RR14. Spinal Cord Injury after Hybrid Endovascular Repair of Thoracoabdominal Aortic Aneurysms in the North American Complex Abdominal Aortic Debranching (NACAAD) Registry

Abstract Background: The etiology of delayed-onset spinal cord injury (SCI) following endovascular repair of thoraco-abdominal aortic aneurysms (TAAA) is still unclear and may be related to multiple factors. Extravascular factors, such as lumbar spinal stenosis (LSS), may play a significant role in the selection of patient at risk of SCI. In this report we describe a case of paraplegia following thoracic endovascular aortic repair (TEVAR) in a patient suffering from severe and symptomatic LSS and undergoing staged endovascular repair of a TAAA.Case presentation: A 70-year-old man was admitted to our department with an asymptomatic type III TAAA in previous open repair for abdominal aortic aneurysm. The patient complained of buttock and thigh claudication in the absence of defects in the pelvic perfusion; a spinal magnetic resonance angiography (MRA) showed a severe narrowing of the lumbar canal. The first-step procedure was estimated at intermediate risk of SCI and considering a recent cardiac procedure requiring double antiplatelet therapy, in agreement with anesthesiologists, a preoperative cerebrospinal fluid (CSF) drainage was not performed during the first-step. After 24 hours from TEVAR paraplegia was detected. The drainage was then placed with incomplete recovery. The second stage was performed in urgency three weeks after, without complications and changes in neurological status.Conclusions: Stenotic damage to the spinal cord is thought to be the result of direct compression of the neural elements and ischemic disruption of arterial and venous structures surrounding the spinal cord. This comorbidity may constitute an additional anatomic risk factor in those patients currently recognized as prognostically associated to the development of SCI.

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Extravascular risk factors in the prognostic evaluation for spinal cord injury during thoraco-abdominal aortic aneurysm exclusion: a case report

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-020-01358-x ◽

2020 ◽

Vol 15 (1) ◽

Author(s):

Flavio Villani ◽

Aaron Thomas Fargion ◽

Alberto Melani ◽

Davide Esposito ◽

Rossella Di Domenico ◽

...

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Abdominal Aortic Aneurysm ◽

Aortic Aneurysm ◽

Endovascular Repair ◽

Aortic Aneurysms ◽

Abdominal Aortic ◽

Cord Injury ◽

Lumbar Spinal ◽

Patient At Risk

Abstract Background The etiology of delayed-onset spinal cord injury (SCI) following endovascular repair of thoraco-abdominal aortic aneurysms (TAAA) is still unclear and may be related to multiple factors. Extravascular factors, such as lumbar spinal stenosis (LSS), may play a significant role in the selection of patient at risk of SCI. In this report we describe a case of paraplegia following thoracic endovascular aortic repair (TEVAR) in a patient suffering from severe and symptomatic LSS and undergoing staged endovascular repair of a TAAA. Case presentation A 70-year-old man was admitted to our department with an asymptomatic type III TAAA in previous open repair for abdominal aortic aneurysm. The patient complained of buttock and thigh claudication in the absence of defects in the pelvic perfusion; a spinal magnetic resonance angiography (MRA) showed a severe narrowing of the lumbar canal.. After 24 h from first-step procedure (TEVAR) paraplegia was detected. A cerebrospinal fluid (CSF) drainage was then placed with incomplete recovery. Conclusions Stenotic damage to the spinal cord is thought to be the result of direct compression of the neural elements and ischemic disruption of arterial and venous structures surrounding the spinal cord. This comorbidity may constitute an additional anatomic risk factor in those patients currently recognized as prognostically associated to the development of SCI.

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Extravascular risk factors in the prognostic evaluation for spinal cord injury during thoraco-abdominal aortic aneurysm exclusion: a case report.

10.21203/rs.3.rs-53569/v2 ◽

2020 ◽

Author(s):

Flavio Villani ◽

Aaron Thomas Fargion ◽

Alberto Melani ◽

Davide Esposito ◽

Rossella Di Domenico ◽

...

