Advertisement

Pro: Fluoroscopic Guidance Should Be Routinely Used to Place Cerebrospinal Fluid Drains for Patients Undergoing Aortic Surgery

Published:September 29, 2022DOI:https://doi.org/10.1053/j.jvca.2022.09.092
      PER THE SOCIETY for Vascular Surgery clinical guidelines, use of cerebrospinal fluid drains (CSFDs) should be considered for appropriately-selected patients undergoing extensive aortic repair.
      • Upchurch GR
      • Escobar GA
      • Azizzadeh A
      • et al.
      Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms.
      Use of CSFDs enhances spinal cord perfusion pressure, thus ameliorating the detrimental effects in vulnerable watershed regions caused by the surgical reduction in blood supply, and thereby preventing devastating spinal cord ischemia (SCI). It is important to note that patients who experience SCI after aortic repairs have significantly worse long-term survival than those without this complication. More importantly, patients who have a return of neurologic function after SCI can anticipate similar life expectancy compared to those without SCI. There is plenty of evidence suggesting that prophylactic use of CSFDs in selected high-risk patients undergoing aortic repairs reduces the incidence of postoperative SCI.
      • DeSart K
      • Scali ST
      • Feezor RJ
      • et al.
      Fate of patients with spinal cord ischemia complicating thoracic endovascular aortic repair.
      A recent meta-analysis that included 3,561 patients from 34 studies, demonstrated a lower incidence of SCI when CSFDs were placed routinely, as opposed to use only in patients meeting specified criteria.
      • Zhang Z
      • Zhou Y
      • Lin S
      • et al.
      Systematic review and meta-analysis of association of prophylactic cerebrospinal fluid drainage in preventing spinal cord ischemia after thoracic endovascular aortic repair.
      Hence, the use of CSFDs will be warranted in selected patients undergoing aortic repairs who are at a high risk of SCI.
      • Arora H
      • Ullery BW
      • Kumar PA
      • et al.
      Pro: Patients at risk for spinal cord ischemia after thoracic endovascular aortic repairs should receive prophylactic cerebrospinal fluid drainage.
      Although CSFDs are an essential tool in the prevention of SCI caused by the surgery, CSFD placement is not without risk. Rong et al. published a meta-analysis that included 4,714 patients across 34 studies who underwent open and endovascular aortic repairs with CSFDs.
      • Rong LQ
      • Kamel MK
      • Rahouma M
      • et al.
      Cerebrospinal-fluid drain-related complications in patients undergoing open and endovascular repairs of thoracic and thoraco-abdominal aortic pathologies: a systematic review and meta-analysis.
      This analysis focused on CSFD-related complications, with a 6.5% rate of pooled events, 2.5% of which represented severe complications, including epidural hematoma, intracranial hemorrhage, subarachnoid hemorrhage, meningitis, and/or catheter-related neurologic deficit. Risk factors for increased technical difficulty or even failed CSFD placement included atypical anatomy, such as from prior lumbar spine surgery, osteoarthritis or scoliosis, and poor surface landmarks, as can occur with a higher body mass index.
      • Awad H
      • Ramadan ME
      • Tili E
      • et al.
      Fluoroscopic-guided lumbar spinal drain insertion for thoracic aortic aneurysm surgery.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Cardiothoracic and Vascular Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Upchurch GR
        • Escobar GA
        • Azizzadeh A
        • et al.
        Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms.
        J Vasc Surg. 2021; 73: 55S-83S
        • DeSart K
        • Scali ST
        • Feezor RJ
        • et al.
        Fate of patients with spinal cord ischemia complicating thoracic endovascular aortic repair.
        J Vasc Surg. 2013; 58 (e2): 635-642
        • Zhang Z
        • Zhou Y
        • Lin S
        • et al.
        Systematic review and meta-analysis of association of prophylactic cerebrospinal fluid drainage in preventing spinal cord ischemia after thoracic endovascular aortic repair.
        J Vasc Surg. 2022; 75 (e5): 1478-1489
        • Arora H
        • Ullery BW
        • Kumar PA
        • et al.
        Pro: Patients at risk for spinal cord ischemia after thoracic endovascular aortic repairs should receive prophylactic cerebrospinal fluid drainage.
        J Cardiothorac Vasc Anesth. 2015; 29: 1376-1380
        • Rong LQ
        • Kamel MK
        • Rahouma M
        • et al.
        Cerebrospinal-fluid drain-related complications in patients undergoing open and endovascular repairs of thoracic and thoraco-abdominal aortic pathologies: a systematic review and meta-analysis.
        Br J Anaesth. 2018; 120: 904-913
        • Awad H
        • Ramadan ME
        • Tili E
        • et al.
        Fluoroscopic-guided lumbar spinal drain insertion for thoracic aortic aneurysm surgery.
        Anesth Analg. 2017; 125: 1219-1222
        • Estrera AL
        • Sheinbaum R
        • Miller CC
        • et al.
        Cerebrospinal fluid drainage during thoracic aortic repair: safety and current management.
        Ann Thorac Surg. 2009; 88 (discussion 15): 9-15
        • Wynn MM
        • Sebranek J
        • Marks E
        • et al.
        Complications of spinal fluid drainage in thoracic and thoracoabdominal aortic aneurysm surgery in 724 patients treated from 1987 to 2013.
        J Cardiothorac Vasc Anesth. 2015; 29: 342-350
        • Chee CG
        • Lee GY
        • Lee JW
        • et al.
