Innovations to Prevent Spinal Cord Ischemia

Ischemic spinal cord injury remains one of the most dreaded complications of open and endovascular complex aortic aneurysm repair, with affected patients facing significantly worse survival rates than those who escape this grave outcome. But recent work is advancing efforts to prevent SCI, as experts will discuss Friday morning in “More About Complex Aneurysm Treatment and Spinal Ischemia.”

We know much more about preventing SCI than we did a decade ago, according to moderator Dr. Gustavo Oderich, who is a professor of surgery at Mayo Clinic Medical College in Rochester, Minn. For example, work by Dr. Randall Griepp and colleagues at Mount Sinai Hospital, New York, has shown that spinal cord perfusion can adapt through an extensive network of collateral vessels, and that SCI rates drop when surgeons use staged aortic coverage to promote collateral enlargement and recruitment, Dr. Oderich said. “The pathophysiology of SCI includes hemodynamic compromise or embolization, which has been increasingly recognized as an important factor during complex aortic repair,” he added. “It is clear that we have a better understanding of the etiology of SCI and possible preventive measures, but that the complication can’t be avoided in every patient.”

The session will be co-moderated by Dr. Christian Etz, a professor at Leipzig University and an attending surgeon at Leipzig Heart Center in Germany. Attendees will learn how staged repair can reduce the risk of permanent SCI, paraplegia, and mortality after endovascular thoraco-abdominal repair. Staging can involve a number of strategies, including proximal thoracic coverage with stent-graft, perfusion branches, or incomplete endovascular repair by leaving one of the side branches or the contralateral iliac limb unstented, Dr. Oderich noted. Dr. Etz also will discuss his group’s alternative, which is to preemptively perform ischemic preconditioning through coil embolization of intercostal arteries.

“We termed this approach ‘minimally invasive segmentaI artery coil embolization’ (MISACE), and published our first-in-human-experience with it recently,” said Dr. Etz.  “I believe this solution has the potential to eliminate SCI or permanent paraplegia once and for all in the next five to 10 years.”

Other experts will describe how to optimize patient selection – a key step in preventing SCI, said Dr. Oderich. “Endovascular procedures should likely be avoided in patients with ‘shaggy aorta’ – that is, extensive atherosclerotic debris – and poor collateral networks to the spine,” he added. Surgeons also should confirm that the patient has adequate iliofemoral access to avoid intraoperative complications and to prevent prolonged pelvic and lower limb ischemia, he said.

There also have been advances in routine protocols to prevent SCI during endovascular repair of thoracoabdominal aortic aneurysms. While a few investigators still debate some of these protocols, most groups now support routine cerebrospinal fluid drainage, permissive hypertension and mean arterial pressure augmentation, revascularization of the left subclavian and internal iliac arteries when indicated, aggressive transfusion in the early postoperative period, and prevention of systemic hypotension, said Dr. Oderich.

Presenters also will discuss preserving internal iliac and vertebral artery flow, which has been shown to help reduce rates of SCI and to increase the chances of recovery when patients do sustain injury. In addition, Dr. Michael Jacobs will discuss intraoperative monitoring of motor and somatosensory evoked potentials, which can help clinicians immediately recognize drops in perfusion of the spine and lower extremities and respond through such maneuvers as increasing MAP, decreasing CSF pressure, early limb reperfusion, and incomplete endovascular repair.

Attendees also will hear Dr. Stephan Haulon, of the Université de Lille and CHRU Lille, France, discuss how to achieve early pelvic and lower limb reperfusion by immediately restoring flow after placing a distal bifurcated component stent graft and iliac limbs. “This has been shown by Haulon and colleagues to improve outcomes of endovascular TAAA repair,” Dr. Oderich said. “The Mayo Clinic group has also recently reported on their protocol to use standardized maneuvers during the repair to prevent SCI.” In the next decade, investigators will continue honing and developing techniques to optimize spinal cord perfusion by recruiting and adapting the collateral vasculature, he added.

Dr. Etz added “This unique session brings together all the world-renowned experts in the field for the very first time. Attendees will really get a completely new understanding of this very complex matter, and will ultimately learn how to prevent SCI in their own patients.”

Session 78: More About Complex Aneurysm Treatment and Spinal Cord Ischemia

8:00 a.m. – 9:07 a.m.

