Spinal Cord Ischemia Prevention Through Hypogastric and Inferior Mesenteric Artery Preservation During Complex Endovascular Aortic Procedures

Objectives: Endovascular procedures have been widely accepted as safe treatment in patients with thoracoabdominal aortic aneurysms (TAAAs). Spinal cord ischemia (SCI) is the most dreaded complication. Its incidence is estimated in 3.9% of patients undergoing thoracoabomi- nal procedures. As reported in American and European guidelines, spinal fluid drainage, mean arterial pressure above 100 mm Hg, hemoglobin above 10 g/dL, transcutaneous oxygen measurement above 95%, staged procedures, and collateral networks preservation are recognized as possible preventive strategies. The aim of the study is to describe the re- sults of distal aortic collateral network preservation (internal iliac artery [IIA], inferior mesenteric artery [IMA]) with different endovascular tech- niques during elective or urgent endovascular procedures for thoracoab- dominal aortic diseases. Methods: Between December 2016 and January 2021, 50 complex aortic endovascular procedures were performed. The following inclusion criteria were identified: IIA occlusion or patent IMA with minimum diam- eter of 5 mm combined with compromised IIA patency. Nine patients matched the inclusion criteria. Staged procedures and spinal fluid drainage were employed in all elective settings (seven patients). Accord- ing to TAAA Crawford classification, 3 were type III, 2 post-dissection type II, 2 type IV, and 2 type V. Early and late mortality, aortic-related mortality, incidence of transient or permanent SCI, and target vessel patency were evaluated during follow-up. Follow-up was performed at 1, 6, and 12 months with computed tomography scan. IMA was preserved in one patient using an iliac branch proximally combined with a branched stent graft. In the second case, a parallel graft technique was employed, whereas in the third patient, a bell bottom graft was deployed above the IMA ostium. In five patients, at least one of the two IIA was recanal- ized using a parallel grafts technique, whereas in one patient, an iliac branch was implanted. Results: None of our patients experienced SCI. One of the two patients treated in the urgent setting died from cardiorespiratory complications 1 week after the procedure. Among the patients treated in the elective setting, no complications were observed. At follow-up, 100% target vessel patency was detected. Conclusions: According to our data, prevention of SCI through distal aortic collateral network preservation is safe and feasible in both the ur- gent and elective settings. This strategy may be an ulterior tool to pre- vent SCI