Lumbar Drains for Vascular Procedures: An Institutional Protocol Review and Guidelines

doi:10.1016/j.wneu.2021.01.068

World Neurosurgery

Volume 149, May 2021, Pages e947-e957

https://doi.org/10.1016/j.wneu.2021.01.068 Get rights and content

Background

Aortic disease requiring open or endovascular repair may result in spinal cord injury in approximately 2%–10% of patients. Cerebrospinal fluid diversion using lumbar drains (LDs) has been validated as a protective measure to mitigate this complication.

Methods

This single-institution retrospective study analyzed the implementation of a standardized protocol and subsequent educational intervention for LDs for aortic vascular procedures over a 4-year period.

Results

In 2016–2019, 45 patients had LDs placed for open or endovascular procedures; group 1 included 19 patients with LDs placed before protocol implementation, and group 2 included 26 patients with LDs placed as per the institutional protocol. Demographics and procedural details in both groups were similar. However, there was a significant difference in the number of patients who had emergent versus planned placement of the LD (group 1, 89.5%; group 2, 50%; P < 0.01), volume of cerebrospinal fluid drained (group 1, 453 mL; group 2, 197 mL; P < 0.01), and compliance with 10 mL/hour drainage recommendation (group 1, 68.4%; group 2, 100%; P < 0.01). In group 1, 5 (31.6%) patients experienced neurological complications compared with only 1 (3.8%) in group 2. LD-related complications occurred 3 patients (15.8%) in group 1, whereas none occurred in group 2. Survey results suggested increased health care worker protocol familiarity with educational interventions.

Conclusions

Implementation of an institutional protocol for LDs for open or endovascular procedures is feasible and beneficial. Educational modules improve familiarity among all health care providers, which can improve patient care and complication avoidance.

Introduction

Spinal cord injury secondary to open or endovascular thoracoabdominal and abdominal aortic aneurysm repair can result in paraparesis or paralysis in 2%–10% of patients.¹ Spinal ischemia in vascular procedures is multifactorial in nature. Many factors may contribute to microvascular collapse and diminished spinal cord perfusion, including factors such as the patient's underlying vasculature and pathology; intraoperative hemodynamic factors such as hypotension or blood flow interruption owing to occlusion of radiculomedullary or reticulospinal vessels; and postoperative factors such as hypotension, anemia, or excess cerebrospinal pressures.¹^,² Spinal cord ischemia may result in paraparesis or paraplegia, loss of sensory function, or compromise of bowel and bladder function.³^,⁴ Techniques to minimize the risk of spinal cord ischemia during these procedures have received considerable attention and include reduced aortic cross-clamping or vascular bypass procedures, pharmacologic protection, hypothermia, and augmentation of the mean arterial pressure (MAP). In addition, cerebrospinal fluid (CSF) diversion via the use of a lumbar drain (LD) is reported to have a salutary effect on spinal cord perfusion.⁵

Hemodynamic changes associated with cross-clamping of the aorta during surgery result in a dramatic decrease in spinal cord perfusion pressure (SCPP) distal to the clamp site. Placement of an LD allows for CSF drainage that can decrease intraspinal pressure and increase blood flow to the spinal cord, thus reducing the risk of spinal cord injury.6, 7, 8, 9 Although ubiquitously used, LD protocols for vascular procedures are not standardized.⁴^,⁶^,10, 11, 12 As a result, parameters for placement of an LD and management of CSF drainage may vary among institutions. Lumbar CSF drainage is not without complications, particularly in patients who have vascular comorbidities and who may be therapeutically anticoagulated or be receiving antiplatelet agents. Hence, careful standardization of the preprocedural checklist, performance of the procedure, intraoperative management of the drain, and postoperative care in the intensive care unit (ICU) are essential to minimize the risk of complications.¹³^,¹⁴ Over the past 2 years, we have standardized a protocol for the placement and management of LDs in patients undergoing vascular procedures with a strict view toward complication avoidance while maximizing protection from spinal cord injury. This protocol was decided on by a multidisciplinary team and subsequently disseminated to nursing and resident staff at our institution to allow uniform implementation.

