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Lower extremity weakness after endovascular aneurysm repair with multibranched thoracoabdominal stent grafts
Objective We conducted our study to describe the incidence, presentation, management, risk factors, and outcomes of lower extremity weakness (LEW) after elective endovascular aneurysm repair with multibranched thoracoabdominal stent grafts. Methods Excluding symptomatic patients and those with aorti...
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| Published in: | Journal of vascular surgery 2015-03, Vol.61 (3), p.623-629 |
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| container_title | Journal of vascular surgery |
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| creator | Sobel, Julia D., BS Vartanian, Shant M., MD Gasper, Warren J., MD Hiramoto, Jade S., MD Chuter, Timothy A.M., DM Reilly, Linda M., MD |
| description | Objective We conducted our study to describe the incidence, presentation, management, risk factors, and outcomes of lower extremity weakness (LEW) after elective endovascular aneurysm repair with multibranched thoracoabdominal stent grafts. Methods Excluding symptomatic patients and those with aortic dissection, between July 2005 and October 2013, 116 patients with aortic aneurysms were treated in a prospective, single-center trial of multibranched endovascular aneurysm repair. LEW that resolved within 30 days of operation was classified as transient. Persistent LEW was defined as inability to walk or stand 30 days after surgery. Perioperative spinal cord protection measures included bypass as needed to maintain flow to the subclavian and internal iliac arteries, cerebrospinal fluid drainage, and permissive hypertension. Results Postoperative LEW occurred in 24 of 116 patients (20.6%). In 15 (12.9%), LEW was transient with full recovery. Nine patients (7.7%) had persistent LEW, three with paraparesis and six with paraplegia. Five of 24 patients (21%) awoke from anesthesia with LEW. Symptoms of LEW developed within 72 hours of operation in 14 of 24 (58%). Late-onset LEW (≥72 hours postoperatively) always occurred in the presence of a precipitating hypotensive event (5 of 24; 21%). Univariate analysis showed no association between LEW and Crawford type, staged repair, aneurysm extent, or postoperative endoleak. Baseline glomerular filtration rate 190 minutes (OR, 3.6; 95% CI, 1.0-12.7; P = .04), and sustained hypotension (OR, 2.9; 95% CI, 1.1-7.7; P = .04) were identified as independent risk factors for LEW in multivariate analysis. Conclusions Most episodes of LEW after multibranched endovascular aneurysm repair are transient and do not occur in the operating room. Adjunctive strategies to maintain spinal perfusion, including cerebrospinal fluid drainage and permissive hypertension, may help prevent permanent LEW. |
| doi_str_mv | 10.1016/j.jvs.2014.10.013 |
| format | article |
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Methods Excluding symptomatic patients and those with aortic dissection, between July 2005 and October 2013, 116 patients with aortic aneurysms were treated in a prospective, single-center trial of multibranched endovascular aneurysm repair. LEW that resolved within 30 days of operation was classified as transient. Persistent LEW was defined as inability to walk or stand 30 days after surgery. Perioperative spinal cord protection measures included bypass as needed to maintain flow to the subclavian and internal iliac arteries, cerebrospinal fluid drainage, and permissive hypertension. Results Postoperative LEW occurred in 24 of 116 patients (20.6%). In 15 (12.9%), LEW was transient with full