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Con: Lumbar Drains Should Routinely Be Placed by a Landmark Approach and Not by Fluoroscopic Guidance for Elective Thoracic Aortic Repairs

Published:September 29, 2022DOI:https://doi.org/10.1053/j.jvca.2022.09.089
      SPINAL CORD ISCHEMIA (SCI) after thoracoabdominal aortic repair is a well-known complication of both open and endovascular surgery, with reported rates as high as 5%-to-21% after open repair.
      • Gravereaux EC
      • Faries PL
      • Burks JA
      • et al.
      Risk of spinal cord ischemia after endograft repair of thoracic aortic aneurysm.
      Resultant morbidity, including paraparesis and paraplegia, are devastating, and a fair amount of research has gone into developing strategies for mitigating SCI-related complications. Cerebrospinal fluid drainage (CSFD) with the placement of lumbar drains (LDs) is considered the current recommendation for both prevention and treatment of SCI in high-risk patients.
      • Coselli JS
      • LeMaire SA
      • Koksoy C
      • et al.
      Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial.
      ,
      • Hiratzka LF
      • Bakris GL
      • Beckman JA
      • et al.
      2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine.
      While there is some controversy over the utility of CSFD for endovascular repairs, it is still a widely accepted practice that is performed frequently for patients at high risk of developing SCI postrepair.
      • Isaak RS
      • Furman W.
      Con: Patients at risk for spinal cord ischemia after thoracic endovascular aortic repairs should not receive prophylactic cerebrospinal fluid drainage.
      Protocols regarding the placement of LDs can vary by institution, whereby some centers may routinely use imaging guidance for the procedure. In this review, the authors examine the specifics of using fluoroscopic guidance for the preoperative placement of LDs in patients who are at a high risk of developing SCI after thoracoabdominal aortic repair. It is the authors’ belief that the universal use of fluoroscopic guidance is unnecessary, potentially harmful, confers additional expense, and is unsupported by the current body of evidence.

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