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Disclosures Dr. Kasprzak (grants, speaker fee, development,
Cook, Gore, Vascutek, Bard, Medtronic, Maquet, UCB
P M Kasprzak
Department of Vascular Surgery ,
Endovascular Surgery
University Hospital Regensburg, Germany
What is the benefit
of MEP´s in BEVAR for TAAA
in preventing paraplegia ?
TAAA
O´Callaghan A et al., J Vasc Surg 2015; 61:347-354.
Dias NV et al. Eur J Vasc Endovac Surg 2015; 49: 403-409.
Kasprzak PM et al. Eur J Vsc Endovasc Surg 2014: 48: 258-265.
Verhoeven ELG et al. Eur J Vasc Endovasc Surg 2015; 49: 524-531.
Bisdas T et al. J Vasc Surg 2015; 61: 1408-1416.
Risk of paraplegie in extensive
coverage of the thoracoabdominal aorta
5 - >20%
decreased perfusion of
• segmental spinal arteries
• anterior spinal artery
spinal collateral network
autoregulation
Endovascular aortic repair: TEVAR and F/BEVAR)
Etz CD et al. J Thorac Cardiovasc Surg. 2011, 141(4):1020-8.
Moritz S et al. Persp Vasc Surg Endovasc Ther 2011; 23(3) 214–222.
Spinal cord ischemia during BEVAR for TAAA
- direct occlusion of intercostal + lumbar arteries
- secondary reduction of spinal cord perfusion
by aneurysm sac thrombosis / hypotension
Chuter TA, Gordon RL, Reilly LM, Goodman JD, Messina LM.
An endovascular system for thoracoabdominal aortic aneurysm repair.
J Endovasc Ther. 2001 Feb;8(1):25-33.
Branched Stengraft
“The endograft was implanted
successfully, imaging documented
an excluded aneurysm and
excellent flow through the
endograft and all prosthetic
branches.”
…..but the patient developed
Paraplegia on day 2.
staged procedures
TEVAR firstTEVAR + BEVAR
with TASP1. surgery
fenestrated stentgraft
ev. not completed distallyTASP completion after
balloon branch occlusion
2. surgery
Completion 3. surgery?
Post-Dissection aneurysm Arteriosclerotis
FEVAR in small true lumen Aneurysm-BEVAR
Step 1:
Branched stent graft
with 1 non-completed
side branchTemporary
aneurysm sac
perfusion
TASP (temporary aneurysm sac perfusion)
Step 2:
secondary side
branch completion
TASP interval
„staged procedure“
Intention:
- maintain perfusion of spinal arteries
- to reduce the risk of SCI
- completion under stable conditions
- after expansion of the spinal collateral network
Kasprzak P et al. 2014 Eur J Vasc Endovasc Surg
Group: 83 TAAA patients after bEVAR (first patient 2008)
Temporary Aneurysm Sack Perfusion (TASP)
in BEVAR for TAAA
0
10
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11:50 12:59 14:05 14:37 15:04 15:19 15:33 15:49
RR
/TO
F
TA
R/T
AL
am
plitu
de
time
tib.ant.Re
tib.ant.Li
bic.fem.R
bic.fem.L
T1%
RR arm
RR bein
staged
procedure?
22 F Branched
Stent Graft
Balloon
Occlusion
Hypotension
Bridging Stents
or renals and
SMA
MEPs in BEVAR
Intraoperative online internet based monitoring and analysis
in cooperation with WH Mess,
Institute of Neurophysiology, University of Maastricht, NL.
Guidelines: Clin Neurophysiol 2013.
0
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9:50 11:30 13:30 13:54 14:11 14:36
RR
/TO
F
TA
R/T
AL
am
plitu
de
time
tib.ant.Retib.ant.Li
bic.fem.Rbic.fem.LT1%
Hypotension temp. SCI (reversible)
0.10
1.00
10.00
09:5011:3013:3013:5414:1114:36
rela
tive c
ha
ng
e (
log
)
time
tib…
MEPs during TEVAR and BEVAR
MEPs in BEVAR with / withoutTemporary Aneurysm Sack Perfusion - TASP
Intraoperative online internet based monitoring and analysis
in cooperation with WH Mess,
Institute of Neurophysiology, University of Maastricht, NL.
Guidelines: Clin Neurophysiol 2013.
MEPs n = 47
SCI
MEPs neg. n = 34 0 % Sensitivity 100 %
MEPs pos. n = 13 DD: spinal vs peripheral Ischemia
Action CSF , MAP Chance for recovery
• MEPs recovered 0 %
• MEPs not recovered n = 3 3 (100 %)
Problem of delayed Paraplegia
TASP interval
Step 1
Step 2
TASP
BEVAR
side branch completion
early (5-14) / late (15-28)
SCI risk evaluation low/high
MEPs (BHT-test)
BEVAR for TAAA: the TASP concept
MEPs (BHT-test)
TASPno MEPS
nonTASP+ MEPS
TASPMEPs /LABHT-test
28 8 30 (9 LA)
3 (10.7 %) 1 (12.5 %) 1 (3.3 %)
nonTASP
n 45
SCI 11 (24%)
No recommendation for
Immediate (day 0) side branch completion
(n = 111)
no BHT delayed SCI (> 24h)
Two-stages: time interval mean: 5 months (1-60 months)
2 patients ruptured (7.4 %)
open branch/
TASP concept
shorter TASP intervals
- side branch occlusion
between 5-14 daysp = 0.025
n=2
n=11 n=15
0
10
20
30
40
50
60
2007-2010 2011-2012 2013-2014
occlusion < 14 days,n=number patients
TASP range (median, days)
side br. completion < 14 days
TASP interval (median, days)
Implementation of MEPs monitoring
2007-2010 20011/2012 2014-2015
Second effect of MEP´s
1. Preoperative coiling
of the intercostal / lumbar arteries
2. FEVAR / BEVAR for TAAA
1. Staged procedure with
BEVAR + TASP + MEPs
2. Completion in LA
Pre-Conditioning (Role of Postoperative Hypotension?)
Other concept to prevent paraplegia
Staged procedure + TASP in BEVAR MISACE
Perfusion preserved but reduced
+ compensated ischemia
-> spinal preconditioning
Open branch/TASP: Perfusion or Preconditioningsp
ina
l se
gm
en
tal a
rte
rie
s(n
)
J Vasc Surg 2016 (accepted)
Universitätsklinikum Regensburg
• intraoperative MEPs analysis detects patients at risk for SCI
• uneventful MEPs allow early side branch completion
with reduction of TASP interval
• we don´t perform single stage procedures due to the problem
of secondary paraplegia (sac thrombosis)
• in staged procedures including TASP concept in BEVAR
we have achieved lowering of paraplegia rate (3,3%)
Future opportunities:
risk stratification
role of embolization of intercostal arteries is to be examined
Conclusions:
Disclosures Dr. Kasprzak (grants, speaker fee, development,
Cook, Gore, Vascutek, Bard, Medtronic, Maquet, UCB
P M Kasprzak
Department of Vascular Surgery ,
Endovascular Surgery
University Hospital Regensburg, Germany
What is the benefit
of MEP´s in BEVAR for TAAA
in preventing paraplegia ?
