Shaggy Aortic Score is Associated with Postoperative Lower Extremity Weakness after Branched Endovascular Aortic Aneurysm Repair

Paraplegia is one of the most feared complications after thoracoabdominal aortic aneurysm repair. The purpose of the present study was to determine whether aortic thrombus characteristics are associated with lower extremity weakness (LEW) after branched endovascular aneurysm repair (BEVAR). From April 2011 to April 2020, 62 patients had undergone elective BEVAR for thoracoabdominal aortic aneurysms and pararenal aortic aneurysms using a low-profile device and had a complete preoperative computed tomography angiogram of the aorta from the sinotubular junction to the aortic bifurcation available. Aortic thrombus was evaluated for thrombus thickness ≥5 mm, thrombus greater than two thirds of the aortic circumference, and the presence of ulcer-like thrombus. One point was assigned at each 5-mm axial image if all three criteria were met, resulting in a total “shaggy score” for the entire aorta (Fig). Data on demographics, procedural details, and outcomes were collected prospectively. All patients had received a standard spinal cord protection protocol, including routine cerebrospinal fluid drainage. In July 2016, an insulin infusion protocol (IIP) was initiated to maintain the postoperative blood glucose levels at <120 mg/dL for 48 hours. The primary clinical endpoint was postoperative LEW. Ten patients (16%) had developed postoperative LEW: six with transient paraparesis, two with persistent paraparesis, and two with persistent paraplegia. The patients with LEW were older, had had higher shaggy scores, and were less likely to have been received the IIP (Table). No significant differences were found in demographics, aneurysm type, or operative parameters. In a logistic multivariate regression model for LEW, age (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.1-1.4; P = .02) and shaggy score (OR, 1.2; 95% CI, 1.1-1.4; P = .02) were independently associated with an increased risk of LEW, and treatment with the IIP was associated with a lower risk of LEW (OR, 0.04; 95% CI, 0.006-0.50; P = .05). Of the individual components of the shaggy score, higher descending thoracic aortic ulcer scores were the most strongly associated with postoperative LEW (P = .009). Preoperative characterization of aortic wall thrombus is an important adjunctive tool for individualized clinical decision-making and patient counseling regarding the risk of LEW after BEVAR.TablePreoperative and operative patient characteristicsCharacteristicTotal cohort (n = 62)Univariate association with LEWLEW (n = 10; 16%)No LEW (n = 52; 84%)P valueAge, years72.4 ± 8.378.6 ± 6.171.3 ± 8.2.005Male sex45 (72)9 (90)36 (69).33Heart disease41 (66)7 (70)34 (65)1.00Diabetes11 (18)2 (20)9 (17)1.00Prior stroke/TIA10 (76)2 (20)8 (15)1.00Smoking history (any)57 (92)10 (100)47 (90).70Shaggy score4.9 ± 5.99.3 ± 7.54.1 ± 5.2.06Crawford type 4 TAAA and pararenal aortic aneurysm28 (45)4 (40)24 (46).99Fluoroscopy time, minutes124 ± 39130 ± 40123 ± 39.62Contrast volume, mL122 ± 53133 ± 46120 ± 55.43Estimated blood loss, mL450 ± 411439 ± 237453 ± 437.89Surgery duration (min)387 ± 101413 ± 98382 ± 102.38Postoperative insulin infusion protocol27 (44)1 (10)26 (50).047LEW, Lower extremity weakness; TAAA, thoracoabdominal aortic aneurysm; TIA, transient ischemic attack.Data presented as mean ± standard deviation or number (%). Open table in a new tab