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.
1Use 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.
- 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
2A 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.
- 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
3Hence, the use of CSFDs will be warranted in selected patients undergoing aortic repairs who are at a high risk of SCI.
- 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
4Although 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.
- 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
5This 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.
- 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
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- Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms.J Vasc Surg. 2021; 73: 55S-83S
- Fate of patients with spinal cord ischemia complicating thoracic endovascular aortic repair.J Vasc Surg. 2013; 58 (e2): 635-642
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Published online: September 29, 2022
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