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Original Articles: Adult Cardiac

Cerebrospinal Fluid Drainage During Thoracic Aortic Repair: Safety and Current Management

^a Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School Houston, Houston, Texas
^b Department of Anesthesia, University of Texas Medical School Houston, Houston, Texas

Accepted for publication March 13, 2009.

^_* Address correspondence to Dr Estrera, Suite 2850, 6400 Fannin St., Houston, TX 77030 (Email: anthony.l.estrera{at}uth.tmc.edu).

Presented at the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.

CARDIOTHORACIC ANESTHESIOLOGY: The Annals of Thoracic Surgery CME Program is located online at http://cme.ctsnetjournals.org. To take the CME activity related to this article, you must have either an STS member or an individual non-member subscription to the journal.

 

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 
Background: The benefit of cerebrospinal fluid (CSF) drainage during thoracic aortic repair has been established. Few studies, however, report management and safety of CSF drainage.

Methods: Between September 1992 and August 2007, 1,353 repairs of the thoracic aorta were performed, with 82% using CSF drainage. The CSF drainage was not used in cases of rupture, acute trauma, infection, or prior paraplegia. Thirty-one percent (76 of 246) of patients without CSF drainage were repaired prior to standardized use. All drains were inserted by cardiovascular anesthesia staff. Repairs were performed using distal aortic perfusion with heparinization. Early management involved free drainage to maintain CSF pressure less than10 mm Hg, but was later modified to limit CSF drainage unless neurologic deficit occurred.

Results: Cerebrospinal fluid drainage was technically achieved in 99.8% (1,105 of 1,107) of cases. The CSF catheter-related complications occurred in 1.5% (17 of 1,107) of patients. No spinal hematomas were observed. The CSF leaks with spinal headache, CSF leak without spinal headache, spinal headache, intracranial hemorrhage, catheter fracture, and meningitis occurred in 6 (0.54%), 1 (0.1%), 2 (0.2%), 5 (0.45%), 1 (0.1%), and 2 (0.2%) cases, respectively. Mortality from subdural hematoma was 40% (2 of 5), and from meningitis was 50% (1 of 2). Spinal headaches resolved with conservative management. All CSF leaks resolved, but 71% (5/7) required blood patches. Since implementation of a limited CSF drainage protocol, no subdural hematomas have been observed.

Conclusions: Cerebrospinal fluid drainage for thoracic aortic repairs can be performed safely with excellent technical success. Perioperative management of CSF drains requires diligent monitoring and judicious drainage. Standardizing CSF management may be beneficial.

Neurologic deficit, paraplegia, and paraparesis, remain devastating complications associated with the repair of descending and thoracoabdominal aortic aneurysms (TAAA), and have previously been reported as high as 50% with extent II TAAA [1]. With the adoption of the adjuncts of distal aortic perfusion and cerebrospinal fluid drainage (CSFD), the incidence of neurologic deficit has dropped to under 5%, even for the extent II TAAA [2]. Moreover, with the increasing application of thoracic endovascular aortic repair (TEVAR) technology for the repair of descending thoracic aortic aneurysms (DTAA) the use of CSFD is becoming an important adjunct for the prevention of neurologic deficits, especially in those who are at increased risk for paraplegia during TEVAR [3–5].

The relationship between cerebrospinal fluid pressure and spinal cord ischemia and the role of cerebrospinal fluid drainage as an adjunct to protect against neurologic injury during thoracic aortic repair has been known for over 50 years, gaining increased acceptance over the past decade [6–13]. Several have reported on the complications related to CSFD, but few have made recommendations on the perioperative management based on evidence [5, 14–24]. Thus, the purpose of this study was to report on complications associated with CSFD, and to provide details of our current perioperative approach to CSFD.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 
The Committee for the Protection of Human Subjects at the University of Texas Houston Medical School approved review of the data collected for this study, and waived the need for patient consent. The study design was a retrospective observational study.

Between September 1992 and August 2007, 1,353 repairs of the thoracic aorta were performed of which 82% (1,107 of 1,353) underwent repair using CSF drainage. The CSF drainage was not used in cases of rupture, acute trauma, infection, or prior paraplegia (see Table 1). Thirty-one percent (76 of 246) of patients without CSF drainage were repaired prior to standardized use. All cerebrospinal drains were inserted by a member of our cardiovascular anesthesia team. Excluding cases of hypotension associated with rupture or cases performed prior to routine use of the adjuncts, all repairs were performed using distal aortic perfusion with moderate passive hypothermia (32°C to 34°C) and patients were systemically anticoagulated with 1 mg/kg heparin.

