Impact of Intermittent Functional Internal Iliac Artery Occlusion on Spinal Cord Blood Supply during TEVAR
14 December 2018
18 March 2019
15 May 2019 (online)
Background Measuring transcranial motor evoked potentials (EPs) and somatosensory EPs is a well-established method to assess spinal cord function during thoracic endovascular aortic repair (TEVAR). Functional occlusion of one or both internal iliac arteries by large bore sheaths during TEVAR can cause unilateral intermittently EP loss.
Methods Between 2006 and 2016, 194 patients underwent TEVAR entailing EP monitoring. The ISIS IOM System (Inomed Medizintechnik GmbH, Emmendingen, Germany) was employed in all patients. EPs were recorded after inducing anesthesia, during the procedure, and before discontinuing anesthesia.
Results We observed a unilateral intermittently EP decrease or loss in 12 (6.2%) patients. Most events were ipsilateral (9 of 12). The underlying pathologies were descending aortic aneurysm in six patients and type B dissection in six patients. An evoked-potential decrease or loss was always associated with the insertion of large bore stent-graft-introducing sheaths. The median duration of the unilaterally EP decrease or loss was 16 (10; 31) minutes (range, 2–77 minutes) with baseline values re-established at the end of the procedure after sheath removal in all cases. No patient developed irreversible symptomatic spinal cord ischemia.
Conclusion A functional occlusion of internal iliac arteries via large bore TEVAR-introducing sheaths is associated with a unilateral intermittent decrease in or loss of EPs returning to baseline after sheath removal. This observation highlights the importance of the internal iliac arteries as one of the major spinal cord's blood supply territories, and may serve as a stimulus to reduce the duration of sheath indwelling to a minimum.
- 1 Maeda T, Yoshitani K, Sato S. , et al. Spinal cord ischemia after endovascular aortic repair versus open surgical repair for descending thoracic and thoracoabdominal aortic aneurism. J Anesth 2012; 26 (06) 805-811
- 2 Uchida N. How to prevent spinal cord injury during endovascular repair of thoracic aortic disease. Gen Thorac Cardiovasc Surg 2014; 62 (07) 391-397
- 3 Wong CS, Healy D, Canning C, Coffey JC, Boyle JR, Walsh SR. A systematic review of spinal cord injury and cerebrospinal fluid drainage after thoracic aortic endografting. J Vasc Surg 2012; 56 (05) 1438-1447
- 4 Feezor RJ, Lee WA. Strategies for detection and prevention of spinal cord ischemia during TEVAR. Semin Vasc Surg 2009; 22 (03) 187-192
- 5 Eagleton MJ, Shah S, Petkosevek D, Mastracci TM, Greenberg RK. Hypogastric and subclavian artery patency affects onset and recovery of spinal cord ischemia associated with aortic endografting. J Vasc Surg 2014; 59 (01) 89-94
- 6 Khoynezhad A, Donayre CE, Bui H, Kopchok GE, Walot I, White RA. Risk factors of neurologic deficit after thoracic aortic endografting. Ann Thorac Surg 2007; 83 (02) S882-S889 , discussion S890–S892
- 7 Natsume K, Shiiya N, Yamashita K, Washiyama N. Spinal cord ischaemia after endovascular aneurysm repair. Interact Cardiovasc Thorac Surg 2017; 25 (05) 827-829
- 8 Czerny M, Eggebrecht H, Sodeck G. , et al. Mechanisms of symptomatic spinal cord ischemia after TEVAR: insights from the European Registry of Endovascular Aortic Repair Complications (EuREC). J Endovasc Ther 2012; 19 (01) 37-43
- 9 Matsuda H, Fukuda T, Iritani O. , et al. Spinal cord injury is not negligible after TEVAR for lower descending aorta. Eur J Vasc Endovasc Surg 2010; 39 (02) 179-186
- 10 Banga PV, Oderich GS, Reis de Souza L. , et al. Neuromonitoring, cerebrospinal fluid drainage, and selective use of iliofemoral conduits to minimize risk of spinal cord injury during complex endovascular aortic Repair. J Endovasc Ther 2016; 23 (01) 139-149
- 11 Maier S, Shcherbakova M, Beyersdorf F. , et al. Benefits and risks of prophylactic cerebrospinal fluid catheter and evoked potential monitoring in symptomatic spinal cord ischemia low-risk thoracic endovascular aortic repair. Thorac Cardiovasc Surg 2019; 67 (05) 379-384
- 12 Vossler DG, Stonecipher T, Millen MD. Femoral artery ischemia during spinal scoliosis surgery detected by posterior tibial nerve somatosensory-evoked potential monitoring. Spine 2000; 25 (11) 1457-1459
- 13 Pankowski R, Roclawski M, Dziegiel K. , et al. Transient monoplegia as a result of unilateral femoral artery ischemia detected by multimodal intraoperative neuromonitoring in posterior scoliosis surgery: a case report. Medicine (Baltimore) 2016; 95 (06) e2748
- 14 Shimoda T, Inoue S, Kakimoto M. , et al. [Intraoperative unilateral changes in myogenic motor evoked potentials in patients undergoing thoracic aortic surgery]. Masui 2001; 50 (08) 874-877