recovery. Nine patients (7.7%) had persistent LEW, three with paraparesis and six with paraplegia. Five of 24 patients (21%) awoke from anesthesia with LEW. Symptoms of LEW developed within 72 hours of operation in 14 of 24 (58%). Late-onset LEW (≥72 hours postoperatively) always occurred in the presence of a precipitating hypotensive event (5 of 24; 21%). Univariate analysis showed no association between LEW and Crawford type, staged repair, aneurysm extent, or postoperative endoleak. Baseline glomerular filtration rate <30 mL/min/1.73 m2 (odds ratio [OR], 4.2; 95% confidence interval [CI], 1.2-14.6; P = .03), fluoroscopy time >190 minutes (OR, 3.6; 95% CI, 1.0-12.7; P = .04), and sustained hypotension (OR, 2.9; 95% CI, 1.1-7.7; P = .04) were identified as independent risk factors for LEW in multivariate analysis. Conclusions Most episodes of LEW after multibranched endovascular aneurysm repair are transient and do not occur in the operating room. Adjunctive strategies to maintain spinal perfusion, including cerebrospinal fluid drainage and permissive hypertension, may help prevent permanent LEW.</description><identifier>ISSN: 0741-5214</identifier><identifier>EISSN: 1097-6809</identifier><identifier>DOI: 10.1016/j.jvs.2014.10.013</identifier><identifier>PMID: 25457458</identifier><language>eng</language><publisher>United States: Elsevier Inc</publisher><subject>Adult ; Aged ; Aged, 80 and over ; Aortic Aneurysm, Abdominal - diagnosis ; Aortic Aneurysm, Abdominal - surgery ; Aortic Aneurysm, Thoracic - diagnosis ; Aortic Aneurysm, Thoracic - surgery ; Blood Vessel Prosthesis ; Blood Vessel Prosthesis Implantation - adverse effects ; Blood Vessel Prosthesis Implantation - instrumentation ; Chi-Square Distribution ; Elective Surgical Procedures ; Endovascular Procedures - adverse effects ; Endovascular Procedures - instrumentation ; Female ; Humans ; Incidence ; Logistic Models ; Lower Extremity ; Male ; Middle Aged ; Multivariate Analysis ; Muscle Weakness - epidemiology ; Muscle Weakness - physiopathology ; Muscle Weakness - therapy ; Muscle, Skeletal - innervation ; Odds Ratio ; Paraparesis - epidemiology ; Paraplegia - epidemiology ; Prospective Studies ; Prosthesis Design ; Risk Factors ; San Francisco - epidemiology ; Stents ; Surgery ; Time Factors ; Treatment Outcome</subject><ispartof>Journal of vascular surgery, 2015-03, Vol.61 (3), p.623-629</ispartof><rights>Society for Vascular Surgery</rights><rights>2015 Society for Vascular Surgery</rights><rights>Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c451t-a45e97d743f9fc84765290efb374779625907ccfa12568635e60d9027f451df13</citedby><cites>FETCH-LOGICAL-c451t-a45e97d743f9fc84765290efb374779625907ccfa12568635e60d9027f451df13</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>315,786,790,27957,27958</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/25457458$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Sobel, Julia D., BS</creatorcontrib><creatorcontrib>Vartanian, Shant M., MD</creatorcontrib><creatorcontrib>Gasper, Warren J., MD</creatorcontrib><creatorcontrib>Hiramoto, Jade S., MD</creatorcontrib><creatorcontrib>Chuter, Timothy A.M., DM</creatorcontrib><creatorcontrib>Reilly, Linda M., MD</creatorcontrib><title>Lower extremity weakness after endovascular aneurysm repair with multibranched thoracoabdominal stent grafts</title><title>Journal of vascular surgery</title><addtitle>J Vasc Surg</addtitle><description>Objective We conducted our study to describe the incidence, presentation, management, risk factors, and outcomes of lower extremity weakness (LEW) after elective endovascular aneurysm repair with multibranched thoracoabdominal stent