Section snippets

LD Protocol

The LD protocol developed at our institution includes a preoperative checklist (Table 1) and recommended equipment list (Table 2). Specific guidelines for management of patients on antiplatelet or anticoagulant agents are also followed (Figure 1). Our institution follows the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) guidelines for indications of LD placement. These indications include patient age >70 years, renal insufficiency, chronic obstructive

Results

Over the 4-year span 2016–2019, 45 patients had LDs placed for vascular procedures. The indication in all cases was to monitor spinal CSF pressures and SCPP and prevent spinal cord ischemia via drainage of lumbar CSF. The historical cohort from 2016–2017 (group 1) before implementation of the institutional protocol had 19 patients with an average age of 63.7 ± 17.2 and an average BMI of 29.1 ± 7.29 kg/m². In this group, 14 (73.7%) were female and 5 were male (26.3%). The post-protocol

Discussion

Surgical and endovascular management of aortic disease can be complicated by spinal cord–related neurological deficits, and multiple strategies to mitigate this are essential. Careful coordination of care between the primary vascular surgery team, the anesthesiologists, the neurosurgical consultants, and the resident and nursing staff is required. Among strategies to mitigate spinal cord ischemia during aortic vascular procedures, placement of an LD to monitor SCP and SCPP has been shown to be

Conclusions

An institutional protocol with guidelines for the use of LDs for open and endovascular aortic procedures can be implemented safely in a health care system and have a significant impact on the management of these complex patients. Having defined parameters to monitor and for drainage is helpful. Careful in-service and educational modules are essential to the successful execution of this protocol.

CRediT authorship contribution statement

Faraz Behzadi: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing - original draft, Writing - review & editing. Miri Kim: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing - original draft, Writing - review & editing. Tara Zielke: Conceptualization, Data

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Cited by (5)

