Mechanisms of symptomatic spinal cord ischemia after TEVAR: insights from the European Registry of Endovascular Aortic Repair Complications (EuREC)

Martin Czerny; Holger Eggebrecht; Gottfried Sodeck; Fabio Verzini; Piergiorgio Cao; Gabriele Maritati; Vicente Riambau; Friedhelm Beyersdorf; Bartosz Rylski; Martin Funovics; Christian Loewe; Jürg Schmidli; Piergiorgio Tozzi; Ernst Weigang; Toru Kuratani; Ugolino Livi; Giampiero Esposito; Santi Trimarchi; Jos C van den Berg; Weiguo Fu; Roberto Chiesa; Germano Melissano; Luca Bertoglio; Lars Lönn; Ingrid Schuster; Michael Grimm

doi:10.1583/11-3578.1

Mechanisms of symptomatic spinal cord ischemia after TEVAR: insights from the European Registry of Endovascular Aortic Repair Complications (EuREC)

Martin Czerny, Holger Eggebrecht, Gottfried Sodeck, Fabio Verzini, Piergiorgio Cao, Gabriele Maritati, Vicente Riambau, Friedhelm Beyersdorf, Bartosz Rylski, Martin Funovics, Christian Loewe, Jürg Schmidli, Piergiorgio Tozzi, Ernst Weigang, Toru Kuratani, Ugolino Livi, Giampiero Esposito, Santi Trimarchi, Jos C van den Berg, Weiguo FuRoberto Chiesa, Germano Melissano, Luca Bertoglio, Lars Lönn, Ingrid Schuster, Michael Grimm

108 Citations (Scopus)

Abstract

Purpose: To test the hypothesis that simultaneous closure of at least 2 independent vascular territories supplying the spinal cord and/or prolonged hypotension may be associated with symptomatic spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR). Methods: A pattern matching algorithm was used to develop a risk model for symptomatic SCI using a prospective 63-patient single-center cohort to test the positive predictive value (PPV) of prolonged intraoperative hypotension and/or simultaneous closure of at least 2 of 4 the vascular territories supplying the spinal cord (left subclavian, intercostal, lumbar, and hypogastric arteries). This risk model was then applied to data extracted from the multicenter European Registry on Endovascular Aortic Repair Complications (EuREC). Between 2002 and 2010, the 19 centers participating in EuREC reported 38 (1.7%) cases of symptomatic spinal cord ischemia among the 2235 patients in the database. Results: In the single-center cohort, direct correlations were seen between the occurrence of symptomatic SCI and both prolonged intraoperative hypotension (PPV 1.00, 95%CI 0.22 to 1.00, p=0.04) and simultaneous closure of at least 2 independent spinal cord vascular territories (PPV 0.67, 95% CI 0.24 to 0.91, p=0.005). Previous closure of a single vascular territory was not associated with an increased risk of symptomatic spinal cord ischemia (PPV 0.07, 95% CI 0.01 to 0.16, p=0.56). The combination of prolonged hypotension and simultaneous closure of at least 2 territories exhibited the strongest association (PPV 0.75, 95%CI 0.38 to 0.75, p<0.0001). Applying themodel to the entire EuREC cohort found an almost perfect agreement between the predicted and observed risk factors (kappa 0.77, 95% CI 0.65 to 0.90). Conclusion: Extensive coverage of intercostal arteries alone by a thoracic stent-graft is not associated with symptomatic SCI; however, simultaneous closure of at least 2 vascular territories supplying the spinal cord is highly relevant, especially in combination with prolonged intraoperative hypotension. As such, these results further emphasize the need to preserve the left subclavian artery during TEVAR.

Original language	English
Journal	Journal of Endovascular Therapy
Volume	19
Issue number	1
Pages (from-to)	37-43
Number of pages	7
ISSN	1526-6028
DOIs	https://doi.org/10.1583/11-3578.1
Publication status	Published - Feb 2012

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Czerny, M., Eggebrecht, H., Sodeck, G., Verzini, F., Cao, P., Maritati, G., Riambau, V., Beyersdorf, F., Rylski, B., Funovics, M., Loewe, C., Schmidli, J., Tozzi, P., Weigang, E., Kuratani, T., Livi, U., Esposito, G., Trimarchi, S., van den Berg, J. C., ... Grimm, M. (2012). Mechanisms of symptomatic spinal cord ischemia after TEVAR: insights from the European Registry of Endovascular Aortic Repair Complications (EuREC). Journal of Endovascular Therapy, 19(1), 37-43. https://doi.org/10.1583/11-3578.1

Mechanisms of symptomatic spinal cord ischemia after TEVAR: insights from the European Registry of Endovascular Aortic Repair Complications (EuREC). / Czerny, Martin; Eggebrecht, Holger; Sodeck, Gottfried et al.
In: Journal of Endovascular Therapy, Vol. 19, No. 1, 02.2012, p. 37-43.