All CSFDs were placed after the patient had been induced and invasive lines were placed. The patient was placed in the right lateral decubitus position with the legs flexed toward the head. The patient's back was sterilely prepped and draped. The CSF catheter kit used (model BL915003) is manufactured by Integra NeuroSciences (Plainsboro, NJ). The kit contains an 80 cm 5 French radiopaque catheter, a guidewire, a Luer-lock connector, and a 14-gauge thin-walled Tuohy needle with obturator.

The Touhy needle was inserted with the bevel facing cephalad in incremental fashion until the subarachnoid space entered. This was confirmed by free flow of CSF from the Touhy needle. A guide wire was threaded into the CSF catheter, and then the CSF catheter (guide wire in place) was inserted through the Touhy needle. The catheter was threaded approximately 5 to 7 cm past the needle into the intrathecal space, and then secured with a clear occlusive dressing. Confirmation of free CSF drainage was obtained prior to dressing the CSFD catheter. If the catheter would not advance past the tip of the Touhy needle despite free CSF flow, minor adjustments of the needle angle or bevel position often facilitated catheter passage. In cases of a "bloody" tap, reintroduction of the Touhy needle in another interspace space was performed. If upon reinsertion of the drain there was still blood in the cerebrospinal fluid which did not clear after 2 mL of fluid, cancellation of the case is considered. No cases were postponed as the result a "bloody" tap. In our experience the use of radiography to facilitate CSFD placement has not been useful.

Drainage issues are usually related to kinked or blocked catheters. Kinked catheters can usually be rectified by retaping the catheters making certain to avoid skin folds, while blocked catheters need to be replaced.

Intraoperative Drainage
After securing the catheter, the CSFD catheter was connected to a pressure transducer for monitoring and zeroed at the midatrial level. The CSF was drained manually by gravity to maintain a CSF pressure less than 15 mm Hg. This threshold was lowered to 10 mm Hg when loss of sensory and motor-evoked potentials was encountered. The CSF was drained in 10 mL increments and the CSF pressure reevaluated.

Postoperative Drainage
The CSF drain is maintained for 3 days postoperatively based on our previous studies on delayed neurologic deficit [25]. Previously, CSF was drained manually to gravity to maintain a CSF pressure of less than 10 mm Hg without limit of volume drained. Currently, if the CSF pressure is greater than 10 mm Hg, CSF is drained to a limit of 15 mL/hour when the patient is neurologically intact. If delayed neurologic deficit (DND) occurred, then CSF is drained to maintain a pressure of less than 5 mm Hg without limit under our CSF drain status/Oxygen delivery/Patient Status (COPS) protocol (see Fig 1). This assumed that the CSF remained clear and was not bloody. Since drain malfunction has been previously identified a risk factor for DND, drain malfunction was actively corrected and replaced if required [26]. If reinsertion is performed in the intensive care unit, operating room standard sterile preparation (ie, full gown and gloves) is undertaken.

View larger version (20K): [in this window] [in a new window]   Fig 1. Treatment of delayed neurologic deficits: the "COPS" Protocol for Cerebrospinal Fluid Drainage Management. Patient status also includes assessing the patient and correcting for conditions that affect oxygen delivery (ie, sepsis, bleeding, compartment syndrome, tamponade, visceral ischemia, atrial fibrillation, pneumothorax, etc). (BP = blood pressure; BSA = body surface area; COPS = CSF drain status/Oxygen delivery/Patient Status; CSFP = cerebrospinal fluid pressure; MAP = mean arterial pressure; SCPP or spinal cord perfusion pressure = mean arterial pressure - cerebrospinal fluid pressure.)

Statistical Analysis
Data were collected prospectively on standardized forms by a trained Masters-level nurse researcher. The information was entered into a dedicated database housed on a secure server. Formal risk analyses could not be conducted for the small number of events, but exact binomial 95% confidence intervals were computed for the event rates.

	Results

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 
CSF Drain Access
Cerebrospinal fluid drainage was technically achieved in 99.8% (1,105 of 1,107) of cases. In the two cases in which percutaneous CSF drain placement could not be achieved, one case required open laminotomy by neurosurgery for direct insertion for an extent II TAAA aneurysm. In this case, an incision was created directly over the space exposing vertebral space and lamina. The CSF catheter was then directly inserted in the CSF space. Removal of the catheter did not require surgical exposure. The other case was an extent A (upper half of the chest, descending thoracic aortic aneurysm). Both patients recovered from the aortic repair without major complications. Despite the use of anticoagulation for distal aortic perfusion, no spinal hematomas were observed. The CSF catheter-related complications occurred in 1.5% (17 of 1,107) of patients (Table 2).

