Emergency endovascular treatment for ruptured abdominal aortic aneurysm and the risk of spinal cord ischemia

Article Outline

• Abstract
• Material and methods
• Results
  • Patient details and treatment outcome
  • Patients with paraplegia
• Discussion
• Conclusion
• References
• Copyright

Background

Spinal cord ischemia is a rare complication after open surgical repair for ruptured abdominal aortic aneurysms (rAAA). The use of emergency endovascular aortic aneurysm repair (eEVAR) is increasing, and paraplegia has been observed in a few patients. The objective of this study was to assess the incidence and pathogenesis of spinal cord ischemia after eEVAR in greater detail.

Methods

This was a retrospective analysis of patients who had eEVAR for rAAA in three hospitals in The Netherlands and Belgium during a 3-year study period that ended in February 2004. The use of aortouniiliac devices combined with a femorofemoral crossover bypass was the preferred technique. Patients with postoperative symptoms of spinal cord ischemia were identified and the influence of potential risk factors was assessed. These factors included the presence of common iliac artery aneurysms necessitating device limb extension to the external iliac artery with associated overlapping the hypogastric artery, the prolonged interruption of bilateral hypogastric artery arterial inflow during the procedure (defined “functional aortic occlusion time” >30 minutes), and the occurrence of preoperative hemodynamic shock.

Results

Thirty-five patients were treated by EVAR and they constituted the study group. The first-month mortality in the study group with EVAR was 23%. Four patients (11.5%) with EVAR developed paraplegia postoperatively; the unilateral or bilateral hypogastric artery in all four patients became occluded during the procedure. In the other 31 patients who did not have paraplegia, the unilateral or bilateral hypogastric arteries became occluded in 14 patients (45%). This constituted a significant difference in the prevalence of hypogastric artery occlusion in patients with or without paraplegia (P = .04). The functional aortic occlusion time was prolonged in all four patients with paraplegia and in five without spinal cord ischemia (P = .0003). All four patients with spinal cord ischemia presented with hemodynamic shock. This factor did not reach a significant difference from nonparaplegic patients.

Conclusion

Emergency EVAR continues to be a promising approach to reduce the high mortality of rAAA, but the incidence of spinal cord ischemia after endovascular treatment of rAAA was worrisome. Although the pathogenesis is most likely multifactorial, interruption of the hypogastric artery inflow appeared to have significant influence. In patients with aneurysmatic common iliac arteries, any effort should be made to minimize hypogastric occlusion time during the procedure and to maintain hypogastric artery inflow afterwards, either by the use of a bell-bottom iliac extension or by electing open repair.

Endovascular repair is increasingly used as an alternative to open surgical repair of ruptured abdominal aortic aneurysms (rAAAs). Emergency endovascular aneurysm repair (eEVAR) keeps the promise that it is associated with lower operative mortality and morbidity than open surgery. A reduction in blood loss and length of intensive care unit stay has been observed in a number of nonrandomized clinical studies. The operative mortality in these studies varied between 0% to 25%,¹, ², ³, ⁴, ⁵, ⁶, ⁷, ⁸, ⁹, ¹⁰ which compares favorably with the mortality rate of 40% to 50% that is usually reported for patients treated by open surgery.¹¹, ¹², ¹³ However, the clinical experience until to date is limited, and published series included only four to 37 patients.

Despite a favorable initial experience, several issues associated with eEVAR have not been fully assessed. For instance, the risk of branch ischemia affecting the bowel, the lower limbs, and the spinal cord may be different from acute surgical repair of the aneurysm. Of these events, spinal cord ischemia is a rare complication in series with open repair of rAAA, with an incidence varying from 1% to 2.8%.¹¹, ¹², ¹³ Until recently, paraplegia after emergency endovascular treatment has only been reported in a single case.¹⁴ We recently observed this complication in a few additional patients, and this caused us to assess the incidence, risk factors, and consequences of spinal cord ischemia after eEVAR. In the present report, we have reviewed the 30-day outcome of eEVAR experiences from three institutions. The previously reported case is included in the present series.

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Material and methods 

The experience with eEVAR was prospectively recorded in three hospitals in The Netherlands and Belgium. These institutions were Catharina Hospital, Eindhoven, and Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands, and University Hospital, Gent, Belgium. In this report, hospitals will be indicated by the name of their city. The clinical information was collected and entered in a database to be assessed retrospectively as a combined patient series. The inclusion period in Eindhoven was from May 2001 until February 2004; in Amsterdam, from January 2003 until February 2004; and in Gent, from February 1997 until February 2004.

