Spinal cord injury after frozen elephant trunk procedures-prevention and management.

Abstract

New techniques and devices have broadened the spectrum of therapeutic strategies for patients with complex aortic pathologies. Total arch replacement (TAR) using the frozen elephant trunk (FET) technique is one of the latest approaches to surgically treat complex arch and proximal descending aortic pathologies. Although this technique has showed excellent results, it is associated with several complications, such as spinal cord injury (SCI). This is related to the coverage of an extended portion of descending aorta, including the origin of intercostal arteries. The longer the portion of descending aorta covered, the higher the risk of SCI occurrence. Consequently, knowing the anatomy and vascularization of the spinal cord is crucial (1). Even though coverage of the descending aorta beyond T8 (due to coverage of the Adamkiewicz artery) seems to be one of the most important factors associated with higher risk of SCI, there are other elements involved, such as prolonged spinal cord ischemia observed during hypothermic circulatory arrest and air or corpuscular thromboembolism (2). A higher incidence of this neurological complication after the FET is more often observed in chronic degenerative aneurysms and acute aortic dissections and is less frequently reported in chronic dissections due to the possibility of pre-conditioning of the spinal cord by collateral networks (3,4). Preventive measures can be employed in extended surgical aortic coverage to reduce the occurrence of spinal cord injuries, such as cerebrospinal fluid (CSF) drainage, keeping the mean arterial pressure (MAP) above 90 mmHg, early evaluation of neurological deficits, and the use of moderate hypothermia. CSF drainage allows monitoring of the peridural pressure, as well as the capability of its reduction when it exceeds critical values. However, intrathecal drainage placement can represent a risk and careful examination of the coagulation panel is strongly recommended. In this video article, we present a case of a FET showing how it can be possible in the prevention and management of SCI. A literature review on this subject will describe the incidence and state of the art perspectives on this neurological complication.