grafts. Methods Excluding symptomatic patients and those with aortic dissection, between July 2005 and October 2013, 116 patients with aortic aneurysms were treated in a prospective, single-center trial of multibranched endovascular aneurysm repair. LEW that resolved within 30 days of operation was classified as transient. Persistent LEW was defined as inability to walk or stand 30 days after surgery. Perioperative spinal cord protection measures included bypass as needed to maintain flow to the subclavian and internal iliac arteries, cerebrospinal fluid drainage, and permissive hypertension. Results Postoperative LEW occurred in 24 of 116 patients (20.6%). In 15 (12.9%), LEW was transient with full recovery. Nine patients (7.7%) had persistent LEW, three with paraparesis and six with paraplegia. Five of 24 patients (21%) awoke from anesthesia with LEW. Symptoms of LEW developed within 72 hours of operation in 14 of 24 (58%). Late-onset LEW (≥72 hours postoperatively) always occurred in the presence of a precipitating hypotensive event (5 of 24; 21%). Univariate analysis showed no association between LEW and Crawford type, staged repair, aneurysm extent, or postoperative endoleak. Baseline glomerular filtration rate <30 mL/min/1.73 m2 (odds ratio [OR], 4.2; 95% confidence interval [CI], 1.2-14.6; P = .03), fluoroscopy time >190 minutes (OR, 3.6; 95% CI, 1.0-12.7; P = .04), and sustained hypotension (OR, 2.9; 95% CI, 1.1-7.7; P = .04) were identified as independent risk factors for LEW in multivariate analysis. Conclusions Most episodes of LEW after multibranched endovascular aneurysm repair are transient and do not occur in the operating room. Adjunctive strategies to maintain spinal perfusion, including cerebrospinal fluid drainage and permissive hypertension, may help prevent permanent LEW.</description><subject>Adult</subject><subject>Aged</subject><subject>Aged, 80 and over</subject><subject>Aortic Aneurysm, Abdominal - diagnosis</subject><subject>Aortic Aneurysm, Abdominal - surgery</subject><subject>Aortic Aneurysm, Thoracic - diagnosis</subject><subject>Aortic Aneurysm, Thoracic - surgery</subject><subject>Blood Vessel Prosthesis</subject><subject>Blood Vessel Prosthesis Implantation - adverse effects</subject><subject>Blood Vessel Prosthesis Implantation - instrumentation</subject><subject>Chi-Square Distribution</subject><subject>Elective Surgical Procedures</subject><subject>Endovascular Procedures - adverse effects</subject><subject>Endovascular Procedures - instrumentation</subject><subject>Female</subject><subject>Humans</subject><subject>Incidence</subject><subject>Logistic Models</subject><subject>Lower Extremity</subject><subject>Male</subject><subject>Middle Aged</subject><subject>Multivariate Analysis</subject><subject>Muscle Weakness - epidemiology</subject><subject>Muscle Weakness - physiopathology</subject><subject>Muscle Weakness - therapy</subject><subject>Muscle, Skeletal - innervation</subject><subject>Odds Ratio</subject><subject>Paraparesis - epidemiology</subject><subject>Paraplegia - epidemiology</subject><subject>Prospective Studies</subject><subject>Prosthesis Design</subject><subject>Risk Factors</subject><subject>San Francisco - epidemiology</subject><subject>Stents</subject><subject>Surgery</subject><subject>Time Factors</subject><subject>Treatment