Research output: Contribution to journal › Journal article › Research › peer-review

Czerny, M, Eggebrecht, H, Sodeck, G, Verzini, F, Cao, P, Maritati, G, Riambau, V, Beyersdorf, F, Rylski, B, Funovics, M, Loewe, C, Schmidli, J, Tozzi, P, Weigang, E, Kuratani, T, Livi, U, Esposito, G, Trimarchi, S, van den Berg, JC, Fu, W, Chiesa, R, Melissano, G, Bertoglio, L, Lönn, L, Schuster, I & Grimm, M 2012, 'Mechanisms of symptomatic spinal cord ischemia after TEVAR: insights from the European Registry of Endovascular Aortic Repair Complications (EuREC)', Journal of Endovascular Therapy, vol. 19, no. 1, pp. 37-43. https://doi.org/10.1583/11-3578.1

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title = "Mechanisms of symptomatic spinal cord ischemia after TEVAR: insights from the European Registry of Endovascular Aortic Repair Complications (EuREC)",

abstract = "Purpose: To test the hypothesis that simultaneous closure of at least 2 independent vascular territories supplying the spinal cord and/or prolonged hypotension may be associated with symptomatic spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR). Methods: A pattern matching algorithm was used to develop a risk model for symptomatic SCI using a prospective 63-patient single-center cohort to test the positive predictive value (PPV) of prolonged intraoperative hypotension and/or simultaneous closure of at least 2 of 4 the vascular territories supplying the spinal cord (left subclavian, intercostal, lumbar, and hypogastric arteries). This risk model was then applied to data extracted from the multicenter European Registry on Endovascular Aortic Repair Complications (EuREC). Between 2002 and 2010, the 19 centers participating in EuREC reported 38 (1.7%) cases of symptomatic spinal cord ischemia among the 2235 patients in the database. Results: In the single-center cohort, direct correlations were seen between the occurrence of symptomatic SCI and both prolonged intraoperative hypotension (PPV 1.00, 95%CI 0.22 to 1.00, p=0.04) and simultaneous closure of at least 2 independent spinal cord vascular territories (PPV 0.67, 95% CI 0.24 to 0.91, p=0.005). Previous closure of a single vascular territory was not associated with an increased risk of symptomatic spinal cord ischemia (PPV 0.07, 95% CI 0.01 to 0.16, p=0.56). The combination of prolonged hypotension and simultaneous closure of at least 2 territories exhibited the strongest association (PPV 0.75, 95%CI 0.38 to 0.75, p<0.0001). Applying themodel to the entire EuREC cohort found an almost perfect agreement between the predicted and observed risk factors (kappa 0.77, 95% CI 0.65 to 0.90). Conclusion: Extensive coverage of intercostal arteries alone by a thoracic stent-graft is not associated with symptomatic SCI; however, simultaneous closure of at least 2 vascular territories supplying the spinal cord is highly relevant, especially in combination with prolonged intraoperative hypotension. As such, these results further emphasize the need to preserve the left subclavian artery during TEVAR.",

author = "Martin Czerny and Holger Eggebrecht and Gottfried Sodeck and Fabio Verzini and Piergiorgio Cao and Gabriele Maritati and Vicente Riambau and Friedhelm Beyersdorf and Bartosz Rylski and Martin Funovics and Christian Loewe and J{\"u}rg Schmidli and Piergiorgio Tozzi and Ernst Weigang and Toru Kuratani and Ugolino Livi and Giampiero Esposito and Santi Trimarchi and {van den Berg}, {Jos C} and Weiguo Fu and Roberto Chiesa and Germano Melissano and Luca Bertoglio and Lars L{\"o}nn and Ingrid Schuster and Michael Grimm",

year = "2012",

month = feb,

doi = "10.1583/11-3578.1",

language = "English",

volume = "19",

pages = "37--43",

journal = "Journal of Endovascular Therapy",

issn = "1526-6028",

publisher = "SAGE Publications",

number = "1",

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TY - JOUR

T1 - Mechanisms of symptomatic spinal cord ischemia after TEVAR

T2 - insights from the European Registry of Endovascular Aortic Repair Complications (EuREC)

