NEUROLOGICAL MONITORING DURING TOTAL AORTIC ARCH DEBRANCHING AND ANEURYSM EXCLUSION: THE SUBCLAVIAN DEBATE

Objective: to report on the safety and reliability of a strict neurological monitoring protocol in patients submitted to total aortic arch debranching and aneurysm exclusion. Methods: All seven patients were submitted to total aortic arch debranching followed by aortic arch aneurysm exclusion in two staged procedures. Bilateral middle cerebral artery-mean velocity (MCA-MV) was monitored during the open surgical procedure by transcranial-Doppler (TCD). Cerebral spinal fluid (CSF) pressure was monitored throughout the entire TEVAR procedure and up to 48 postoperative hours. Death, spinal cord ischemia, stroke/TIA rates were recorded perioperatively. Endoleak occurrence, endograft integrity and supraortic by-passes patency were detected by CT scans at 1, 12 months and annually thereafter. Results: In all patients an aortic-innominate-carotid by-pass was performed, preceded by a left carotid-subclavian by-pass in all but 1 patients. Proximal landing zone was in “zone 0” and distal landing zone never exceeded T8. CSF pressure was maintained <10 cm/H2O. A carotid shunt was implanted when MCA-MV on the clamped side was <12 cm/sec. No death or stroke/TIA was recorded. Neurological complication rate was 14%: in 1 patient without revascularization of the left subclavian artery, a mean CSF drainage of 250 cc/die was performed but a perioperative total paraplegia occurred. Mean follow-up was 17±6 months. In 6 patients no neurological complication, no endoleaks or endograft-related complications and no supraortic by-passes occlusion were observed perioperatively or at follow-up. Conclusions: In total aortic debranching left subclavian artery revascularization seems essential to provide an adequate spinal vascularization. Strict neurological monitoring is able to detect early signs of ischemia.