Selection criteria of patients for eEVAR differed between hospitals. Preferential treatment of patients by eEVAR was used in Eindhoven¹⁵ and Amsterdam. In these centers, the anatomic suitability for EVAR was the primary determinant for stent-graft repair. In Gent, selection for eEVAR was based on available staff and time of presentation in addition to a suitable anatomy. Only patients that were actually operated were taken into account. Patients who died before the operation started were excluded, as were patients with previous endovascular or open aortic procedures and those with suprarenal or thoracoabdominal ruptured aneurysms and dissections.

The written protocols in the three centers were that upon the patient’s arrival in the emergency department, the intravenous fluid infusion rate was minimized and an emergency computed tomography (CT) examination was performed. For the diagnosis of a rAAA, the preoperative CT examination was required to demonstrate extravasation of blood. Diameter and length of the infrarenal neck of the aneurysm were measured, and the decision on whether endovascular repair was feasible was made and communicated with the operating room staff. After the CT examination, patients were quickly transported to the operating room for the selected emergency procedure.

In endovascularly treated patients, the preferred operative technique in rAAA consisted of an aortouniiliac (AUI) graft. The reasons for this preference, which are shared with other groups, have been described previously. This main arguments include a greater application rate of the stent-graft technique because of fewer anatomic restrictions and a quicker decompression of the bleeding aneurysm.¹, ², ⁷, ⁸, ¹⁵ AUI endografting was combined with a crossover bypass. Standard emergency sets of AUI stent grafts and distal extender iliac device limbs (Talent, Medtronic, Santa Rosa, Calif) were permanently available in the three centers.

Emergency EVAR commenced under local anesthesia of the groin at the selected access side. The rational for using local anesthesia in the initial part of the procedure has been described previously by our group and by others.¹⁵, ¹⁶ The main purpose is to avoid a severe circulatory collapse associated with the induction of general anesthesia in the patient with extensive retroperitoneal blood loss.¹⁷

After introduction of an angiography catheter, the renal arteries were visualized, delineated, and marked on the fluoroscopy screen. This was used as a guide to deploy the proximal part of the AUI set. Next, the distal component of the stent graft to the selected iliac artery was positioned and deployed. Sealing within the common iliac arteries was preferred. However, in case of a common iliac artery aneurysm, the external iliac was the landing site and the hypogastric artery (HA) inflow was inevitably sacrificed in this process. Occasionally HA coiling was used for obliteration and prevention of type II endoleaks, but most frequently this was done by ligature, or no coiling was performed.

At this point of the procedure, general anesthesia was induced and the contralateral common femoral artery exposed. This artery was used for introduction of the occluder device into the common iliac artery. The operation was completed by performing a crossover femorofemoral bypass. A completion angiogram was used to check for endoleaks.

Patients who demonstrated symptoms of spinal cord ischemia after the eEVAR procedure were examined by neurologists. Their consultation notes were used to classify the neurologic status of the patients according to the categories described by Gloviczki et al.¹⁸ In this classification, type I involves complete infarction of the distal spinal cord, type II is also known as the anterior spinal artery syndrome in which proprioception is saved, and types III to VI represent different patterns of infarction of lumbosacral nerve roots and segmental or patchy infarctions of the spinal cord.

Several factors were examined for correlation with the occurrence of postoperative development of spinal cord ischemia:

After a number of subsequent operative steps, including exposure of the contralateral the common femoral artery, deployment of the occluder plug, and construction of the femorofemoral bypass, the retrograde flow to the contralateral HA is established and pelvic ischemia is terminated. Prolonged functional aortic occlusion time was arbitrarily defined as an interruption of inflow to both HAs of >30 minutes.

Statistical analysis was performed using SPSS version 9.0 software (SPSS Inc, Chicago Ill) for Windows (Microsoft, Redmond, Wash). The χ², Fisher’s exact, and Mann-Whitney U tests were used as appropriate, depending on whether the variables were discrete or continuous and on group size. Variables were presented as means and ranges. P < .05 was considered significant.

