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Jehangir J. Appoo
Joseph E. Bavaria
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Ann Thorac Surg 2005;80:1280-1289
© 2005 The Society of Thoracic Surgeons

Original article: Cardiovascular

Strategies to Manage Paraplegia Risk After Endovascular Stent Repair of Descending Thoracic Aortic Aneurysms

Albert T. Cheung, MD a , * , Alberto Pochettino, MD c , Michael L. McGarvey, MD b , Jehangir J. Appoo, MD c , Ronald M. Fairman, MD c , Jeffrey P. Carpenter, MD c , William G. Moser, RN c , Edward Y. Woo, MD c , Joseph E. Bavaria, MD c

a Department of Anesthesia, University of Pennsylvania, Philadelphia, Pennsylvania
b Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
c Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania

Accepted for publication April 21, 2005.

* Address reprint requests to Dr Cheung, University of Pennsylvania, Department of Anesthesia, 3400 Spruce St, Dulles 680, Philadelphia, PA 19104-4283 (Email: cheunga{at}uphs.upenn.edu).

Presented at the Forty-first Annual Meeting of The Society of Thoracic Surgeons, Tampa, FL, Jan 24–26, 2005.

BACKGROUND: Paraplegia is a recognized complication after endovascular stent repair of descending thoracic aortic aneurysms. A management algorithm employing neurologic assessment, somatosensory evoked potential monitoring, arterial pressure augmentation, and cerebrospinal fluid drainage evolved to decrease the risk of postoperative paraplegia.

METHODS: Patients in thoracic aortic aneurysm stent trials from 1999 to 2004 were analyzed for paraplegic complications. Lower extremity strength was assessed after anesthesia and in the intensive care unit. A loss of lower extremity somatosensory evoked potential or lower extremity strength was treated emergently to maintain a mean arterial pressure 90 mmHg or greater and a cerebrospinal fluid pressure 10 mm Hg or less.

RESULTS: Seventy-five patients (male = 49, female = 26, age = 75 ± 7.4 years) had descending thoracic aortic aneurysms repaired with endovascular stenting. Lumbar cerebrospinal fluid drainage (n = 23) and somatosensory evoked potential monitoring (n = 15) were performed selectively in patients with significant aneurysm extent or with prior abdominal aortic aneurysm repair (n = 17). Spinal cord ischemia occurred in 5 patients (6.6%); two had lower extremity somatosensory evoked potential loss after stent deployment and 4 developed delayed-onset paraplegia. Two had full recovery in response to arterial pressure augmentation alone. Two had full recovery and one had near-complete recovery in response to arterial pressure augmentation and cerebrospinal fluid drainage. Spinal cord ischemia was associated with retroperitoneal bleed (n = 1), prior abdominal aortic aneurysm repair (n = 2), iliac artery injury (n = 1), and atheroembolism (n = 1).

CONCLUSIONS: Early detection and intervention to augment spinal cord perfusion pressure was effective for decreasing the magnitude of injury or preventing permanent paraplegia from spinal cord ischemia after endovascular stent repair of descending thoracic aortic aneurysm. Routine somatosensory evoked potential monitoring, serial neurologic assessment, arterial pressure augmentation, and cerebrospinal fluid drainage may benefit patients at risk for paraplegia.




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