Trends in Use of Cerebrospinal Drains and Outcomes Related to Spinal Cord Ischemia after TEVAR and complex EVAR in the Vascular Quality Initiative.

INTRODUCTION Spinal cord ischemia (SCI) is a dreaded complication of thoracic and complex endovascular aortic repair (TEVAR/cEVAR). Controversy exists surrounding cerebrospinal fluid drain (CSFD) use, especially preoperative prophylactic placement, due to concerns regarding catheter-related complications. However, these risks are balanced by widely accepted benefits of CSFDs in open repairs to either prevent and/or rescue patients with SCI. The importance of this issue is underscored by the paucity of data on CSFD practice patterns which limits ability to develop practice guidelines. Therefore, the purpose of this analysis was to evaluate differences between patients who developed SCI despite preoperative CSFD placement compared to those treated with a therapeutic postoperative CSFD. METHODS All elective TEVAR/cEVAR procedures for degenerative aneurysm pathology in the SVS VQI from 2014-2019 were analyzed. CSFD use over time, factors associated with preoperative prophylactic vs. postoperative therapeutic drain placement in patients with SCI (transient or permanent), and outcomes were evaluated. Survival differences were estimated using Kaplan-Meier methodology. RESULTS 3,406 TEVAR/cEVAR procedures met inclusion criteria with an overall SCI rate of 2.3% (N=88). The SCI rate decreased from 4.55% in 2014 to 1.43% in 2018. Prophylactic preoperative drain use was similar over time (2014-30% vs. 2018-27%; P=.8). After further exclusions to evaluate CSFD use in those who developed SCI, 72 patients were available for analysis, 48 patients with SCI and prophylactic CSFD and 24 patients with SCI and therapeutic CSFD. Specific to SCI, patient demographics and comorbidities were not significantly different between prophylactic and therapeutic drains with the exception of prior aortic surgery history which was more common with the prophylactic CSFD cohort (46% vs. 23%; P<.001). SCI outcome was significantly worse for therapeutic drain patients as 79% had documented permanent paraplegia at discharge compared to 54% of prophylactic CSFD subjects (P=.04). SCI patients receiving a postoperative therapeutic CSFD had worse survival compared to those with a preoperative prophylactic drains (50±10% vs. 71±9%; log-rank P=.1, Wilcoxon P=.05). CONCLUSIONS Prophylactic CSFD use with TEVAR/cEVAR has remained stable over time. Among SCI patients, a postoperative therapeutic CSFD was associated with worse sustained neurologic outcome and overall survival compared to those with preoperative prophylactic drains. These findings highlight the need for a randomized clinical trial examining prophylactic vs therapeutic CSFD placement with TEVAR/cEVAR.