Outcome</subject><issn>0741-5214</issn><issn>1097-6809</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2015</creationdate><recordtype>article</recordtype><recordid>eNp9kUFv1DAQhS0EokvhB3BBPnLJ4knsOBYSEqpaWmklDpSz5XUmrNMkXmxnt_vv62gLBw6cRh6_96T3DSHvga2BQf2pX_eHuC4Z8PxeM6hekBUwJYu6YeolWTHJoRAl8AvyJsaeMQDRyNfkohRcSC6aFRk2_oiB4mMKOLp0okc0DxPGSE2Xlo-p9QcT7TyYQM2EczjFkQbcGxfo0aUdHechuW0wk91hS9POB2O92bZ-dJMZaEw4Jfor5Lj4lrzqzBDx3fO8JD9vru-vbovN9293V183heUCUmG4QCVbyatOdbbhshalYthtK8mlVHUpFJPWdgZKUTd1JbBmrWKl7LK97aC6JB_Pufvgf88Ykx5dtDgMuYCfo4ZaVkzWIBYpnKU2-BgDdnof3GjCSQPTC2Td6wxZL5CXVYacPR-e4-ftiO1fxx-qWfD5LMBc8uAw6GgdThZbF9Am3Xr33_gv_7jt4CZnzfCAJ4y9n0MGm1voWGqmfyxXXo4MnEGjRFU9ASsyo50</recordid><startdate>20150301</startdate><enddate>20150301</enddate><creator>Sobel, Julia D., BS</creator><creator>Vartanian, Shant M., MD</creator><creator>Gasper, Warren J., MD</creator><creator>Hiramoto, Jade S., MD</creator><creator>Chuter, Timothy A.M., DM</creator><creator>Reilly, Linda M., MD</creator><general>Elsevier Inc</general><scope>6I.</scope><scope>AAFTH</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope></search><sort><creationdate>20150301</creationdate><title>Lower extremity weakness after endovascular aneurysm repair with multibranched thoracoabdominal stent grafts</title><author>Sobel, Julia D., BS ; Vartanian, Shant M., MD ; Gasper, Warren J., MD ; Hiramoto, Jade S., MD ; Chuter, Timothy A.M., DM ; Reilly, Linda M., MD</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c451t-a45e97d743f9fc84765290efb374779625907ccfa12568635e60d9027f451df13</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2015</creationdate><topic>Adult</topic><topic>Aged</topic><topic>Aged, 80 and over</topic><topic>Aortic Aneurysm, Abdominal - diagnosis</topic><topic>Aortic Aneurysm, Abdominal - surgery</topic><topic>Aortic Aneurysm, Thoracic - diagnosis</topic><topic>Aortic Aneurysm, Thoracic - surgery</topic><topic>Blood Vessel Prosthesis</topic><topic>Blood Vessel Prosthesis Implantation - adverse effects</topic><topic>Blood Vessel Prosthesis Implantation - instrumentation</topic><topic>Chi-Square Distribution</topic><topic>Elective Surgical Procedures</topic><topic>Endovascular Procedures - adverse effects</topic><topic>Endovascular Procedures - instrumentation</topic><topic>Female</topic><topic>Humans</topic><topic>Incidence</topic><topic>Logistic Models</topic><topic>Lower Extremity</topic><topic>Male</topic><topic>Middle Aged</topic><topic>Multivariate Analysis</topic><topic>Muscle Weakness - epidemiology</topic><topic>Muscle Weakness - physiopathology</topic><topic>Muscle Weakness - therapy</topic><topic>Muscle, Skeletal - innervation</topic><topic>Odds Ratio</topic><topic>Paraparesis - epidemiology</topic><topic>Paraplegia - epidemiology</topic><topic>Prospective Studies</topic><topic>Prosthesis Design</topic><topic>Risk Factors</topic><topic>San Francisco - epidemiology</topic><topic>Stents</topic><topic>Surgery</topic><topic>Time Factors</topic><topic>Treatment Outcome</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Sobel, Julia D., BS</creatorcontrib><creatorcontrib>Vartanian, Shant M., MD</creatorcontrib><creatorcontrib>Gasper, Warren J., MD</creatorcontrib><creatorcontrib>Hiramoto, Jade S., MD</creatorcontrib><creatorcontrib>Chuter, Timothy A.M., DM</creatorcontrib><creatorcontrib>Reilly, Linda M., MD</creatorcontrib><collection>ScienceDirect Open Access Titles</collection><collection>Elsevier:ScienceDirect:Open Access</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>Journal of vascular surgery</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Sobel, Julia D., BS</au><au>Vartanian, Shant M., MD</au><au>Gasper, Warren J., MD</au><au>Hiramoto, Jade S., MD</au><au>Chuter, Timothy A.M., DM</au><au>Reilly, Linda M., MD</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Lower extremity weakness after endovascular aneurysm repair with multibranched thoracoabdominal stent grafts</atitle><jtitle>Journal of vascular surgery</jtitle><addtitle>J Vasc