Spinal drain for TEVAR

I had a patient come in for a 2 stage endovascular aortic repair. The patient had a 1st stage left carotid to subclavian bypass done about 3 days ago. We did a 2nd stage TEVAR for a descending aortic aneurysm. The patient did really well. Stayed in constant communication with the vascular surgeon as well as endovascular surgeon. A plan was in place. Patient was maximally beta blocked. I found dexmetetomidine to be a great drug for sedation pre-induction as well as blunting any responses to laryngoscopy during induction. Cordis for volume. Used the side port of the cordis for drips (nicardipine, phenylephrine). There were various times during the surgery where the surgeon wanted hypotension vs. hypertension. During deployment of the stent, SBP < 90. Once the stent was deployed, goal SBP 140 (MAP>90). Overall great case and great outcome for the patient.

What is a TEVAR (Thoracic EndoVascular Aortic Repair)?

• TEVAR: Endovascular Repair of the Thoracic Aorta. Semin Intervent Radiol. 2015 Sep; 32(3): 265–271.
• Society for Vascular Surgery website
• Implementation of a bundled protocol significantly reduces risk of spinal cord ischemia after branched or fenestrated endovascular aortic repair.  Journal of Vascular Surgery. Volume 67, Issue 2, February 2018, Pages 409-423.e4
• Spinal cord injury after thoracic endovascular aortic aneurysm repair.  Canadian Journal of Anesthesia/Journal canadien d’anesthésie. December 2017, Volume 64, Issue 12,pp 1218–123

Why place a spinal drain?

• Perioperative cerebrospinal fluid drainage for the prevention of spinal ischemia after endovascular aortic repair.  Gefasschirurgie. 2017; 22(Suppl 2): 35–40.
• Spinal cord protection in aortic endovascular surgery.  BJA: British Journal of Anaesthesia, Volume 117, Issue suppl_2, September 2016, Pages ii26–ii31, https://doi.org/10.1093/bja/aew217

Management of spinal drain:

• Lumbar drain management for TEVAR PPT
• Sharing of Best Practices in Managing Lumbar CSF Drains PPT
• Cerebrospinal Fluid Drainage During Thoracic Aortic Repair: Safety and Current Management. Ann Thorac Surg 2009;88:9–15.

Potential complications

• Images in Anesthesiology: Spinal Subdural Hematoma after Spinal Drain for Endovascular Thoracic Aortic Aneurysm Repair. Anesthesiology 5 2018, Vol.128, 1004.

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• YouTube: Spinal Drain insertion
• YouTube: Lumbar Drain
• YouTube: Planning a TEVAR

Key Points:

• Pre-op planning: chat with the surgeon before hand regarding a plan. Make sure the OR team understands the plan.
• Communication: before, during, after the case.
• Be vigilant about tight BP control