Fractured Catheter
One patient required laminotomy by neurosurgery for a catheter that fractured and was retained in the spinal column. No adverse events occurred with this patient.

No cases of spinal hematoma were encountered. Since implementation of a modified CSFD protocol, no subdural hematomas have been observed.

	Comment

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 
The relationship between cerebrospinal fluid pressure and the development of paraplegia during repairs of the thoracic aorta was first suggested by Sugie and colleagues in 1957 [6] and Miyomoto and colleagues in 1960 [7], followed by Blaisdell and Cooley in 1962 [8]. Although the prospect of CSFD as an adjunct to spinal cord protection in animal studies was encouraging, technical aspects of drain insertion and associated complications (eg, spinal headaches) limited its use.

Almost three decades later, experimental work by McCullough and colleagues [9] and Bower and colleagues [10] at the Mayo clinic, led to reports on the benefit of perioperative CSFD and renewed interest in the use of CSFD for thoracic aortic repairs. Based on this work, Safi and colleagues [11] adopted the use of CSFD for thoracic aortic repairs and combined it with the adjunct of distal aortic perfusion and moderate hypothermia. With this approach, we have reported marked improvements in the incidence of neurologic deficit during repairs of the descending thoracic and thoracoabdominal aorta, observing an overall decrease in incidence from 10% to 1% [2]. Others have also reported the benefits of CSFD during thoracic aortic repairs [3, 12, 27].

Although the use of CSFD as an adjunct is supported by several studies, few have reported on associated complications of CSFD or details on current management approaches [14–23]. Overall complications from CSFD insertion have been reported as high as 5%, with the most significant of these complications being intracranial hemorrhage, associated with a mortality as high as 50% [23, 24]. This led us to analyze our experience with the CSFD and determine if modification was necessary.

Our overall experience with CSFD has been associated with a very low incidence of complications at 1.5%. Moreover, CSFD can be achieved in almost all elective patients regardless of anatomy or previous spinal surgery; we achieved access in 99.8% of attempted patients. Some have reported the use of fluoroscopy as an aid in the insertion but we have not found this necessary [24]. Currently, inability to obtain CSF access will lead to a neurosurgical consult or postponement of the elective thoracic aortic repair.

The most pressing concern regarding CSFD-associated complications has been intracranial hemorrhage (ICH). Similar to previous reports [23, 24], we also observed a high associated mortality of 40% when intracranial hemorrhage occurred with CSFD. Interestingly, the majority of hemorrhagic events were cerebellar hemorrhage (80%, 4 of 5), with one subdural hemorrhage. A study by Wynn and colleagues [24] identified 24 of 486 (5%) patients undergoing thoracic aortic repair with CSFD patients with bloody CSF, all of which were subsequently evaluated with head computed tomographic (CT) scans. Of the 24 patients with bloody CSF, 17 patients were found to have some degree of intracranial bleeding of varying locations and types (subarachnoid, intraparenchymal, and subdural). Interestingly, of these patients with some degree of ICH, only 3 developed significant clinically evident neurologic deficits, one ataxia (cerebellar), one hemiplegia (subdural), and one death from herniation (subdural). We do not obtain CT scans on all patients with bloody or "blood-tinged" CSF, but rather obtain radiographic testing based on a patient's clinical status. Our current approach to the "bloody or blood-tinged" CSF is to stop draining and correct any coagulopathy. After correction of the coagulopathy, the CSFD is drained to determine if the CSF clears. If it clears it is used per routine. If it does not clear, it is removed and replaced depending on the patient's neurologic status. If the patient develops any neurologic sequelae such as altered mental status or focal deficits, then immediate CT scan of the head is performed to exclude intracranial hemorrhage. The dilemma arises in the patient with bloody or blood-tinged CSF who also develops delayed neurologic deficit, paraplegia. In this case, the CSFD is stopped and emergent CT of the head and spine (to exclude spinal hematoma) is performed. If no CT evidence of intracranial bleed or spinal hematoma is present, then attempts at clearing the CSF are made, or a replacing of the drain if necessary.