Surg</addtitle><date>2015-03-01</date><risdate>2015</risdate><volume>61</volume><issue>3</issue><spage>623</spage><epage>629</epage><pages>623-629</pages><issn>0741-5214</issn><eissn>1097-6809</eissn><notes>ObjectType-Article-2</notes><notes>SourceType-Scholarly Journals-1</notes><notes>ObjectType-Feature-1</notes><notes>content type line 23</notes><abstract>Objective We conducted our study to describe the incidence, presentation, management, risk factors, and outcomes of lower extremity weakness (LEW) after elective endovascular aneurysm repair with multibranched thoracoabdominal stent grafts. Methods Excluding symptomatic patients and those with aortic dissection, between July 2005 and October 2013, 116 patients with aortic aneurysms were treated in a prospective, single-center trial of multibranched endovascular aneurysm repair. LEW that resolved within 30 days of operation was classified as transient. Persistent LEW was defined as inability to walk or stand 30 days after surgery. Perioperative spinal cord protection measures included bypass as needed to maintain flow to the subclavian and internal iliac arteries, cerebrospinal fluid drainage, and permissive hypertension. Results Postoperative LEW occurred in 24 of 116 patients (20.6%). In 15 (12.9%), LEW was transient with full recovery. Nine patients (7.7%) had persistent LEW, three with paraparesis and six with paraplegia. Five of 24 patients (21%) awoke from anesthesia with LEW. Symptoms of LEW developed within 72 hours of operation in 14 of 24 (58%). Late-onset LEW (≥72 hours postoperatively) always occurred in the presence of a precipitating hypotensive event (5 of 24; 21%). Univariate analysis showed no association between LEW and Crawford type, staged repair, aneurysm extent, or postoperative endoleak. Baseline glomerular filtration rate <30 mL/min/1.73 m2 (odds ratio [OR], 4.2; 95% confidence interval [CI], 1.2-14.6; P = .03), fluoroscopy time >190 minutes (OR, 3.6; 95% CI, 1.0-12.7; P = .04), and sustained hypotension (OR, 2.9; 95% CI, 1.1-7.7; P = .04) were identified as independent risk factors for LEW in multivariate analysis. Conclusions Most episodes of LEW after multibranched endovascular aneurysm repair are transient and do not occur in the operating room. Adjunctive strategies to maintain spinal perfusion, including cerebrospinal fluid drainage and permissive hypertension, may help prevent permanent LEW.</abstract><cop>United States</cop><pub>Elsevier Inc</pub><pmid>25457458</pmid><doi>10.1016/j.jvs.2014.10.013</doi><tpages>7</tpages><oa>free_for_read</oa></addata></record> |
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| subjects | Adult Aged Aged, 80 and over Aortic Aneurysm, Abdominal - diagnosis Aortic Aneurysm, Abdominal - surgery Aortic Aneurysm, Thoracic - diagnosis Aortic Aneurysm, Thoracic - surgery Blood Vessel Prosthesis Blood Vessel Prosthesis Implantation - adverse effects Blood Vessel Prosthesis Implantation - instrumentation Chi-Square Distribution Elective Surgical Procedures Endovascular Procedures - adverse effects Endovascular Procedures - instrumentation Female Humans Incidence Logistic Models Lower Extremity Male Middle Aged Multivariate Analysis Muscle Weakness - epidemiology Muscle Weakness - physiopathology Muscle Weakness - therapy Muscle, Skeletal - innervation Odds Ratio Paraparesis - epidemiology Paraplegia - epidemiology Prospective Studies Prosthesis Design Risk Factors San Francisco - epidemiology Stents Surgery Time Factors Treatment Outcome |
| title | Lower extremity weakness after endovascular aneurysm repair with multibranched thoracoabdominal stent grafts |
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