Hypogastric Artery Thrombectomy for Spinal Cord Ischemia Following Fenestrated Endovascular Aortic Repair
Veena Mehta, Mathew Wooster
Medical University of South Carolina, Charleston, SC
INTRODUCTION:Spinal cord ischemia resulting in paraparesis or paraplegia can be a devastating complication after thoracoabdominal aortic surgery. Most commonly seen in patients undergoing open repair, the incidence of SCI after FEVAR has been cited in literature between 3.3-17.7%. Development of spinal cord ischemia is not fully understood, although it has been associated with several factors, such as prolonged operative time, difficult anatomy, longer aortic stent graft coverage, and intraoperative hypotension. Occlusion of the artery of Adamkiewicz is a well-documented cause of SCI. However, hypogastric artery embolization and occlusion have also been associated with development of SCI, suggesting a significant role of this artery in spinal cord perfusion. METHODS:We report an interesting case of a patient with lower extremity weakness in the setting of ipsilateral hypogastric artery occlusion after FEVAR that resolved completely with thrombectomy. RESULTS:A 56 year-old woman with a prior aortic dissection and aneurysmal degeneration previously treated with open ascending repair, open descending thoracic repair, and endovascular arch repair with TEVAR presented for annual follow-up and imaging. CTA demonstrated growth of the visceral segment aneurysm to 7cm. Our patient elected to proceed with repair using a physician modified 4-vessel fenestrated graft and iliac branch device. Postoperatively, she developed weakness in her right leg concerning for spinal ischemia. Given our intraoperative concern of her right hypogastric flow, a CT angiogram was obtained, which showed an occluded right hypogastric artery. We determined that endovascular intervention for her occluded right hypogastric artery would be the best option to relieve her symptoms. Via percutaneous left femoral access the right hypogastric was selectively cannulated and Indigo CAT 8 aspiration catheter (Penumbra, Alhambra Ca) was passed across the lesion with return of clot and improved flow. We extended the right hypogastric stent with 10mm self-expanding, bare metal stent for presumed kink in the original stent. Postoperatively, there was complete resolution of her right leg weakness within hours. Reconstruction remains patent with patient doing well at one month follow-up (Figure 1) CONCLUSIONS:Hypogastric collateral supply to the spinal cord is frequently discussed as vital to preventing spinal cord ischemia following long segment aortic replacement, but few reports of direct implication exist. Mechanisms of SCI may not be fully understood, especially the role of hypogastric arteries in spinal cord perfusion.
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