Complications of spinal fluid drainage in thoracoabdominal aortic aneurysm repair: a report of 486 patients treated from 1987 to 2008.
ABSTRACT Spinal fluid drainage reduces paraplegia risk in thoracic (TAA) and thoracoabdominal (TAAA) aortic aneurysm repair. There has not been a comprehensive study of the risks of spinal fluid drainage and how these risks can be reduced. Here we report complications of spinal fluid drainage in patients undergoing TAA/TAAA repair.
The study comprised 648 patients who had TAA or TAAA repair from 1987 to 2008. Spinal drains were used in 486 patients. Spinal fluid pressure was measured continuously, except when draining fluid, and was reduced to <6 mm Hg during thoracic aortic occlusion and reperfusion. After surgery, spinal fluid pressure was kept <10 mm Hg until patients were awake with normal leg lift. Drains were removed 48 hours after surgery. Spinal and head computed tomography (CT) scans were performed in patients with bloody spinal fluid or neurologic deficit. We studied the incidence of headache treated with epidural blood patch, infection, bloody spinal fluid, intracranial and spinal bleeding on CT, as well as the clinical consequences.
Twenty-four patients (5%) had bloody spinal fluid. CT exams showed seven had no evidence of intracranial hemorrhage, 14 (2.9%) had intracranial blood without neurologic deficit, and three with intracranial bleeding and cerebral atrophy had neurologic deficits (1 died, 1 had permanent hemiparesis, and 1 with transient ataxia recovered fully). Two patients without bloody spinal fluid or neurologic deficit after surgery presented with neurologic deficits 5 days postoperatively and died from acute on chronic subdural hematoma. Neurologic deficits occurred after spinal fluid drainage in 5 of 482 patients (1%), and 3 died. The mortality from spinal fluid drainage complications was 0.6% (3 of 482). By univariate and multivariate analysis, larger volume of spinal fluid drainage (mean, 178 mL vs 124 mL, P < .0001) and higher central venous pressure before thoracic aortic occlusion (mean, 16 mm Hg vs 13 mm Hg, P < .0012) correlated with bloody spinal fluid.
Strategies that reduce the volume of spinal fluid drainage but still control spinal fluid pressure are helpful in reducing serious complications. Patients with cerebral atrophy are at increased risk for complications of spinal fluid drainage.
- Annals of cardiothoracic surgery. 05/2014; 3(3):336-8.
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ABSTRACT: Objective: To study the complications after cerebrospinal fluid (CSF) drainage and predictors of spinal cord ischemia (SCI) after advanced endovascular therapy with CSF drainage for complex aortic disease.Methods:Between 2009 and 2012, 88 attempts of CSF drainage insertions/84 operations/83 patients, of the 658 operations for aortoiliac diseases, were performed. Results: Indications for therapy were aortic dissection (n = 13) and aortic aneurysm (n = 70), of whom 38 had thoracoabdominal aortic aneurysm (TAAA). In all, 10 had ruptured aorta. The CSF drainages were inserted preoperatively (n = 75) and postoperatively (n = 9). In all, 14 CSF drainages were nonfunctioning. The SCI was present in 29 patients, transient/permanent in 12/17. Intraoperative circulatory instability (P = .001) and operation for TAAA, type II (P = .036), were associated with SCI. Meningitis (n = 1), epidural (n = 1), and subdural (n = 2) hematoma and needle-mediated paresis in 1 leg (n = 1) occurred after CSF drainage.Conclusions: Complication to CSF drainage occurred too frequently in this selected group of patients with high rate of SCI.Vascular and Endovascular Surgery 07/2013; · 0.77 Impact Factor
Article: Anaesthesia for vascular emergencies[Show abstract] [Hide abstract]
ABSTRACT: Patients presenting with vascular emergencies including acute aortic syndrome, ruptured thoracic or abdominal aortic aneurysms, thoracic aortic trauma and acute lower limb ischaemia have a high risk of peri-operative morbidity and mortality. Although anatomical suitability is not universal, endovascular surgery may improve mortality and the results of ongoing randomised controlled trials are awaited. Permissive hypotension pre-operatively should be the standard of care with the systolic blood pressure kept to 50–100 mmHg as long as consciousness is maintained. The benefit of local anaesthesia over general anaesthesia is not definitive and this decision should be tailored for a given patient and circumstance. Cerebrospinal fluid drainage for prevention of paraplegia is often impractical in the emergency setting and is not backed by strong evidence; however, it should be considered postoperatively if symptoms develop. We discuss the pertinent anaesthetic issues when a patient presents with a vascular emergency and the impact that endovascular repair has on anaesthetic management.Anaesthesia 01/2013; 68(s1). · 3.85 Impact Factor