Grand Ballroom East, 3rd Floor

Ischemic spinal cord injury remains one of the most dreaded complications of open and endovascular complex aortic aneurysm repair, with affected patients facing significantly worse survival rates than those who escape this grave outcome. But recent work is advancing efforts to prevent SCI, as experts will discuss Friday morning in “More About Complex Aneurysm Treatment and Spinal Ischemia.”

We know much more about preventing SCI than we did a decade ago, according to moderator Dr. Gustavo Oderich, who is a professor of surgery at Mayo Clinic Medical College in Rochester, Minn. For example, work by Dr. Randall Griepp and colleagues at Mount Sinai Hospital, New York, has shown that spinal cord perfusion can adapt through an extensive network of collateral vessels, and that SCI rates drop when surgeons use staged aortic coverage to promote collateral enlargement and recruitment, Dr. Oderich said. “The pathophysiology of SCI includes hemodynamic compromise or embolization, which has been increasingly recognized as an important factor during complex aortic repair,” he added. “It is clear that we have a better understanding of the etiology of SCI and possible preventive measures, but that the complication can’t be avoided in every patient.”

The session will be co-moderated by Dr. Christian Etz, a professor at Leipzig University and an attending surgeon at Leipzig Heart Center in Germany. Attendees will learn how staged repair can reduce the risk of permanent SCI, paraplegia, and mortality after endovascular thoraco-abdominal repair. Staging can involve a number of strategies, including proximal thoracic coverage with stent-graft, perfusion branches, or incomplete endovascular repair by leaving one of the side branches or the contralateral iliac limb unstented, Dr. Oderich noted. Dr. Etz also will discuss his group’s alternative, which is to preemptively perform ischemic preconditioning through coil embolization of intercostal arteries.

“We termed this approach ‘minimally invasive segmentaI artery coil embolization’ (MISACE), and published our first-in-human-experience with it recently,” said Dr. Etz.  “I believe this solution has the potential to eliminate SCI or permanent paraplegia once and for all in the next five to 10 years.”

Other experts will describe how to optimize patient selection – a key step in preventing SCI, said Dr. Oderich. “Endovascular procedures should likely be avoided in patients with ‘shaggy aorta’ – that is, extensive atherosclerotic debris – and poor collateral networks to the spine,” he added. Surgeons also should confirm that the patient has adequate iliofemoral access to avoid intraoperative complications and to prevent prolonged pelvic and lower limb ischemia, he said.

There also have been advances in routine protocols to prevent SCI during endovascular repair of thoracoabdominal aortic aneurysms. While a few investigators still debate some of these protocols, most groups now support routine cerebrospinal fluid drainage, permissive hypertension and mean arterial pressure augmentation, revascularization of the left subclavian and internal iliac arteries when indicated, aggressive transfusion in the early postoperative period, and prevention of systemic hypotension, said Dr. Oderich.

Presenters also will discuss preserving internal iliac and vertebral artery flow, which has been shown to help reduce rates of SCI and to increase the chances of recovery when patients do sustain injury. In addition, Dr. Michael Jacobs will discuss intraoperative monitoring of motor and somatosensory evoked potentials, which can help clinicians immediately recognize drops in perfusion of the spine and lower extremities and respond through such maneuvers as increasing MAP, decreasing CSF pressure, early limb reperfusion, and incomplete endovascular repair.

Attendees also will hear Dr. Stephan Haulon, of the Université de Lille and CHRU Lille, France, discuss how to achieve early pelvic and lower limb reperfusion by immediately restoring flow after placing a distal bifurcated component stent graft and iliac limbs. “This has been shown by Haulon and colleagues to improve outcomes of endovascular TAAA repair,” Dr. Oderich said. “The Mayo Clinic group has also recently reported on their protocol to use standardized maneuvers during the repair to prevent SCI.” In the next decade, investigators will continue honing and developing techniques to optimize spinal cord perfusion by recruiting and adapting the collateral vasculature, he added.

Dr. Etz added “This unique session brings together all the world-renowned experts in the field for the very first time. Attendees will really get a completely new understanding of this very complex matter, and will ultimately learn how to prevent SCI in their own patients.”

Session 78: More About Complex Aneurysm Treatment and Spinal Cord Ischemia

8:00 a.m. – 9:07 a.m.

