Commentary: Cerebrospinal fluid drainage: One component of a successful distal aortic surgery program

Central MessageCerebrospinal fluid drainage, together with other adjuncts, are important strategies to protect against spinal cord injury during open descending and thoracoabdominal aneurysm repair.See Article page 1. Cerebrospinal fluid drainage, together with other adjuncts, are important strategies to protect against spinal cord injury during open descending and thoracoabdominal aneurysm repair. See Article page 1. Spinal cord injury (SCI) remains the most devastating complication following descending thoracic and thoracoabdominal aortic aneurysm repair (DT/TAAA). Cerebrospinal fluid drainage (CSFD), along with other protective adjuncts, have reduced the rate of permanent SCI to 5% to 8%.1Coselli J.S. LeMaire S.A. Preventza O. de la Cruz K.I. Cooley D.A. Price M.D. et al.Outcomes of 3309 thoracoabdominal aortic aneurysm repairs.J Thorac Cardiovasc Surg. 2016; 151: 1323-1337Abstract Full Text Full Text PDF PubMed Scopus (327) Google Scholar, 2Safi H.J. Estrera A.L. Miller C.C. Huynh T.T. Porat E.E. Azizzadeh A. et al.Evolution of risk for neurologic deficit after descending and thoracoabdominal aortic repair.Ann Thorac Surg. 2005; 80 (discussion 2179): 2173-2179Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar, 3Gaudino M. Khan F.M. Rahouma M. Naik A. Hameed I. Spadaccio C. et al.Spinal cord injury after open and endovascular repair of descending thoracic and thoracoabdominal aortic aneurysms: a meta-analysis.J Thorac Cardiovasc Surg. May 13, 2020; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (9) Google Scholar, 4Rocha R.V. Lindsay T.F. Austin P.C. Al-Omran M. Forbes T.L. Lee D.S. et al.Outcomes after endovascular versus open thoracoabdominal aortic aneurysm repair: a population-based study.J Thorac Cardiovasc Surg. 2019; 161: 516-527.e6Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar In this issue of the Journal, Abdelbaky and colleagues5Abdelbaky M. Papanikolaou D. Zafar M.A. Ellauzi H. Shaikh M. Ziganshin B.A. et al.Safety of perioperative cerebrospinal fluid drain as a protective strategy during descending and thoracoabdominal open aortic repair.J Thorac Cardiovasc Surg Tech. 2021; 6: 1-8Scopus (3) Google Scholar present a retrospective review of 100 patients who underwent open DT/TAAA repair with CSFD as a routine adjunct, with excellent outcomes, including a permanent paraplegia rate of 2% and an in-hospital mortality rate of 6%. This success is likely secondary to several factors, including surgical expertise, routine use of other protective adjuncts, and case mix; nearly one-half of the population underwent lower-risk DT rather than TAAA repair, and the proportion of emergent patients was low. Notwithstanding the excellent results, the lack of a comparator group precludes this article from offering evidence to support or discourage the use of CSFD for SCI prevention. Acute changes in the spinal cord occur in response to ischemia/reperfusion during distal aortic repair, resulting in edema and increased CSF pressure.6Acher C.W. Wynn M.M. Hoch J.R. Popic P. Archibald J. Turnipseed W.D. Combined use of cerebral spinal fluid drainage and naloxone reduces the risk of paraplegia in thoracoabdominal aneurysm repair.J Vasc Surg. 1994; 19 (discussion 247-8): 236-246Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar CSFD works by lowering the intrathecal pressure and augmenting spinal cord perfusion. The effectiveness of CSFD in reducing SCI has been demonstrated in multiple observational series2Safi H.J. Estrera A.L. Miller C.C. Huynh T.T. Porat E.E. Azizzadeh A. et al.Evolution of risk for neurologic deficit after descending and thoracoabdominal aortic repair.Ann Thorac Surg. 2005; 80 (discussion 2179): 2173-2179Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar,6Acher C.W. Wynn