701 - Endovascular Techniques for Paraplegia Reversal Following Endograft Repair of Thoracoabdominal Aneurysm

Learning Objectives: Review the pathophysiology of spinal cord ischemia (SCI) in thoraco abdominal aneurysm repair
Review potential steps to minimize this event including hemodynamic interventions and cerebrospinal fluid drainage
Review the algorhythm if patients develop SCI post endograft
Demonstrate the technical steps to induce endoleak to reperfuse the spinal arteries
Demonstrate the technical aspects in closing the endoleaks

Background: Spinal cord ischemia is the most devastating complication of thoracoabdominal aneurysm (TAA) repair with reported incidence of 2-15% {1}. This complication is related to the extent of the repair, related to the length of coverage by the endograft.
Spinal cord arterial supply is from multiple vessels including vertebral arteries, intercostal, lumbar and internal iliac {2}.
Spinal cord perfusion pressure is directly proportional to arterial pressure, hence risk of SCI increases with the extent of aortic coverage by endograft {3}.
Once SCI occurred post endograft placement, the conventional management is to improve spinal cord perfusion pressure/oxygenation by correcting hemodynamic parameters including blood pressure, oxygen saturation, and lowering CSF pressure by insertion of spinal drain {4}. However, despite these measures, many patients have little clinical improvement. Hence in this abstract, we wish to share our experience in inducing endoleaks rapidly to reperfuse the aneurysm sac and therefore revascularize intercostal and lumbar arteries.

Clinical Findings/Procedure Details: Methods of inducing endoleaks to reperfuse the aneurysm sac.
1. Dislocate a renal/visceral artery stent. This is technically challenging and may result in occlusion of the vessel
2. In situ fenestration of the aortic graft into the aneurysm sac. - This require the use of RFA or Laser to perforate the endograft fabric
3. Creation of type 1 endoleak by placing a chimney/periscope stent at edge of the main body
4. Creation of type 3 endoleak by placing a stent between the main body components

The last 2 methods are simple to perform with no specialized equipment required.
In the presentation, we will show the technical steps in creating these endoleaks succesfully in 4 patients with complete SCI reversal. We will also show the steps in closing these endoleaks at later stage when the patients have recovered from the acute event.

Conclusion and/or Teaching Points: SCI is a serious and devastating complication of TAA endograft repair. Reperfusing the aneurysm sac by creating a type 1 or type 3 endoleak rapidly can reverse the ischemia.