CSF Drainage in TEVARAnesthetic Considerations
Dr. Gregory Hans
CHU of Liege
Disclosure of Interest
None
Plan
• Epidemiology of SCI in TEVAR
• Pathophysiology of SCI and CSF drainage
• Evidence and Guidelines
• Risks of CSF drainage
• Tips and tricks
Epidemiology
Etz CD et al. Eur J Cardiothorac Surg 2015;47:943-957.
Epidemiology
• Risk factors for SCI after TEVAR
– Extent of the repair
– PAD or previous aortic surgery
– Preoperative CKD
Consequences
Conrad MF et al. J Vasc Surg 2008;48:47-53.
Can CSF drainage help ?
SCPP = MAP – (CSFP or CVP)
Etz CD et al. Eur J Cardiothorac Surg 2015;47:943-957.
1. No proximal cross clamp
2. Permanent sacrifice of segmental arteries
Isaak, R. S. J Cardiothorac Vasc Anesth. 2015.
Bajwa, A. Eur J Vasc Endovasc Surg.
2008
Azevedo Mendes, M., J Cardiothorac Vasc Anesth.
2015
Xue, L., et al. Chin Med J (Engl). 2013.
Etz, C. D. J Thorac Cardiovasc Surg. 2011.
Wong CS et al., J Vasc Surg, 2012
Hnath JC et al., J Vasc Surg, 2008
0 % 8 %
Guidelines
Erbel, R., Eur Heart J. 2014.
Risks of CSF drainage
1-3 %
• Intracranial hemorrhage
• “Spinal” hematoma
• Meningitis
5-10 %
• Post-puncture headache
• Skin infection
• Catheter fracture
• Cranial nerve palsy
Wynn MM et al., J Vasc Surg, 2009
Leyvi G et al., J Cardiothorac Vasc Anesth,
2005
Conclusions• When ?
– Therapeutically: all episodes of SCI following TEVAR
– Prophylactically in high risk patients ?
• How ?
– Guidelines for regional anesthesia in anticoagulated patients
– Pressure transducers at the level of the RA
– Continuous reading, drain for CSF≤15 mmHg
– MAP and CVP reading and optimization
• How long ?
– 48-72 hours
– 24 hours of close monitoring following drain removal