M.M. Hoch J.R. Popic P. Archibald J. Turnipseed W.D. Combined use of cerebral spinal fluid drainage and naloxone reduces the risk of paraplegia in thoracoabdominal aneurysm repair.J Vasc Surg. 1994; 19 (discussion 247-8): 236-246Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar, 7Estrera A.L. Sandhu H.K. Charlton-Ouw K.M. Afifi R.O. Azizzadeh A. Miller III, C.C. et al.A quarter century of organ protection in open thoracoabdominal repair.Ann Surg. 2015; 262: 660-668Crossref PubMed Scopus (90) Google Scholar, 8Coselli J.S. Green S.Y. Price M.D. Zhang Q. Preventza O. de la Cruz K.I. et al.Spinal cord deficit after 1114 extent II open thoracoabdominal aortic aneurysm repairs.J Thorac Cardiovasc Surg. 2020; 159: 1-13Abstract Full Text Full Text PDF Scopus (27) Google Scholar, 9Safi H.J. Bartoli S. Hess K.R. Shenaq S.S. Viets J.R. Butt G.R. et al.Neurologic deficit in patients at high risk with thoracoabdominal aortic aneurysms: the role of cerebral spinal fluid drainage and distal aortic perfusion.J Vasc Surg. 1994; 20 (discussion 442-3): 434-444Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar, 10Safi H.J. Hess K.R. Randel M. Iliopoulos D.C. Baldwin J.C. Mootha R.K. et al.Cerebrospinal fluid drainage and distal aortic perfusion: reducing neurologic complications in repair of thoracoabdominal aortic aneurysm types I and II.J Vasc Surg. 1996; 23 (discussion 229): 223-228Abstract Full Text Full Text PDF PubMed Scopus (171) Google Scholar and a randomized trial.11Coselli J.S. LeMaire S.A. Köksoy C. Schmittling Z.C. Curling P.E. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial.J Vasc Surg. 2002; 35: 631-639Abstract Full Text Full Text PDF PubMed Scopus (505) Google Scholar Both the American Heart Association12Hiratzka L.F. Bakris G.L. Beckman J.A. Bersin R.M. Carr V.F. Casey Jr., D.E. 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.Circulation. 2010; 121: e266-e369Crossref PubMed Scopus (1800) Google Scholar and the European Association for Cardiothoracic Surgery13Etz C.D. Weigang E. Hartert M. Lonn L. Mestres C.A. Di Bartolomeo R. et al.Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery.Eur J Cardiothorac Surg. 2015; 47: 943-957Crossref PubMed Scopus (152) Google Scholar guidelines recommend CSFD for patients at high risk of SCI undergoing open and endovascular TAAA repair. Although guidelines provide consensus on the use of CSF drains,12Hiratzka L.F. Bakris G.L. Beckman J.A. Bersin R.M. Carr V.F. Casey Jr., D.E. 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.Circulation. 2010; 121: e266-e369Crossref PubMed Scopus (1800) Google Scholar, 13Etz C.D. Weigang E. Hartert M. Lonn L. Mestres C.A. Di Bartolomeo R. et al.Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery.Eur J Cardiothorac Surg. 2015; 47: 943-957Crossref PubMed Scopus (152) Google Scholar, 14Chung J.C. Lodewyks C.L. Forbes T.L. Chu M.W.A. Peterson M.D. Arora R.C. et al.Prevention and management of spinal cord ischemia following aortic surgery: a survey of contemporary practice.J Thorac Cardiovasc Surg. March 21, 2020; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (6) Google Scholar the protocols for CSFD, including timing, duration, and drainage protocols, are based on institutional experience and expert opinion. Most recommend maintaining CSF pressure <10 mmHg with continuous monitoring, limiting drainage to 10-15 mL/hour, early removal within 24 to 48 hours after surgery (in the absence of SCI), and cautious use of anticoagulation therapy even after drain removal.13Etz C.D. Weigang E. Hartert M. Lonn L. Mestres C.A. Di Bartolomeo R. et al.Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery.Eur J Cardiothorac Surg. 2015; 47: 943-957Crossref PubMed Scopus (152) Google Scholar,15Parotto M. Ouzounian M. Djaiani G. Spinal cord protection in elective thoracoabdominal aortic procedures.J Cardiothorac Vasc Anesth. 