Systematic Review and Meta-Analysis of Cerebro-Spinal Fluid Drain-Related Mortality and Morbidity After Fenestrated-Branched Endovascular Aortic Repair

Objective This study aimed to investigate the incidence of cerebrospinal fluid drainage (CSFD)-related complications specifically in patients undergoing fenestrated and branched endovascular aortic repair (F/B-EVAR). This objective was chosen considering the limitations and uncertainties surrounding its efficacy in preventing spinal cord injury (SCI). Methods A systematic review following Cochrane Handbook and PRISMA guidelines was conducted (PROSPERO; #CRD42022359223). Literature searches of MEDLINE, Embase, and Scopus were performed until May 1, 2023, focusing on studies published after January 1, 2000. The inclusion criteria encompassed studies reporting on F/B-EVAR, CSFD, and drain-related complications. Data extraction and quality assessment using the Newcastle-Ottawa scale (NOS) were performed by multiple reviewers to ensure accuracy and reliability. A proportion meta-analysis was conducted to calculate the pooled rate and 95% confidence interval (CI). The primary and secondary outcomes were CSFD-related mortality and morbidity, respectively. Results Six retrospective, observational, single-center studies were included, totaling 1 079 patients and 730 CSFD placements (all prophylactic except for one). NOS showed a high to moderate risk of bias. The analysis revealed a CSFD-related mortality rate of 1.4% (95%CI 0.0-4.8; I2= 67.7%) and an overall morbidity rate of 25.6% (95%CI 13.6-39.7; I2= 83.2%). The overall major, moderate, and minor estimated complication rates were 6.1% (95%CI 4.1-8.5; I2= 0%), 4.6% (95%CI 2.4-7.3; I2= 33.5%), and 26.4% (95%CI 16.5-37.7; I2= 84.9%), respectively. Severe complications included intracranial hemorrhage (2.8%), spinal hematoma (1.4%), subarachnoid hemorrhage (1.4%), and CSFD-related neurological deficits (1.1%). A pooled estimate of 11.4% for non-functioning drainage was found. Conclusion F/B-EVAR patients showed a notable incidence of CSFD-related death and substantial morbidity. This study highlights the limitations of the available data, the high prevalence of complications associated with CSFD, and the need for further research to better understand the risks and benefits of CSFD in F/B-EVAR. This calls for careful consideration regarding the routine use of prophylactic drainage due to the accumulating evidence of the risks associated with CSFD without proven benefit in this specific contex.