Clinical Outcomes with Therapeutic Cerebrospinal Fluid Drainage for Spinal Cord Ischemia in Complex Endovascular Aortic Repair Using Fenestrated and Branched Stent-Grafts

PURPOSE: Spinal cord ischemia (SCI) remains a major concern following thoracoabdominal aortic aneurysm (TAAA) repair, even with advances in endovascular techniques. The clinical efficacy of selective therapeutic cerebrospinal fluid drainage (CSFD) over routine prophylactic strategies for managing postprocedural SCI remains to be fully elucidated. This study evaluated outcomes of fenestrated and branched endovascular aortic repair (F/B-EVAR) using the Zenith t-Branch device and assessed the neurological outcomes of therapeutic CSFD in patients who developed postoperative SCI. MATERIALS AND METHODS: A single-center retrospective observational cohort study was conducted at a tertiary academic medical center between January 2017 and January 2022, including 17 patients who underwent total endovascular repair for Crawford type I-V TAAA or pararenal AAA using the t-Branch device. The primary outcome was neurological recovery following therapeutic CSFD, assessed using the modified Tarlov scale. Secondary outcomes included technical success, in-hospital mortality, and aneurysm sac regression during follow-up. A standardized, multidisciplinary spinal cord protection protocol was followed, and therapeutic CSFD was initiated within 1 hour of confirmed SCI. RESULTS: Technical success was achieved in 59 of 62 planned target vessels (95%). Five patients (29%) developed SCI, all of whom underwent therapeutic CSFD. Median time from confirmed SCI to drain placement was 46 minutes (range 31-51). Median Tarlov scale score improved from 1 (range 0-2) at SCI onset to 4 (range 3-5) at discharge. One patient achieved complete neurological recovery (Tarlov 5); 4 had residual mild-to-moderate motor deficits. In-hospital mortality was 12% (2/17), both from nonaortic causes. During a median follow-up of 13 months (IQR 9-24), all surviving patients demonstrated aneurysm sac regression, and no secondary interventions were required. CONCLUSIONS: Therapeutic CSFD, implemented within a structured multidisciplinary protocol, was associated with neurological improvement in our small cohort, although the majority of patients retained residual mild-to-moderate deficits at discharge. These findings support a symptom-triggered, protocol-based CSFD strategy as a feasible rescue strategy that warrants cautious interpretation given its observational nature, and further validation through larger multicenter studies is required.