Cerebrospinal fluid is produced by the choroid plexus and walls of the ventricles at a rate of 400 to 600 mL per day, circulating at a volume of 140 mL in the brain and spinal cord where it is reabsorbed in the venous sinuses [28]. Changes in CSF volume and pressure alter intracranial dynamics such that intracranial hypotension occurs, leading to the potential for intracranial hemorrhage [24]. With intracranial hypotension, it is thought that caudal displacement of the brain may lead to stretching of sensory receptors in the dural sinuses leading to spinal headaches [29, 30]. Intracranial hemorrhage may result from traction of the dural veins due to this caudal displacement as well as from the intracranial pressure, which leads to venous engorgement of these dural venous sinuses [29]. In addition, intracranial hypotension may tear cortical veins crossing the dural space [31, 32]. Location of the intracranial hemorrhage is likely related to the degree of displacement and the rate of change of displacement of the brain. In our experience, cerebellar involvement was most frequent and likely related to sagging of the cerebellum into the foramen magna after caudal displacement [24].

Others have also recognized the correlation between CSF drainage volume and intracranial hemorrhage. In the study by Dardik and colleagues [23] the authors identified that draining a larger amount of CSF, 690 versus 359 mL, was associated with a greater risk of subdural hemorrhage. In this study, we did not demonstrate a significant difference in total amount of CSF drained between those that suffered ICH and those that did not (440 ± 318 mL vs 442 ± 199 mL, p = not significant). One reason for this relates to immediate discontinuation of CSF drainage when ICH was suspected. With ICH occurring between 1 to 2 days postoperatively, CSFD was discontinued, limiting the total amount of volume drained. At any rate, CSFD volume is likely not the only reason for ICH. Other factors that likely increase the risk of intracranial hemorrhage include rate of CSF drainage, extent of venous engorgement, size of the veins that rupture, preexisting intracranial pathology, coagulopathy, and arterial hypertension [24].

Because of the concern for ICH, we modified our perioperative approach and limited CSF drainage in the neurologically intact patient to 15 mL/hour if the CSF pressure was greater than 10 mm Hg. Since introduction of this modification, we have not observed ICH. However, it remains unclear what has been responsible for this; either the decreased volume of CSF drainage, or our heightened awareness of this complication with immediate discontinuation of CSF drainage upon the first appearance of blood in the CSF. Further prospective evaluation is necessary.

Postcatheter removal leakage is rare despite the size needle used; 0.6% in this series. We theorize this may be due to duration of catheter placement. The catheter remains in place for 3 days, allowing for a fibrotic response to develop around the catheter. When the catheter is removed, the fibrous tissue aids in sealing the rent caused by the needle. It is important not to confuse leakage of edema fluid from around the catheter with true CSF leakage. This can be aided by fluid analysis of glucose, cell count, pH, and electrolytes. The CSFD catheter is removed without capping prior to removal. We believe that waiting for the CSF pressure to rise prior to removal could result in a higher incidence of CSF leaks.

Treatment of CSF leak is first addressed using conservative measures, which include bed rest, limiting the patient's head less than 30 degrees, and hydration. If the CSF leak does not resolve or improve after 24 hours, then a blood patch is performed. This was required in 55% (5 of 9) of patients. It was encouraging that all CSF leaks and associated headaches resolved prior to discharge.

This study should be viewed with certain limitations. First, the study period extended over 15 years and our operative technique, anesthetic management, and nursing care have evolved. Moreover, technical specifications in manufacturing of the CSF catheters, now provided as single sets, have advanced. Such sets include smaller, noncutting introducing needles that may be less traumatic than previously used [33]. Such issues cannot be controlled and but must be acknowledged as a limitation to this retrospective study. Second, although CSF fluid volumes were recorded, the color or presence of blood in the CSF was not recorded on all patients. For this reason, the number of patients with blood-tinged CSF that resolved or who were without neurologic deficits was not recorded. Wynn and colleagues [24] obtained a CT scan on all patients who developed bloody CSF and identified that 71% (17 of 24) patients with bloody CSF had suffered an ICH of some degree. Interestingly, only 3 of the 17 patients (18%) with ICH had clinically evident neurologic deficits. Because we did not obtain a CT scan on all patients with bloody CSF, we may have underestimated the true number of patients with ICH. The status of the asymptomatic patient with ICH remains unknown and requires further prospective evaluation. Last, a change in our CSF drainage protocol was based on the concern for ICH and its suggested association with increased amount of CSF drained. Although we have not recently observed ICH after limiting drainage, other previously mentioned factors that may contribute to CSFD-associated ICH need to be assessed in a prospective manner. Moreover, the effect of limiting CSF drainage on the incidence of delayed neurologic deficit needs to be addressed prospectively. At any rate, this study does provide important information about incidences of complications related to CSF drainage.