        Fluoroscopy-guided lumbar drainage of cerebrospinal fluid for patients in whom a blind beside approach is difficult.
        Korean J Radiol. 2015; 16: 860-865
        • Drescher D
        • Bourauel C
        • Schumacher HA.
        [The loss of force by friction in arch-guided tooth movement].
        Fortschr Kieferorthop. 1990; 51: 99-105
        • Vincent F
        • Spillemaeker H
        • Kyheng M
        • et al.
        Ultrasound guidance to reduce vascular and bleeding complications of percutaneous transfemoral transcatheter aortic valve replacement: A propensity score-matched comparison.
        J Am Heart Assoc. 2020; 9e014916
        • Brass P
        • Hellmich M
        • Kolodziej L
        • et al.
        Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization.
        Cochrane Database Syst Rev. 2015; 1CD006962
        • Bomberg H
        • Wetjen L
        • Wagenpfeil S
        • et al.
        Risks and benefits of ultrasound, nerve stimulation, and their combination for guiding peripheral nerve blocks: A retrospective registry analysis.
        Anesth Analg. 2018; 127: 1035-1043
        • Barrington MJ
        • Kluger R.
        Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade.
        Reg Anesth Pain Med. 2013; 38: 289-299
        • Kärkkäinen JM
        • Cirillo-Penn NC
        • Sen I
        • et al.
        Cerebrospinal fluid drainage complications during first stage and completion fenestrated-branched endovascular aortic repair.
        J Vasc Surg. 2020; 71 (e2): 1109-1118
        • Eskey CJ
        • Ogilvy CS.
        Fluoroscopy-guided lumbar puncture: decreased frequency of traumatic tap and implications for the assessment of CT-negative acute subarachnoid hemorrhage.
        AJNR Am J Neuroradiol. 2001; 22: 571-576
        • Narouze S
        • Benzon HT
        • Provenzano D
        • et al.
        Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications (Second Edition): guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain.
        Reg Anesth Pain Med. 2018; 43: 225-262
        • Youngblood SC
        • Tolpin DA
        • LeMaire SA
        • et al.
        Complications of cerebrospinal fluid drainage after thoracic aortic surgery: a review of 504 patients over 5 years.
        J Thorac Cardiovasc Surg. 2013; 146: 166-171
        • Chaudhary O
        • Sharkey A
        • Schermerhorn M
        • et al.
        Protocolized based management of cerebrospinal fluid drains in thoracic endovascular aortic aneurysm repair procedures.
        Ann Vasc Surg. 2021; 72: 409-418
        • Kitpanit N
        • Ellozy SH
        • Connolly PH
        • et al.
        Risk factors for spinal cord injury and complications of cerebrospinal fluid drainage in patients undergoing fenestrated and branched endovascular aneurysm repair.
        J Vasc Surg. 2021; 73 (e1): 399-409
        • Yang GK
        • Misskey J
        • Arsenault K
        • et al.
        Outcomes of a spinal drain and intraoperative neurophysiologic monitoring protocol in thoracic endovascular aortic repair.
        Ann Vasc Surg. 2019; 61: 124-133
        • Makito K
        • Mouri H
        • Matsui H
        • et al.
        Spinal epidural hematoma and abscess after neuraxial anesthesia: a historical cohort study using the Japanese Diagnosis Procedure Combination database.
        Can J Anaesth. 2021; 68: 42-52
        • Kroll H
        • Duszak R
        • Nsiah E
        • et al.
        Trends in lumbar puncture over 2 decades: a dramatic shift to radiology.
        AJR Am J Roentgenol. 2015; 204: 15-19
        • Trunz LM
        • Gandhi AV
        • Karambelkar AD
        • et al.
        National trends in lumbar puncture from 2010 to 2018: A shift reversal from the emergency department to the hospital setting for radiologists and advanced practice providers.
        AJNR Am J Neuroradiol. 2021; 42: 206-210
        • Broadbent CR
        • Maxwell WB
        • Ferrie R
        • et al.
        Ability of anaesthetists to identify a marked lumbar interspace.
        Anaesthesia. 2000; 55: 1122-1126
        • Snider KT
        • Snider EJ
        • Degenhardt BF
        • et al.
        Palpatory accuracy of lumbar spinous processes using multiple bony landmarks.
        J Manipulative Physiol Ther. 2011; 34: 306-313
        • Yang H
        • Schaffer K
        • Liu L
        • et al.
        Benchmarking lumbar puncture fluoroscopy time during fellowship training.
        AJNR Am J Neuroradiol. 2017; 38: 656-658
        • Boddu SR
        • Corey A
        • Peterson R
        • et al.
        Fluoroscopic-guided lumbar puncture: fluoroscopic time and implications of body mass index–a baseline study.
        AJNR Am J Neuroradiol. 2014; 35: 1475-1480
        • Brook AD
        • Burns J
        • Dauer E
        • et al.
        Comparison of CT and fluoroscopic guidance for lumbar puncture in an obese population with prior failed unguided attempt.
        J Neurointerv Surg. 2014; 6: 324-328
        • Howells P
        • Eaton R
        • Patel AS
        • et al.
        Risk of radiation exposure during endovascular aortic repair.
        Eur J Vasc Endovasc Surg. 2012; 43: 393-397
        • Li L
        • Tao W
        • Cai X.
        Ultrasound-guided vs. landmark-guided lumbar puncture for obese patients in emergency department.
        Front Surg. 2022; 9874143