LAUSR

OBJECTIVE Spinal cord injury (SCI) is one of the most devastating complications of thoracoabdominal aortic aneurysm (TAAA) repair. Cerebrospinal fluid drainage (CSFD) is routinely used to prevent and treat SCI during open TAAA repair. However, the risks and benefits of CSFD during fenestrated-branched endovascular aneurysm repair (F-BEVAR) are unclear. This study aims to determine the risk of SCI after F-BEVAR and to assess the risks and benefits of CSFD. METHODS We analyzed 106 consecutive patients with TAAAs treated with F-BEVAR from 2014-2019 in a prospective physician-sponsored investigational device exemption study (G130193) registered with ClinicalTrials.gov (NCT02323581). Data were collected prospectively and audited by an independent external monitor. All patients were treated with Cook manufactured patient-specific F-BEVAR devices or the Cook t-Branch devices. CSFD was used at the discretion of the principal investigator. Risk factors for SCI were identified and CSFD complications were assessed. RESULTS Prophylactic CSFD was utilized in 78 patients (73.6%) and 28 patients (26.4%) underwent F-BEVAR without CSFD. Four patients (3.8%) with prophylactic CSFD developed SCI, including 2 patients (1.9%) with permanent paraplegia (Tarlov Grade 1-2) and 2 patients (1.9%) with paraparesis (Tarlov Grade 3). Multivariate analysis revealed that greater extent of thoracic aortic coverage (P=0.02, OR 1.06, 95%CI 1.00-1.11) and intraoperative blood loss (IBL) (P=0.04 , OR 1.00, 95%CI 1.00-1.002) were the significant risk factors for SCI. Six patients (7.6%; 6/78) experienced major CSFD-related complications including: subarachnoid hemorrhage in 2.6% (2), spinal hematoma in 2.6% (2), cerebellar hemorrhage in 1.3% (1) , and spinal drain fracture requiring surgical laminectomy in 1.3% (1). Minor CSFD-related complications occurred in 20 patients (25.6%; 20/78), including: paresthesia during CSFD insertion (10), minimal bloody CSF (7), drain malfunction (2), and reflex hypotension (1). Technical difficulties during CSFD catheter placement were noted in 7 patients (9.0%). Excluding 4 patients with SCI, ICU length of stay (LOS) was 3.3±4.0 days in CSFD group versus 1.2±0.9 days in No-CSFD group (P=0.007). Total hospital LOS was 6.0±4.9 days in CSFD group versus 3.5±1.9 days in No-CSFD group (P=0.01). CONCLUSION The incidence of SCI after F-BEVAR with selective CSFD was low and risk factors for SCI were greater extent of thoracic aortic coverage and IBL. However, the incidence of major CSFD-related complications exceeded the incidence of SCI and CSFD significantly increased both ICU and total hospital LOS. Therefore, routine prophylactic CSFD may not be justified and a prospective randomized trial of CSFD in patients undergoing F-BEVAR seems appropriate.