Role of historical and procedural staging during elective fenestrated and branched endovascular treatment of extensive thoraco-abdominal aortic aneurysms

Objectives: Procedural staging is often performed to reduce spinal cord ischemia (SCI) rates during endovascular treatment of extensive thoracoabdominal aortic aneurysms (TAAA) but its role in case of previous thoracic or infrarenal aortic repairs (historical staging) is controversial. This study aims to evaluate the SCI rates when procedural staging is routinely used and to study its potential benefits when previous aortic repairs were already performed. Methods: Data of patients treated electively with fenestrated/branched endografts (F/BEVAR) for extent I, II, III and V TAAA were retrieved from a multicenter registry (four high-volume national teaching hospitals) and analyzed. The primary endpoint was the rate of SCI and its association with preoperative and postoperative variables, including historical staging, procedural staging, and impaired collateral network (subclavian or hypogastric stenosis >75%/occlusion). Variables were defined according to Society for Vascular Surgery reporting standards. A logistic regression model with stepwise selection was used to identify predictors of SCI. Results: A total of 240 patients (76% males; median age: 73 years) were analyzed: 43 patients (18%) presented an impaired collateral network, 136 (57%) had historical staging, and 157 (65%) received a procedural staging. Preoperative spinal fluid cerebrospinal drainage was performed in 130 patients (54%). Permanent grade 3 SCI was observed in 13 patients (5%) and was negatively affected by both an impaired collateral network (OR: 17.3, 95%CI: 1.7-176, p=.016) and the presence of bilateral iliac occlusive disease (OR: 10.1, 95%CI: 1.1-98.3, p=.046). Both historical (OR: 0.02, 95%CI: 0.001-0.46, p=.014) and procedural staging (OR: 0.01, 95%CI: 0.02-0.7, p=.019) mitigated permanent SCI rates. Need for postoperative transfusions (OR: 1.4, 95%CI: 1.1-1.8, p=.014) and postoperative renal complications (OR: 6.5, 95%CI: 1.2-35.0, p<.001) were associated with SCI. Among patients with historical staging, no further benefit of procedural staging was observed (SCI in procedural staged 1% vs non-staged 2%; p=ns). Conclusion: In patients with extensive TAAA treated with F/BEVAR, both historical and planned procedural staging were associated with reduced permanent SCI rates, but no additional benefit was observed when a procedural staging was performed in patients with historical staging and intact collateral network. The protective role of preoperative cerebrospinal fluid drainage placement requires further investigations.