AU - Czerny, Martin

AU - Eggebrecht, Holger

AU - Sodeck, Gottfried

AU - Verzini, Fabio

AU - Cao, Piergiorgio

AU - Maritati, Gabriele

AU - Riambau, Vicente

AU - Beyersdorf, Friedhelm

AU - Rylski, Bartosz

AU - Funovics, Martin

AU - Loewe, Christian

AU - Schmidli, Jürg

AU - Tozzi, Piergiorgio

AU - Weigang, Ernst

AU - Kuratani, Toru

AU - Livi, Ugolino

AU - Esposito, Giampiero

AU - Trimarchi, Santi

AU - van den Berg, Jos C

AU - Fu, Weiguo

AU - Chiesa, Roberto

AU - Melissano, Germano

AU - Bertoglio, Luca

AU - Lönn, Lars

AU - Schuster, Ingrid

AU - Grimm, Michael

PY - 2012/2

Y1 - 2012/2

N2 - Purpose: To test the hypothesis that simultaneous closure of at least 2 independent vascular territories supplying the spinal cord and/or prolonged hypotension may be associated with symptomatic spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR). Methods: A pattern matching algorithm was used to develop a risk model for symptomatic SCI using a prospective 63-patient single-center cohort to test the positive predictive value (PPV) of prolonged intraoperative hypotension and/or simultaneous closure of at least 2 of 4 the vascular territories supplying the spinal cord (left subclavian, intercostal, lumbar, and hypogastric arteries). This risk model was then applied to data extracted from the multicenter European Registry on Endovascular Aortic Repair Complications (EuREC). Between 2002 and 2010, the 19 centers participating in EuREC reported 38 (1.7%) cases of symptomatic spinal cord ischemia among the 2235 patients in the database. Results: In the single-center cohort, direct correlations were seen between the occurrence of symptomatic SCI and both prolonged intraoperative hypotension (PPV 1.00, 95%CI 0.22 to 1.00, p=0.04) and simultaneous closure of at least 2 independent spinal cord vascular territories (PPV 0.67, 95% CI 0.24 to 0.91, p=0.005). Previous closure of a single vascular territory was not associated with an increased risk of symptomatic spinal cord ischemia (PPV 0.07, 95% CI 0.01 to 0.16, p=0.56). The combination of prolonged hypotension and simultaneous closure of at least 2 territories exhibited the strongest association (PPV 0.75, 95%CI 0.38 to 0.75, p<0.0001). Applying themodel to the entire EuREC cohort found an almost perfect agreement between the predicted and observed risk factors (kappa 0.77, 95% CI 0.65 to 0.90). Conclusion: Extensive coverage of intercostal arteries alone by a thoracic stent-graft is not associated with symptomatic SCI; however, simultaneous closure of at least 2 vascular territories supplying the spinal cord is highly relevant, especially in combination with prolonged intraoperative hypotension. As such, these results further emphasize the need to preserve the left subclavian artery during TEVAR.

AB - Purpose: To test the hypothesis that simultaneous closure of at least 2 independent vascular territories supplying the spinal cord and/or prolonged hypotension may be associated with symptomatic spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR). Methods: A pattern matching algorithm was used to develop a risk model for symptomatic SCI using a prospective 63-patient single-center cohort to test the positive predictive value (PPV) of prolonged intraoperative hypotension and/or simultaneous closure of at least 2 of 4 the vascular territories supplying the spinal cord (left subclavian, intercostal, lumbar, and hypogastric arteries). This risk model was then applied to data extracted from the multicenter European Registry on Endovascular Aortic Repair Complications (EuREC). Between 2002 and 2010, the 19 centers participating in EuREC reported 38 (1.7%) cases of symptomatic spinal cord ischemia among the 2235 patients in the database. Results: In the single-center cohort, direct correlations were seen between the occurrence of symptomatic SCI and both prolonged intraoperative hypotension (PPV 1.00, 95%CI 0.22 to 1.00, p=0.04) and simultaneous closure of at least 2 independent spinal cord vascular territories (PPV 0.67, 95% CI 0.24 to 0.91, p=0.005). Previous closure of a single vascular territory was not associated with an increased risk of symptomatic spinal cord ischemia (PPV 0.07, 95% CI 0.01 to 0.16, p=0.56). The combination of prolonged hypotension and simultaneous closure of at least 2 territories exhibited the strongest association (PPV 0.75, 95%CI 0.38 to 0.75, p<0.0001). Applying themodel to the entire EuREC cohort found an almost perfect agreement between the predicted and observed risk factors (kappa 0.77, 95% CI 0.65 to 0.90). Conclusion: Extensive coverage of intercostal arteries alone by a thoracic stent-graft is not associated with symptomatic SCI; however, simultaneous closure of at least 2 vascular territories supplying the spinal cord is highly relevant, especially in combination with prolonged intraoperative hypotension. As such, these results further emphasize the need to preserve the left subclavian artery during TEVAR.

U2 - 10.1583/11-3578.1

DO - 10.1583/11-3578.1

M3 - Journal article

C2 - 22313200

SN - 1526-6028

VL - 19

SP - 37

EP - 43

JO - Journal of Endovascular Therapy

JF - Journal of Endovascular Therapy

IS - 1

ER -

Mechanisms of symptomatic spinal cord ischemia after TEVAR: insights from the European Registry of Endovascular Aortic Repair Complications (EuREC)

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