary endoleak Neuromonitoring All studies

Permanent paraplegia in endoTAAA

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SLIDE 10

Distribution of types of TAAA in published series

10 20 30 40 50 60 70 80 90 100

1 2 3 4 5 6 7 8 37,5 33,3 16,7 50,6 60,4 50 30,7 14,2 12,2 40 28,1 10,4 25 37,7 14,2 8,9 16,7 16,9 10,4 100 21,3 31,8 45,6 26,7 4,5 16,7 25 8,2

Type IV Type III Type II Type I

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SLIDE 11

Strategies to prevent SCI

Introduction of:

  • TEVAR staging
  • LSA & HA preservation
  • CSF drainage in type 1-3
  • Early pelvic reperfusion
  • Aggressive blood, plasma and platelet Tx
  • MAP 85-90 mmHg
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SLIDE 12

Staging TAAA

Both open and endo repair:

  • Previous aortic repair (Historical staging)
  • Multiple aortic repair (open or TEVAR)
  • Segmental Artery Coil Embolization

(MIS2ACE) Only Endo repair

  • “Open branch” staging
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SLIDE 13

Results EndoTAAA (n=112)

  • Historical staging: 28%

– 35% abdominal aorta – 58% thoracic aorta – 7% both thoracic &abd aorta

  • TEVAR staging: 9 %

– TAAA type 2 with carotid-subclavian bypass

  • Open branch staging: 20%

– Using MEPs during last branch occlusion – Reason for open branch:

  • 86% MEP. (> 50%)
  • 14% Endoleak during branch occlusion
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SLIDE 14
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SLIDE 15

MEPS @ Crawford extent 2 endo TAAA repair with multivessel BEVAR

10 20 30 40 50 60 70 80 90 100 110 100 200 300 400 500 600 700 800 900 1000 1100 1200 1300 1400 1500 MEP amplitude [mV] time

tib.ant.Re tib.ant.Li abd.poll.br.Re abd.poll.br.Li rect.fem.R rect.fem.L T1%

Peripheral ischemia Right Leg Spinal Cord Ischemia Increase vs decrease upperleg MEPS

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SLIDE 16

Results EndoTAAA (n=112)

  • Spinal cord ischemia: 6%

– 4/7 improved (all walking) – 1/7 cured – 2/7 no improvement

2 4 6 8 10 12 14 16 SCI no SCI

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SLIDE 17

0% 5% 10% 15% 20% 25% type I (ER=82;OR=51) type II (ER=16;OR=59) type III (ER=22;OR=62) type IV (ER=69;OR=64)

Cleveland Clinic Experience

Endovascular Repair (n=189) Open Repair (n=236)

Greenberg, Circulation. 2008;118:808-817

Cleveland Clinic Experience

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SLIDE 18

SCI in endoTAAA (n=112)

  • Preop. Crawford classification

Spinal Cord Ischemia

type N= complete partial

I 23 II 18 1 2 III 34 1 1 IV 27 1 1

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SLIDE 19

‘Open Branch’ staging in endoTAAA

5 10 15 20 25 30 35

type I type II type III type IV

13% 29% 28% 14%

TRUE UNTRUE

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SLIDE 20

Conclusions

  • Spinal cord ischemia is still a serious problem in

endovasc repair of TAAA.

  • In endoTAAA SCI seem to decrease with current

protocols.

  • Current protocol is set of adjunctive measures

– not clear which is essential/unimportant

  • Staging is an effective way to reduce SCI
  • Selective staging with MEP during branch test
  • cclusion is associated

– with low spinal cord ischemia rate in endoTAAA – more frequent staging in Crawford type 2 and 3 – no need for staging in 80%