Grand Ballroom East, 3rd Floor

Ischemic spinal cord injury remains one of the most dreaded complications of open and endovascular complex aortic aneurysm repair, with affected patients facing significantly worse survival rates than those who escape this grave outcome. But recent work is advancing efforts to prevent SCI, as experts will discuss Friday morning in “More About Complex Aneurysm Treatment and Spinal Ischemia.”

We know much more about preventing SCI than we did a decade ago, according to moderator Dr. Gustavo Oderich, who is a professor of surgery at Mayo Clinic Medical College in Rochester, Minn. For example, work by Dr. Randall Griepp and colleagues at Mount Sinai Hospital, New York, has shown that spinal cord perfusion can adapt through an extensive network of collateral vessels, and that SCI rates drop when surgeons use staged aortic coverage to promote collateral enlargement and recruitment, Dr. Oderich said. “The pathophysiology of SCI includes hemodynamic compromise or embolization, which has been increasingly recognized as an important factor during complex aortic repair,” he added. “It is clear that we have a better understanding of the etiology of SCI and possible preventive measures, but that the complication can’t be avoided in every patient.”

The session will be co-moderated by Dr. Christian Etz, a professor at Leipzig University and an attending surgeon at Leipzig Heart Center in Germany. Attendees will learn how staged repair can reduce the risk of permanent SCI, paraplegia, and mortality after endovascular thoraco-abdominal repair. Staging can involve a number of strategies, including proximal thoracic coverage with stent-graft, perfusion branches, or incomplete endovascular repair by leaving one of the side branches or the contralateral iliac limb unstented, Dr. Oderich noted. Dr. Etz also will discuss his group’s alternative, which is to preemptively perform ischemic preconditioning through coil embolization of intercostal arteries.

“We termed this approach ‘minimally invasive segmentaI artery coil embolization’ (MISACE), and published our first-in-human-experience with it recently,” said Dr. Etz.  “I believe this solution has the potential to eliminate SCI or permanent paraplegia once and for all in the next five to 10 years.”

Other experts will describe how to optimize patient selection – a key step in preventing SCI, said Dr. Oderich. “Endovascular procedures should likely be avoided in patients with ‘shaggy aorta’ – that is, extensive atherosclerotic debris – and poor collateral networks to the spine,” he added. Surgeons also should confirm that the patient has adequate iliofemoral access to avoid intraoperative complications and to prevent prolonged pelvic and lower limb ischemia, he said.

There also have been advances in routine protocols to prevent SCI during endovascular repair of thoracoabdominal aortic aneurysms. While a few investigators still debate some of these protocols, most groups now support routine cerebrospinal fluid drainage, permissive hypertension and mean arterial pressure augmentation, revascularization of the left subclavian and internal iliac arteries when indicated, aggressive transfusion in the early postoperative period, and prevention of systemic hypotension, said Dr. Oderich.

Presenters also will discuss preserving internal iliac and vertebral artery flow, which has been shown to help reduce rates of SCI and to increase the chances of recovery when patients do sustain injury. In addition, Dr. Michael Jacobs will discuss intraoperative monitoring of motor and somatosensory evoked potentials, which can help clinicians immediately recognize drops in perfusion of the spine and lower extremities and respond through such maneuvers as increasing MAP, decreasing CSF pressure, early limb reperfusion, and incomplete endovascular repair.

Attendees also will hear Dr. Stephan Haulon, of the Université de Lille and CHRU Lille, France, discuss how to achieve early pelvic and lower limb reperfusion by immediately restoring flow after placing a distal bifurcated component stent graft and iliac limbs. “This has been shown by Haulon and colleagues to improve outcomes of endovascular TAAA repair,” Dr. Oderich said. “The Mayo Clinic group has also recently reported on their protocol to use standardized maneuvers during the repair to prevent SCI.” In the next decade, investigators will continue honing and developing techniques to optimize spinal cord perfusion by recruiting and adapting the collateral vasculature, he added.

Dr. Etz added “This unique session brings together all the world-renowned experts in the field for the very first time. Attendees will really get a completely new understanding of this very complex matter, and will ultimately learn how to prevent SCI in their own patients.”

Session 78: More About Complex Aneurysm Treatment and Spinal Cord Ischemia

8:00 a.m. – 9:07 a.m.

Grand Ballroom East, 3rd Floor