Neuromonitoring during Endovascular Thoracoabdominal Aortic Aneurysm Repair: A Systematic Review

Myat Soe Thet; Mario D'Oria; Davorin Sef; Tomislav Klokocovnik; Aung Ye Oo; Sandro Lepidi

doi:10.1016/j.avsg.2024.06.012

Neuromonitoring during Endovascular Thoracoabdominal Aortic Aneurysm Repair: A Systematic Review

Ann Vasc Surg. 2024 Dec:109:206-215. doi: 10.1016/j.avsg.2024.06.012. Epub 2024 Jul 14.

Authors

Myat Soe Thet¹, Mario D'Oria², Davorin Sef³, Tomislav Klokocovnik⁴, Aung Ye Oo⁵, Sandro Lepidi⁶

Affiliations

¹ Department of Surgery and Cancer, Imperial College London, UK.
² Division of Vascular and Endovascular Surgery, Department of Clinical Surgical and Health Sciences, University of Trieste, Italy. Electronic address: [email protected].
³ Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton, UK.
⁴ Department of Cardiac Surgery, General Hospital Celje, Celje, Slovenia.
⁵ Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK.
⁶ Division of Vascular and Endovascular Surgery, Department of Clinical Surgical and Health Sciences, University of Trieste, Italy.

PMID: 39009132
DOI: 10.1016/j.avsg.2024.06.012

Abstract

Background: Spinal cord ischemia (SCI) is a potentially devastating complication of thoracic endovascular aortic repair (TEVAR) and fenestrated-branched endovascular aortic repair (F-BEVAR). The aim of this systematic review was to evaluate the efficacy of neuromonitoring modalities to mitigate the risk of SCI during TEVAR and F-BEVAR procedures.

Methods: Following the PRISMA guidelines, we conducted a detailed literature search of databases including PubMed, MEDLINE via Ovid, Embase, Scopus, and Cochrane CENTRAL, from 1998 to the present. Inclusion criteria were original research articles examining neuromonitoring during TEVAR and F-BEVAR. The primary outcome was the incidence of SCI, while the secondary outcome included early mortality. The quality of studies was assessed using the Newcastle-Ottawa Scale.

Results: From 1,450 identified articles, 11 met inclusion criteria, encompassing data from 1,069 patients. Neuromonitoring modalities included motor-evoked potentials (MEPs), somatosensory evoked potentials (SSEPs), and near-infrared spectroscopy. The combination of MEPs and SSEPs was most commonly used, with 93% sensitivity and 96% specificity for detecting SCI risks. SCI incidence ranged from 3.8 to 17.3%, with permanent deficits occurring in 2.7-5.8% of cases. In-hospital mortality ranged from 0.4 to 8%. Risk factors for SCI were identified, including operation duration and extent of aortic coverage.

Conclusions: Neuromonitoring with MEPs and SSEPs appears to be effective in detecting perioperative SCI risk during TEVAR and F-BEVAR. However, discrepancies between neuromonitoring changes and actual SCI outcomes suggest the need for cautious interpretation. While the incidence of SCI remains variable, identified risk factors may guide clinical decisions, particularly in high-risk procedures. Future research should focus on prospective studies and randomized controlled trials to validate these findings and improve SCI prevention strategies in TEVAR and F-BEVAR.

Publication types

Systematic Review
Review

MeSH terms

Aged
Aortic Aneurysm, Thoracic* / diagnostic imaging
Aortic Aneurysm, Thoracic* / mortality
Aortic Aneurysm, Thoracic* / physiopathology
Aortic Aneurysm, Thoracic* / surgery
Aortic Aneurysm, Thoracoabdominal
Blood Vessel Prosthesis Implantation* / adverse effects
Blood Vessel Prosthesis Implantation* / mortality
Endovascular Procedures* / adverse effects
Endovascular Procedures* / mortality
Evoked Potentials, Motor*
Evoked Potentials, Somatosensory*
Female
Humans
Incidence
Intraoperative Neurophysiological Monitoring*
Male
Middle Aged
Predictive Value of Tests*
Risk Assessment
Risk Factors
Spectroscopy, Near-Infrared
Spinal Cord Ischemia* / diagnosis
Spinal Cord Ischemia* / etiology
Spinal Cord Ischemia* / physiopathology
Spinal Cord Ischemia* / prevention & control
Treatment Outcome