Safety of Prophylactic Spinal Fluid Drainage in Open and Endovascular Repair of Thoracic and Thoracoabdominal Aortic Aneurysms

Spinal cord injury remains one of the most devastating complications of thoracic and thoracoabdominal aneurysm repair, mainly associated to a compromised the Adamkiewicz artery and its collateral network. Prophylactic cerebrospinal fluid (CSF) drainage is used to reduce this risk by increasing spinal perfusion pressure.

This single-center retrospective study evaluated its safety in 1,445 patients treated between 1987 and 2023 (1,029 with open repair, 416 with endovascular approach); 1,007 of these patients received prophylactic drainage (777 open and 230 endovascular). Patient mean age was 68, and 56% were male. Before 2000, smaller-caliber catheters were used, with an average intraoperative drainage volume of 125 mL; between 2000 and 2023, drained mean volume was 132 mL in open surgery and 81 mL in endovascular repair.

The primary endpoint was incidence of neurological complications attributable to drainage, while the secondary endpoint included minor events (blood in the CSF, post-puncture headache, intracranial bleeding without neurological deficit) and frequency of transient or permanent spinal cord injury.

Drainage driven severe neurological complications were extremely rare: only 6 patients (0.6% of the total), 5 in open surgery (0.77%) and one in endovascular repair (0.43%). Recorded events included three subdural hematomas, one cerebellar hematoma, one spinal epidural hematoma, and one cerebellar hematoma associated with intraoperative hypertension. Four patients died, while the remaining two recovered completely or with mild residual ataxia.

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Among minor events, bloody CSF was observed in 20.7% of open cases and 21.7% of endovascular cases; asymptomatic intracranial blood on CT was seen in 9.9% and 6.1%, respectively; and headache requiring a blood patch was seen in 7.6% and 11.7%. As regards the most significant complication — spinal cord injury secondary to Adamkiewicz artery compromise — permanent paraplegia or tetraplegia overall incidence resulted low: 4.2% in open surgery and 1.2% in endovascular repair, while transient injuries occurred in 5.6% and 3.6%, respectively.

Conclusion 

To sum up, prophylactic CSF drainage was shown to be safe, with severe neurological complications rate below 1% and a potential benefit in post aortic repair spinal cord injury reduction, as evidenced by lower rates of paraplegia or tetraplegia vs historical reported data (up to 13% without drainage).

Original Title: A report of the safety of prophylactic spinal fluid drainage in open and endovascular thoracic and thoracoabdominal aortic aneurysm patients.

Reference: Lucas Skoda, DO; Charles Acher, MD; et al. Journal of Vascular Surgery, Volumen 82, 1549–1555, 2025.