Risk Factors Associated with Spinal Cord Ischemia During Aortic Aneurysm Repair
2023, Annals of Vascular Surgery
The risk of spinal cord ischemia (SCI) with aortic aneurysm repair can cause significant neurological morbidity. Prevention of SCI is critical. We sought to identify risk factors that predispose to SCI that may guide strategies to mitigate the occurrence of SCI during and following these procedures.
This study includes all adults who underwent atraumatic, unruptured, thoracic, and suprarenal aortic aneurysm repairs (endovascular or open) at our institution over 11 years (2010–2020). Our database included patient demographics, aneurysm anatomic features, and operative characteristics and an extreme gradient boost (XGB) machine method was used to develop a predictive model for SCI. The model was trained on an 80% randomly stratified cohort of the data and tested on the remaining 20% testing cohort. Shapley values were used to determine the most important predictive factors of SCI and decision trees were used to identify risk factor threshold values and highest risk factor combinations.
Information was collected for 174 adult patients undergoing thoracic and suprarenal aortic repair from 2010 to 2020. Fifty eight percent of the patients were male. Ninety seven (55.7%) patients had open aortic repair and 87 (44.3%) had endovascular repair. Twenty seven (15%) of all patients had major complications and were considered to have SCI. The XGB model converged over the training cohort with a testing cohort accuracy of 0.841 [Sensitivity = 75%, Specificity = 68%] and area under the curve of receiver operating characteristic of 0.774. The XGB model identified older age (> 65 years), history of neurologic disease, hyperlipidemia, diabetes, coronary artery disease, heart failure, poor renal function, < 6 months since last aortic repair, chronic anticoagulant use, preoperational anemia (Hemoglobin < 9), thrombocytopenia (platelet < 90,000), coagulopathy (prothrombin time > 15s and activated partial thromboplastin time > 40s), hypotension (mean arterial pressure < 70 mm Hg), longer operations (> 100 min), aneurysms longer than 5 cm, and anatomic location of aneurysm caudal to T-11 as risk factors for SCI in all types of aortic repair. Diabetic and heart failure patients undergoing longer operations (> 100 min) with thrombocytopenia or aneurysms longer than 5 cm were at the highest risk.
The XGB model accurately identified risk factors of SCI with aortic aneurysm repair that may guide patient selection, timing of surgery, and strategies to minimize the risk of SCI.
Safety and efficacy of fluoroscopically guided cerebrospinal fluid drainage for thoracoabdominal aortic aneurysm repair
2023, Annals of Vascular Surgery - Brief Reports and Innovations
To review the safety and efficacy of perioperative cerebrospinal fluid (CSF) drainage catheter placement using fluoroscopic guidance in patients undergoing thoracoabdominal aortic aneurysm (TAAA) repair.
Research Ethics Board approval was obtained for this retrospective study. The medical records of patients who underwent fluoroscopically guided lumbar CSF drainage between September 2008 and April 2021 were reviewed. Major complications were defined as CSF leak requiring a blood patch, intracranial hemorrhage, meningitis, symptomatic spinal hematoma, bloody tap causing a delay in surgery, catheter fracture or occlusion, and death. Minor complications included CSF leak not requiring intervention, asymptomatic spinal hematoma, and bloody tap without surgical delay.
Eighty-four drainage catheters were attempted in 75 consecutive patients (age, 70.8 ± 8.9 years; 67.9% male) for 15 thoracic endovascular aortic repairs (TEVARs), 59 complex (fenestrated/branched) endovascular aortic repairs (EVARs), and 10 open repairs for 76 aneurysms (90.5%), 1 acute dissection (1.2%), and 7 chronic dissections with aneurysms (8.3%). The technical success rate was 97.6% (82/84). Bloody tap accounted for both technical failures. Most catheters were placed prophylactically (89.3%). There were 4 major complications (2 bloody taps causing a delay in surgery, 1 catheter occlusion, and 1 symptomatic spinal hematoma) and 2 minor complications (CSF leak with no intervention and asymptomatic spinal hematoma).
The use of fluoroscopic guidance for CSF drainage catheter placement in patients undergoing open or endovascular TAAA repair is associated with a low complication rate and high technical success rate.
Con: Lumbar Drains Should Routinely Be Placed by a Landmark Approach and Not by Fluoroscopic Guidance for Elective Thoracic Aortic Repairs
2023, Journal of Cardiothoracic and Vascular Anesthesia
The Evolution and Future of Spinal Drains for Thoracic Aortic Aneurysm Repair: A Review
2021, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
It has been demonstrated that, in addition to CSF drainage, bundled clinical protocols with standardized application of multiple therapies and interventions significantly reduce spinal cord ischemia.62 Implementation of a protocol also may result in fewer drain-related complications,63 and there are reports of protocols being modified in response to complications that resulted in improved patient outcomes.60,62 The timing and conditions under which the drain is placed usually are not specified in the literature, although it has potential to play a role in drain-related complications either due to inadvertent loss of CSF or vascular injury occurring during placement.
For decades, spinal drains for cerebrospinal fluid (CSF) pressure monitoring and drainage have been used as adjuncts to protect against spinal cord injury resulting from thoracic aortic aneurysm repair. There are many different approaches to placement and management of CSF drains, with no true consensus on best practice. Furthermore, the incidence of complications resulting from spinal drains largely has been stagnant. This review describes the history and rationale behind placement of CSF drains, explore various considerations, techniques, and equipment, and discuss potential considerations for developing more comprehensive protocols.
Interdisciplinary German clinical practice guidelines on the management of type B aortic dissection
2023, Gefasschirurgie

: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Original ArticleLumbar Drains for Vascular Procedures: An Institutional Protocol Review and Guidelines

Background

Methods

Results

Conclusions

Introduction

Section snippets

LD Protocol

Results

Discussion

Conclusions

CRediT authorship contribution statement

Br J Anaesth

Ann Vasc Surg

J Vasc Surg

Ann Thorac Surg

J Vasc Surg

Spinal cord injury after thoracic endovascular aortic aneurysm repair

Can J Anaesth

Cerebrospinal fluid drainage and blood pressure elevation to treat acute spinal cord infarct

Surg Neurol Int

Controversies in the anesthetic management of lumbar drains for endovascular aortic surgery

Glob Anesth Perioper Med

Original Article
Lumbar Drains for Vascular Procedures: An Institutional Protocol Review and Guidelines