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Results 

Patient details and treatment outcome 

Thirty-five patients with rAAA were treated by eEVAR and constituted the study group. This group consisted of 31 men and four women with a median age of 73 years (53 to 89 years). Patients’ ages were comparable in the three participating institutions, and men predominated (Table I). The study group of 35 was part of an overall group of 101 patients treated for rAAA during the study period, for an eEVAR in rAAA application rate of 35%. This rate varied considerably between institutions. In Eindhoven, 22 of 39 patients underwent eEVAR for a 56% application rate of eEVAR in rAAA; in Amsterdam, it was four (36%) of 11 patients; and in Gent, it was nine (18%) of 51 patients. The 66 patients who did not receive eEVAR were treated by open surgery.

Table I. Patient characteristics of the study group

	Total	Eindhoven	Gent	Amsterdam
Patients	35	22	9	4
Male/female	31/4	18/4	9/0	4/0
Age (y) median (range)	73(53-89)	75(61-88)	70(53-89)	74(72-77)
Hospital stay days, median (range)	10(0-82)	14(0-82)	15(5-62)	10(6-33)
Severe morbidity of survivors (%)	10(37)	6(35)	2(22)	2(50)
First month mortality (%)	8(23)	6(27)	2(22)	0(0)

Figures represent number of patients unless indicated otherwise.

The mean length of hospital stay in the study group was 10 days (0 to 82 days). The 30-day mortality was 23% (8 patients). In comparison, the first-month mortality in the patients with open surgery was 29% (19 patients). There was no difference in the 30-day mortality, severe morbidity, and length of hospital stay in EVAR-treated patients among the institutions (Table I). The causes of death in the study group included continued hemorrhage, bowel ischemia, and multiorgan failure. Ten of the surviving patients (37%) had the following severe postoperative complications: pneumonia (3 patients), myocardial infarction or congestive heart failure (3 patients), cerebrovascular accidents (1 patient), and other adverse events (3 patients). Four patients (11.5%) had postoperative paraplegia, and these patients will be discussed in detail in the next section.

Preoperative hemodynamic shock was present in 20 patients (57%) in the study group. AUI endografts were used in 32 patients (91%). HAs were postoperatively occluded in 18 patients (51%) because of overlapping by the distal device component (Table II). In all cases, this was necessitated by aneurysmatic dilatation of the common iliac arteries >28 mm, except in one patient in whom HA ligation was required because of iliac artery kinking (see next section). In one patient with bilateral HAs overlapping a bypass, revascularization was performed during the initial procedure to both HAs. This patient was counted in the analysis as having open HAs. The functional aortic occlusion time was prolonged in the nine patients (26%) who had ipsilateral HA overlapping (mean, 52; range, 38 to 70 minutes).

Table II. Postoperative patency of hypogastric arteries

HA, hypogastric artery.

Patients with paraplegia 

In four (11.5%) of the 35 patients, paraplegia developed 10 to 96 hours after the procedure. No patients with open repair during the study period had symptoms of spinal cord ischemia (P = .13). In three of the patients with spinal cord ischemia, spinal fluid drainage was instituted (Table III). Partial neurologic improvement in sensory function and rectal tone was observed in one patient after spinal fluid drainage. The spinal cord ischemia was classified as type I in two patients and as type II in the other two. Two of the patients with spinal cord ischemia died within the first month from multiorgan failure. None of the patients had symptoms of peripheral arterial emboli.

Table III. Patient characteristics of the patients with spinal cord ischemia

Patient	Age	AAA	Lowest RR systolic	Hypogastric arteries	Type II endoleak	Spinal tap procedure	Classification of SCI (type)	Neurologic improvement	Outcome
A	77 y	7.7cm	55 mm Hg	Bilateral occluded⁎	Yes	Yes	I	No	Survived
B	84 y	7.5cm	65 mm Hg	Ipsilateral occluded	No	Yes	I	Yes	Survived
C	71 y	5.5cm†	55 mm Hg	Ipsilateral occluded	Yes	Yes	II	No	Died‡
D	70 y	11.7cm	55 mm Hg	Bilateral occluded	No	No	II	No	Died§

SCI, Spinal cord ischemia.

Three patients with spinal cord ischemia had AAA diameters of 75 to 117 mm, and one patient had an iliac aneurysm of 55 mm in diameter. All four patients had hemodynamic shock preoperatively, were treated with an AUI device, and had either an ipsilateral or bilateral HA occlusion during the procedure (Table II, Table III). In one patient, the occlusion of the ipsilateral HA resulted from ligation and division of this artery that had been performed to resolve a severe kinking and obstruction of the stented iliac artery (Fig 2).

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• Fig 2. 

