Multidisciplinary Approach to Direct Segmental Artery Revascularization to Prevent Spinal Cord Ischemia Associated With Endovascular Thoracoabdominal Aortic Repair.

Autor:	Ganapathy AV; Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck Hospital of USC, University of Southern California, Los Angeles, CA, USA., DiBartolomeo AD; Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck Hospital of USC, University of Southern California, Los Angeles, CA, USA., Mack WJ; Department of Neurological Surgery, Keck Hospital of USC, University of Southern California, Los Angeles, CA, USA., Magee GA; Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck Hospital of USC, University of Southern California, Los Angeles, CA, USA., Atai N; Department of Neurological Surgery, Keck Hospital of USC, University of Southern California, Los Angeles, CA, USA., Carey JN; Division of Plastics Surgery, Department of Surgery, Keck Hospital of USC, University of Southern California, Los Angeles, CA, USA., Russin JJ; Department of Neurological Surgery, Keck Hospital of USC, University of Southern California, Los Angeles, CA, USA., Han SM; Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck Hospital of USC, University of Southern California, Los Angeles, CA, USA.
Jazyk:	angličtina
Zdroj:	Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists [J Endovasc Ther] 2024 Nov 13, pp. 15266028241294216. Date of Electronic Publication: 2024 Nov 13.
DOI:	10.1177/15266028241294216
Abstrakt:	Purpose: Despite advances in complex endovascular aortic repair techniques, spinal cord ischemia (SCI) remains a devastating complication following endovascular thoracoabdominal aortic repairs. Novel strategies to preserve key intercostal/lumbar arteries have been described. We report our early results of patients who underwent direct intercostal/lumbar artery revascularization using endovascular incorporation of fenestrations/branches or extra-anatomic approaches for fenestrated-branched endovascular aortic repairs (FBEVARs). Materials and Methods: A retrospective review of consecutive patients who underwent FBEVAR with intercostal/lumbar artery revascularization from 2018 to 2022 was performed. Patient characteristics, intraoperative details, and outcomes including SCI and branch occlusions were evaluated. Results: Among 317 patients who underwent FBEVAR during the study period, 12 patients were included. Aortic pathologies consisted of degenerative aneurysms (33%), postdissection aneurysms (33%), extensive penetrating aortic ulcers with intramural hematoma (25%), and visceral patch pseudoaneurysm (8%). Full thoracoabdominal coverage was required in 8 patients and supraceliac coverage >10 cm was required in 4. Nine patients received endovascular incorporation, including directional branches (5/9), unstented fenestrations (2/9), and stented fenestration (2/9). Three patients received extra-anatomic subcutaneous femoral-to-radicular artery bypass using a composite graft of polytetrafluoroethylene (PTFE) and venous conduit. Our institutional SCI prevention protocol, consisting of prophylactic cerebral spinal fluid drain (CSFD) for high-risk patients, hemodynamic augmentation, and oxygen supplementation, was followed. Prophylactic CSFD was placed in 9 patients. One patient had unsuccessful drain placement attempts. The other 2 patients had previous unsuccessful attempts at CSFD placement. Median number of target vessels for FBEVAR was 4 with fluoroscopy time 66±31 minutes, contrast usage 109±51 ml. There were no in-hospital mortalities. Tarlov grade II SCI (ASIA grade D) were seen in 2 patients (1 endovascular and 1 extra-anatomic bypass), which resolved before discharge. At mean follow-up of 472±447 days, 3 patients had thrombosed intercostal/lumbar branches (1 extra-anatomic bypass and 2 endovascular branches) with no new SCI symptoms. Conclusions: In patients at high risk for SCI undergoing FBEVAR, direct revascularization of an intercostal or lumbar artery is feasible using endovascular or extra-anatomic bypass approach. Further studies are planned to identify key contributing segmental arteries and optimization of revascularization strategies. Clinical Impact: This study demonstrates the feasibility of Endovascular and extra-anatomic bypass to preserve segmental artery flow, aimed at reducing the risk of spinal cord ischemia during endovascular thoracoabdominal aortic repairs. Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Mack has the following conflicts: Consultant for Rebound Therapeutics, Viseon, Imperative Care, Integra, Q’Apel, Stream Biomedical, Spartan Micro; Egret; Stock Options in Egret, Spartan Micro, Q’Apel, Stream Biomedical; and Investor in Cerebrotech, Q’ Apel, Endostream, Viseon, Rebound, Truvic/Imperative Care, Radical Catheters, Vastrax, Borvo. Dr Magee has the following conflicts: Consultant for W.L. Gore & Associates & Silk Road. Dr Han has the following conflicts: Consultant for W.L. Gore & Associates, Cook Medical, Terumo, Vestek; and is on the Scientific Advisory Board for W.L. Gore & Associates, Cook Medical, and Vestek. The other authors have no conflicts.
Databáze:	MEDLINE
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