Cerebrospinal fluid drainage for thoracic aortic repairs can be performed safely with excellent technical success. Perioperative management of CSF drains requires diligent monitoring and judicious drainage. Bloody cerebrospinal fluid must raise the suspicion for intracranial hemorrhage. Standardizing CSF management may be beneficial.

	Discussion

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 
DR LAURENS PICKARD (Houston, TX): Tony, I really enjoyed this great paper and your terrific contributions to this field. I wanted to ask you if you included the complications of the drainage in your informed consent process with the patients' preop, which I am sure you do, and wondered if you had any patients that shied away or declined to have that adjunct as a result of those talks?

DR ESTRERA: Yes, that is a good point, Larry. As you probably might have seen, Hazim's (Dr. Safi) consent form, the one that I have adopted as well, is a three page consent form that lists really anything and everything that can occur. The reality is most of the patients have aneurysmal disease and are very thankful to just have the opportunity to get something done. So, no, we have not had any patients that shy away from this procedure because of the risk of CSF drain complications, but, yes, they are listed in our consent form.

DR JOSEPH C. CLEVELAND (Denver, CO): Tony, that was an outstanding series and I think you all have taught us a lot about the management of these patients. A couple of operational things. When does the drain go in? Does it go in right before surgery, does it go in the night before? And then if you do have a "bloody tap" or there is blood, do you abort the operation? How do you manage those two scenarios?

DR ESTRERA: The drain is inserted by our anesthesiologist in the operating room just after induction, intubation, and central line placement, just before prepping. So the patient is not anticoagulated at that point. We will suspend procedures if the patient's INR is elevated greater than 1.5, if they have been on Plavix, or Lovenox, recently, because of the concern of spinal hematoma. So those are some practical points about how we insert these drains.

Your second question, Joe?

DR CLEVELAND: It was just if you get a bloody tap.

DR ESTRERA: A very important question. There is a nice study by Wynn, and she looked at their experience at Wisconsin, and identified every patient with a bloody tap. They performed a CAT [computerized axial tomography] scan on every one of those patients, 24 patients. Seventeen of the 24 patients had some degree of intracranial hemorrhage, which I thought was very interesting, but only three of those patients had clinical evidence of neurological changes. So the reality is that you have to be very concerned if you get a bloody tap. Now, what causes a bloody tap? There are a lot of different reasons. One reason may be related to true intracranial bleeding which is the one we are most concerned about. CSF [cerebrospinal fluid] drainage may lead to bleeding due to dural tenting causing subdural veins to tear. There are also insertion site causes leading to local epidural bleeding. The site where the needle enters can also lead to bleeding from the soft tissues of the back. Now, what we do when we do get a bloody tap is that we see if it clears. We will let it drain continuously. If it does not clear, then we will actually take the drain out and let the patient settle, and then the anesthesiologist will reinsert the drain in a different location. If it clears, then we have to think that it is likely related to insertion. One of the main points that I have learned from reviewing this data is that if you have a bloody tap, you need to stop drainage and thoroughly investigate why that tap is bloody so you can exclude this complication of intracranial hemorrhage during CSF drainage.

DR ALEXANDER KULIK (St. Louis, MO): Just to follow up on the previous question, I wanted to know if you change your operative strategy in the circumstance whereby the anesthesiologist cannot insert a spinal drain?

DR ESTRERA: As I mentioned, there were two cases where they could not insert it. One case we actually stopped the case, consulted with neurosurgery, rescheduled the case, and they actually performed a laminotomy to insert the drain; this was an extent II thoraco. This reiterates the importance of the CSF drain in our experience. The other patient was an upper half descending thoracic aneurysm, which, in our experience, has a very low incidence of paraplegia. So we did not insert the drain for that case and that patient did well.

DR KULIK: And did you change your operative strategy in that circumstance, the second patient?

DR ESTRERA: No. We used distal aortic perfusion.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 
We express appreciation for assistance to the University of Texas Department of Cardiovascular Anesthesia: Craig Ignacio, MD, Shao-Feng Zhou, MD, Sreelatha Panthayi, MD, and Brian Marasigan, MD. We also thank Ken Goodrick for editing, and Chris Akers for figures. The research reported here was supported by a grant from the National Heart Lung Blood Institute 5 P50 HL083794-02 (TAAD-SCCOR). The opinions contained herein are solely those of the authors.

	References

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 

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