  A, Same patient as in Fig 1. Preoperative computed tomography examination demonstrated on the right side severe iliac kinking at the hypogastric artery origin. External iliac artery indicated by a white arrow and the hypogastric artery by an open arrow. B, Schematic visualization of the mechanism of severe kinking of iliac artery causing an occlusion of aortouniiliac stent graft. Large arrow indicates obstructed stent-graft outflow. Small arrows indicate site of aneurysm rupture. C, When the right hypogastric artery was ligated (indicated by arrow), the kinking was relieved and flow to the extremity was re-established; however, this patient became paraplegic after the procedure.

Correlation of several risk factors demonstrated that HA occlusion and prolonged functional aortic occlusion time were the only significant variables associated with spinal cord ischemia (P = .04 and P = .0003, respectively) (Table IV). Statistical correlation with unilateral or bilateral HA occlusion and with occlusion ipsilateral or contralateral to an AUI endograft demonstrated no significant differences, perhaps because of the small size of these subgroups. In patients without spinal cord ischemia, preoperative shock was observed in 52%, 90% were treated with an AUI device, and 10% had coexistent occurrence of colon ischemia. These three variables had no significant correlation with paraplegia. Consequences of spinal cord ischemia involved a higher risk of postoperative death (50% vs 19% of patients without this complication, P = .04).

Table IV. Univariate correlation of clinical variables and spinal cord ischemia

	All patients N = 35 (%)	Without SCI N = 31 (%)	With SCI N = 4 (%)	P
Preoperative hemodynamic shock(systolic BP <90 mm Hg)	20(57)	16(52)	4(100)	.18
Prolonged functional aorta occlusion time (>30 min bilateral HA flow interruption)	9(26)	5(16)	4(100)	.0003
HA blockage (any)	18(51)	14(45)	4(100)	.04
HA occlusion by overlapping stent graft	4(11)	2(6)	2(50)	.31
HA occlusion on site of occluder plug in case of AUI device	9(26)	9(29)	—	.30
Bilateral HA occlusion	5(14)	3(10)	2(50)	.89
Colon ischemia	3(9)	3(10)	—	.7
Use of AUI endografts	32(91)	28(90)	4(100)	.9

SCI, Spinal cord ischemia; BP, blood pressure; AUI, aortouniiliac; HA, hypogastric artery.

Data are given as number (percentage) of patients in each group unless stated otherwise

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Discussion 

The first-month mortality of 23% in this series of patients with endovascular treatment of their rAAA was in agreement with the mortality rates observed in previous studies on eEVAR¹, ², ³, ⁴, ⁵, ⁶, ⁷, ⁸, ⁹, ¹⁰ and compared favorably with the results of open surgery. However, in the patients receiving open surgery during the study period in the three participating institutions, a comparable mortality of 29% was observed. Because the present series, similar to any of the previous studies on eEVAR, was retrospective in design, one may conclude that the outcomes of prospective randomized studies need to be awaited before a better comparison of the mortality rates can be made. Meanwhile, the evolving clinical experience allows us to study the pattern of complications in patients receiving eEVAR.

Paraplegia is a severe complication of aortic surgery with the highest incidence after surgical repair of thoracoabdominal aneurysms, in particular those with Crawford’s classification II and III.¹⁹ Ischemic neurologic injury to the spinal cord or the lumbo-sacral plexus after operations on the abdominal aorta is reportedly more frequent after surgical repair of ruptured aneurysms,²⁰ although the incidence in large series varied from only 1% to 2.8%.¹¹, ¹², ¹³

The use of endovascular techniques for the elective management of infrarenal AAA was also associated with a low incidence of spinal cord ischemia. In a study by EUROSTAR of 2862 patients, six (0.21%) developed postoperative spinal cord ischemia.²¹ A few additional reports on paraplegia after elective EVAR have meanwhile appeared.²², ²³ Only 149 patients with emergency stent-graft repair for rAAA were accounted for in the previous literature (Table V).¹, ², ³, ⁴, ⁵, ⁶, ⁷, ⁸, ⁹, ¹⁰ There were no reported patients with postoperative paraplegia in any of the previous series.

Table V. Publications on patient series with emergency endovascular repair of ruptured abdominal aortic aneurysm

AUI, Aortouniiliac device; SCI, spinal cord ischemia; NA, not applicable.