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Abdominal Aortic Aneurysm ◽

Aortic Aneurysm ◽

Endovascular Repair ◽

Aortic Aneurysms ◽

Abdominal Aortic ◽

Cord Injury ◽

Lumbar Spinal ◽

Patient At Risk

Abstract Background: The etiology of delayed-onset spinal cord injury (SCI) following endovascular repair of thoraco-abdominal aortic aneurysms (TAAA) is still unclear and may be related to multiple factors. Extravascular factors, such as lumbar spinal stenosis (LSS), may play a significant role in the selection of patient at risk of SCI. In this report we describe a case of paraplegia following thoracic endovascular aortic repair (TEVAR) in a patient suffering from severe and symptomatic LSS and undergoing staged endovascular repair of a TAAA. Case presentation : A 70-year-old man was admitted to our department with an asymptomatic type III TAAA in previous open repair for abdominal aortic aneurysm. The patient complained of buttock and thigh claudication in the absence of defects in the pelvic perfusion; a spinal magnetic resonance angiography (MRA) showed a severe narrowing of the lumbar canal. After 24 hours from first-step procedure (TEVAR) paraplegia was detected. A cerebrospinal fluid (CSF) drainage was then placed with incomplete recovery. Conclusions : Stenotic damage to the spinal cord is thought to be the result of direct compression of the neural elements and ischemic disruption of arterial and venous structures surrounding the spinal cord. This comorbidity may constitute an additional anatomic risk factor in those patients currently recognized as prognostically associated to the development of SCI.

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Optimization of the decision-making process for the selection of therapeutics to undergo clinical testing for spinal cord injury in the North American Clinical Trials Network

Journal of Neurosurgery Spine ◽

10.3171/2012.5.aospine1289 ◽

2012 ◽

Vol 17 (Suppl1) ◽

pp. 94-101 ◽

Cited By ~ 9

Author(s):

James Guest ◽

James S. Harrop ◽

Bizhan Aarabi ◽

Robert G. Grossman ◽

James W. Fawcett ◽

...

Keyword(s):

Clinical Trial ◽

Decision Making ◽

Spinal Cord ◽

Spinal Cord Injury ◽

Clinical Trials ◽

North American ◽

Clinical Testing ◽

Data Set ◽

The North ◽

Cord Injury

The North American Clinical Trials Network (NACTN) includes 9 clinical centers funded by the US Department of Defense and the Christopher Reeve Paralysis Foundation. Its purpose is to accelerate clinical testing of promising therapeutics in spinal cord injury (SCI) through the development of a robust interactive infrastructure. This structure includes key committees that serve to provide longitudinal guidance to the Network. These committees include the Executive, Data Management, and Neurological Outcome Assessments Committees, and the Therapeutic Selection Committee (TSC), which is the subject of this manuscript. The NACTN brings unique elements to the SCI field. The Network's stability is not restricted to a single clinical trial. Network members have diverse expertise and include experts in clinical care, clinical trial design and methodology, pharmacology, preclinical and clinical research, and advanced rehabilitation techniques. Frequent systematic communication is assigned a high value, as is democratic process, fairness and efficiency of decision making, and resource allocation. This article focuses on how decision making occurs within the TSC to rank alternative therapeutics according to 2 main variables: quality of the preclinical data set, and fit with the Network's aims and capabilities. This selection process is important because if the Network's resources are committed to a therapeutic, alternatives cannot be pursued. A proposed methodology includes a multicriteria decision analysis that uses a Multi-Attribute Global Inference of Quality matrix to quantify the process. To rank therapeutics, the TSC uses a series of consensus steps designed to reduce individual and group bias and limit subjectivity. Given the difficulties encountered by industry in completing clinical trials in SCI, stable collaborative not-for-profit consortia, such as the NACTN, may be essential to clinical progress in SCI. The evolution of the NACTN also offers substantial opportunity to refine decision making and group dynamics. Making the best possible decisions concerning therapeutics selection for trial testing is a cornerstone of the Network's function.

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North American Clinical Trials Network for the Treatment of Spinal Cord Injury: goals and progress

Journal of Neurosurgery Spine ◽

10.3171/2012.4.aospine1294 ◽

2012 ◽

Vol 17 (Suppl1) ◽

pp. 6-10 ◽

Cited By ~ 19

Author(s):

