On neurological complications and innovations in endovascular aortic surgery

Diseases of the aorta, most commonly aneurysms and dissections, have historically been treated with open technique. Endovascular aortic repair has, in recent years, replaced open repair as the gold standard for aortic diseases, resulting in decreased patient morbidity and mortality. The endovascular field is constantly evolving, with novel devices and methods regularly introduced to push the threshold of what is treatable while simultaneously reducing procedural risk. Despite this, emergent, complex aortic diseases continue to be a technically challenging problem to solve in the operating theatre and endovascular procedures are still not without risks. The most notable are risks involving the neurological system, stroke, and spinal cord ischemia (SCI). These complications can be devastating and often highly disabling for the patient. The aim of this PhD was, therefore, to examine the relevance, incidence, consequences and treatment options of neurological complications in endovascular aortic repair and to explore novel methods that could facilitate the use of endovascular aortic repair in emergent, complex aortic diseases. In paper I, we explored the association between spinal fluid biomarkers and endovascular aortic repair, where the spinal cord perfusion is affected due to the aortic coverage that occurs after stent graft deployment. Paper II explored the viability of prophylactic, volume-based cerebrospinal fluid drainage, an established method for reversing spinal cord ischemia (SCI). In Paper III, we explored the incidence of perioperative stroke in endovascular aortic repair based on the proximal aortic landing zone nationally. Additionally, we examined the effect of these perioperative strokes on long-term survival. In paper IV, we designed a novel stent graft for deployment in emergent, complex aortic repair. Finally, paper V examined the technical viability and mid-term outcomes of in-situ laser fenestration. This method can be deployed in emergent aortic repair in combination with the novel stent graft design from Study IV.