Differences in patient selection for eEVAR in these studies may preclude an accurate comparison of the incidence of spinal cord ischemic injury with the present study group. As a result of our preference to use eEVAR in all anatomically eligible patients, the present study included approximately twice as many patients with severe hypotension than any of the previous studies. In addition >50% in our series had a common iliac artery aneurysm, which constitutes an issue with important interventional complexity implications. In most of the previous studies, the occurrence or treatment of this complexity was not discussed. These aspects indicate the selection of patients with a higher-risk profile in the present series. Nevertheless, the relatively high rate of spinal cord ischemia of 11.5% was the main reason for our analysis.

In the etiology of spinal cord neurologic deficit after open abdominal aortic aneurysm procedures, the following risk factors have been indicated:

Most authorities in this field consider that spinal cord ischemia after abdominal aortic operations is likely multifactorial and may involve interference of multiple of the above etiologies.²⁴, ²⁸ The occurrence of paraplegia after implantation of endovascular aneurysm devices may be associated with somewhat different etiologic factors.

Severe hemodynamic shock with systolic blood pressures <65 mmHg was present in all four patients with paraplegia in our report. A difference with patients receiving open surgery may be the time delay to the operation because of the CT examination required for the stent-graft procedure. This may prolong the duration of shock. The average time delay may be relatively small, as CT scanning usually took <15 minutes and was performed during the preparation of an operating room. We assume that a longer hypotensive period only was of significance in conjunction with other factors.

Embolization of atheromatous debris caused by the catheter procedures or introduction of the endoluminal device may also be a potential cause of spinal cord ischemia. However, the incidence of embolism after elective EVAR is low, and in our patient group, there were no symptoms of peripheral emboli.

Aortic clamping as a technical, routine procedure in open surgery is not used in EVAR. However, in patients with common iliac aneurysms treated by endovascular implantation of an AUI stent graft, the procedure was associated with overlapping of the ipsilateral HA in nine patients (26% of the study group). Despite the advantages of the AUI technique over the bifurcated endograft, indicated in the methods section, a potential disadvantage may include a longer time period before arterial flow is reconstituted in the HA contralateral to the AUI device. This period of pelvic ischemia, which was defined as functional aortic occlusion time, is determined by the time needed to explore the contralateral groin, place the occluding plug in the contralateral iliac artery, and perform the crossover femorofemoral bypass. The mean functional aortic occlusion time was 51 minutes, which seems only slightly longer than the usual time of infrarenal aortic clamping in open surgery. Nevertheless, a prolonged functional aortic occlusion time appeared to be a significant factor to spinal cord ischemia, and we must conclude that the duration of HA inflow interruption during the procedure should be minimized.

Permanent obstruction of HA inflow appeared another significant cause of the spinal cord ischemia in our patients. In four, the ipsilateral HA became occluded, and two had also occlusion of the contralateral HA. The cause in all patients was device limb extension to exclude a common iliac artery aneurysm >28 mm, except in one patient in whom the HA was ligated to release kinking. From this series, the evidence is lacking to clearly demonstrate a greater importance of maintaining antegrade inflow of the ipsilateral HA compared with retrograde inflow of the contralateral HA in case of use of an AUI device. We did not have information on hypogastric secondary branch arteries in this series. However, previous studies have demonstrated their importance.²⁷, ²⁹

We assume that frequent occlusion of HAs using the stent-graft technique for rAAA treatment compared with open surgery may be part of the explanation of a higher prevalence of paraplegia after eEVAR in our series. Most publications on eEVAR have not indicated the rate of HA overlapping, precluding a comparison with the present series. The precise incidence of HA inflow interruption with open surgery could not be retrieved from the literature. However, this will probably be lower than with eEVAR in the present series.

It seems important to maintain hypogastric inflow in emergency endovascular management of patients with ruptured AAA. In case of aneurysmatic common iliac arteries, we now use bell-bottom iliac device limbs to land in the least aneurysmatic common iliac artery proximal to the level of the HA.³⁰ When this is not possible, as in case of bilateral extensively aneurysmatic common iliac arteries, conventional open surgery may be safer than a stent-graft procedure.

Weaknesses of this report included the retrospective nature of the study and the fact that in one of the centers, eEVAR use was partly based on logistic factors rather than on anatomic factors only.

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Conclusion 

Although eEVAR continues to be a promising approach to reduce the high mortality of rAAA, the prevalence of spinal cord ischemia after endovascular repair of rAAA combined with HA inflow interruption is worrisome. The duration of inflow interruption of the HAs during the procedure should be restricted. In the case of a common iliac aneurysm, the use of a bell-bottom iliac extension should be considered to avoid blockage of HA blood flow.

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