Robert G. Grossman ◽

Elizabeth G. Toups ◽

Ralph F. Frankowski ◽

Keith D. Burau ◽

Susan Howley

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Clinical Trials ◽

Phase I ◽

Data Management ◽

North American ◽

Conducting Phase ◽

The North ◽

Number Of Patients ◽

Cord Injury

The North American Clinical Trials Network (NACTN) for the Treatment of Spinal Cord Injury is a consortium of 10 neurosurgery departments, a data management center, and a pharmacological center. The NACTN was established with the goal of bringing recent molecular and cell-based discoveries in neuroprotection and regeneration from the laboratory into clinical trials that optimize meaningful data outcomes and maximum safety to patients. The requirements of planning and executing clinical trials in spinal cord injury (SCI) and the steps that the NACTN has taken to address these requirements are discussed and illustrated in articles in this issue of the Journal of Neurosurgery: Spine. The progress that the NACTN has made in meeting these goals can be summarized as organizing a network of hospitals capable of enrolling a sufficient number of patients for conducting Phase I and II trials; creating a Data Management Center and a database of the natural history of recovery after SCI (at the time of this writing 485 patients were enrolled in the database); creating a database of the incidence and severity of complications that occur during acute and subacute treatment after SCI; developing a Pharmacological Center capable of performing pharmacokinetic and pharmacodynamic studies of therapeutic drugs; completing enrollment of 36 patients in NACTN's first clinical trial, a Phase I study of riluzole, a neuroprotective drug; and performing pharmacokinetic and pharmacodynamic studies of riluzole in acute SCI.

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PVSS11. Outcomes of Ischemic Colitis after Hybrid Endovascular Repair of Complex Aortic Aneurysms in the North American Complex Abdominal Aortic Debranching (NACAAD) Registry

Journal of Vascular Surgery ◽

10.1016/j.jvs.2012.03.052 ◽

2012 ◽

Vol 55 (6) ◽

pp. 9S

Author(s):

Carlos H. Timaran ◽

Gustavo S. Oderich ◽

Mark A. Farber ◽

William Quinones-Baldrich ◽

Peter Gloviczki ◽

...

Keyword(s):

Endovascular Repair ◽

Ischemic Colitis ◽

North American ◽

Aortic Aneurysms ◽

The North ◽

Abdominal Aortic

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Minimally Invasive Segmental Artery Occlusion Prior to Endovascular Repair of Thoraco-Abdominal Aortic Aneurysm to Reduce the Risk of Spinal Cord Injury

European Journal of Vascular and Endovascular Surgery ◽

10.1016/j.ejvs.2019.06.605 ◽

2019 ◽

Vol 58 (6) ◽

pp. e79

Author(s):

Daniela Branzan ◽

Christian Etz ◽

Moche Michael ◽

Holger Staab ◽

Konstantin Von Aspern ◽

...

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Abdominal Aortic Aneurysm ◽

Aortic Aneurysm ◽

Minimally Invasive ◽

Endovascular Repair ◽

Artery Occlusion ◽

Segmental Artery ◽

Abdominal Aortic ◽

Cord Injury

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Endovascular repair and open repair surgery of thoraco-abdominal aortic aneurysms cause drastically different types of spinal cord injury

Scientific Reports ◽

10.1038/s41598-021-87324-6 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Hamdy Awad ◽

Esmerina Tili ◽

Gerard Nuovo ◽

Hesham Kelani ◽

Mohamed Ehab Ramadan ◽

...

Keyword(s):

Spinal Cord ◽

Endovascular Repair ◽

Open Repair ◽

Abdominal Aortic Aneurysms ◽

Dorsal Column ◽

Aortic Aneurysms ◽

Medial Lemniscus ◽

Metabolome Analysis ◽

Abdominal Aortic ◽

Cord Injury

AbstractBoth endovascular repair (EVR) and open repair (OR) surgery of thoraco-abdominal aortic aneurysms cause spinal cord (SC) injury that can lead to paraparesis or paraplegia. It has been assumed that mechanisms responsible for SC damage after EVR are similar to those after OR. This pilot study compared the pathophysiology of SC injury after EVR versus OR using a newly developed EVR dog model. An increasing number of stents similar to those used in patients were inserted in the aorta of three dogs to ensure thoracic or thoracic plus lumbar coverage. The aorta of OR dogs was cross-clamped for 45 min. Behavior assessment demonstrated unique patterns of proprioceptive ataxia and evolving paraparesis in EVR versus irreversible paraplegia in OR. MRI showed posterior signal in lumbar SC after EVR versus central cord edema after OR. Histopathology showed white matter edema in L3–L5 localized to the dorsal column medial lemniscus area associated with loss of myelin basic protein but not neurons after EVR, versus massive neuronal loss in the gray matter in L3–L5 after OR. Metabolome analysis demonstrates a distinctive chemical fingerprint of cellular processes in both interventions. Our results call for the development of new therapeutics tailored to these distinct pathophysiologic findings.

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