2019; 33: 200-208Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 16Wynn M.M. Sebranek J. Marks E. Engelbert T. Acher C.W. 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: 342-350Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 17Estrera A.L. Sheinbaum R. Miller C.C. Azizzadeh A. Walkes J.C. Lee T.Y. et al.Cerebrospinal fluid drainage during thoracic aortic repair: safety and current management.Ann Thorac Surg. 2009; 88: 9-15Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar, 18Fedorow C.A. Moon M.C. Mutch W.A.C. Grocott H.P. Lumbar cerebrospinal fluid drainage for thoracoabdominal aortic surgery: rationale and practical considerations for management.Anesth Analg. 2010; 111: 46-58Crossref PubMed Scopus (94) Google Scholar One important learning point from the Yale series is that routine CSFD is safe, with a low incidence of serious complications. Over the past decade, various adjunctive strategies have been introduced to minimize SCI, including distal aortic perfusion, neurophysiological monitoring, segmental artery reattachment, and aggressive blood pressure management.13Etz C.D. Weigang E. Hartert M. Lonn L. Mestres C.A. Di Bartolomeo R. et al.Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery.Eur J Cardiothorac Surg. 2015; 47: 943-957Crossref PubMed Scopus (152) Google Scholar,15Parotto M. Ouzounian M. Djaiani G. Spinal cord protection in elective thoracoabdominal aortic procedures.J Cardiothorac Vasc Anesth. 2019; 33: 200-208Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar,19Arora L. Hosn M.A. Spinal cord perfusion protection for thoraco-abdominal aortic aneurysm surgery.Curr Opin Anaesthesiol. 2019; 32: 72-79Crossref PubMed Scopus (8) Google Scholar With advances in endovascular surgery, newer techniques have been proposed to increase spinal cord tolerance to hypoperfusion. Staging of aortic coverage has been suggested to stimulate the development of the collateral network for perfusion of the cord.20Bischoff M.S. Brenner R.M. Scheumann J. Zoli S. Di Luozzo G. Etz C.D. et al.Staged approach for spinal cord protection in hybrid thoracoabdominal aortic aneurysm repair.Ann Cardiothorac Surg. 2012; 1: 325-328PubMed Google Scholar Minimally invasive segmental artery coil embolization of intercostal arteries before thoracoabdominal aortic repair has been suggested to provoke collateral flow and reduce SCI and is currently being evaluated in a randomized trial.21Etz C.D. Debus E.S. Mohr F.W. Kölbel T. First-in-man endovascular preconditioning of the paraspinal collateral network by segmental artery coil embolization to prevent ischemic spinal cord injury.J Thorac Cardiovasc Surg. 2015; 149: 1074-1079Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar,22Petroff D. Czerny M. Kölbel T. Melissano G. Lonn L. Haunschild J. et al.Paraplegia prevention in aortic aneurysm repair by thoracoabdominal staging with 'minimally invasive staged segmental artery coil embolisation' (MIS2ACE): trial protocol for a randomised controlled multicentre trial.BMJ Open. 2019; 9: e025488Crossref PubMed Scopus (22) Google Scholar In summary, CSFD along with other adjuncts are important strategies to protect against SCI during open descending and thoracoabdominal aneurysm repair. As with most complex aortic surgeries, it is difficult to attribute a team's success to a single factor. Rather, it is likely a combination of surgical judgment, experience, attention to management details, and a mature team that can lead to such excellent results. Safety of perioperative cerebrospinal fluid drain as a protective strategy during descending and thoracoabdominal open aortic repairJTCVS TechniquesVol. 6PreviewWe present our experience with routine application of the cerebrospinal fluid (CSF) drain (CSFD) during open aortic repair. Full-Text PDF Open Access

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