PC072. Impact of Functional Recovery and Prediction of Spinal Cord Ischemia After Thoracic Endovascular Aortic Repair in the Vascular Quality Initiative

Spinal cord ischemia (SCI) is a dreaded complication of thoracic endovascular aortic repair (TEVAR). There are limited data describing the influence of in-hospital SCI recovery on survival, and no validated risk assessment tools currently exist. The purpose of this analysis was to analyze the Vascular Quality Initiative (VQI) to determine the survival impact of SCI with or without in-hospital recovery, and develop a preoperative SCI prediction tool for patients undergoing TEVAR. All VQI TEVAR procedures (2013-2014) were reviewed. The primary end point was development of in- hospital SCI, defined as any new neurologic deficit and/or paralysis not attributable to intracranial pathology. Functional outcomes were independently determined by treating physicians. Kaplan-Meier methodology was used to estimate survival. A logistic regression model of all candidate preoperative SCI predictors (P < .2) was created and the Akaike information criterion was used for model reduction. The model was validated by bootstrapping 5000 iterations. The overall rate of SCI was 9.7% (204 of 2104 patients with complete data). The survival impact of SCI after TEVAR is highlighted in the Fig. Patients who developed SCI but had resolution of symptoms before discharge had similar survival to those without SCI (1 year: SCI with recovery 85% ± 6% vs No SCI, 89% ± 8%; log-rank P = .2). However, patients without SCI recovery had significantly worse overall survival (1-year: SCI with no recovery 64 ± 4% vs No SCI, 89% ± 8%; P < .0001). Several patient and procedure related factors were selected as the most important independent predictors of SCI (AUC = .75; Table). In 5000 bootstrap runs, the risk scores assigned to each patient by this model had mean AUC of .75 (95% CI, .71-.78). Model calibration was excellent (Hosmer-Lemeshow P = 1; intercept = −.004; slope = −1.06). SCI is a devastating complication after TEVAR, with a significant impact on overall survival, particularly when no functional recovery occurs by time of discharge. Importantly, this analysis is the first description of a validated preoperative prediction tool for determining SCI risk after TEVAR. We have identified variables that can guide use of interventions that may mitigate the risk of developing SCI, and application of this simple model may potentially improve TEVAR outcomes nationally.TablePreoperative independent predictors of spinal cord ischemia after thoracic endovascular aortic repair in the Vascular Quality InitiativePredictorOdds ratio95% CIP valueCoverage length (mm)OR×1.004 per mm1.000-1.01.05Emergency/rupture presentation2.61.5-4.4.0004Creatinine >1.8 mg/dL2.31.5-3.5<.0001Chronic obstructive lung disease1.61.1-2.2.006ASA Physical Status Classification1.51.2-2.0.002Proximal landing zone 0-21.4.9-1.9.07Ejection fraction 50%1.1.7-1.5.9Aspirin.9.7-1.2.4Clopidogrel.7.4-1.3.2Diabetes mellitus.7.5-1.0.07ASA, American Society of Anesthesiologists; CI, confidence interval. Open table in a new tab