Cerebrospinal fluid (CSF) drainage systems in thoracic endovascular aneurysm repair (TEVAR) patients - Management of

Publication: 27/09/2018  --
Last review: 01/01/1900  
Next review: 27/09/2021  
Clinical Guideline
CURRENT 
ID: 5712 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Please check the patients allergy status, as they may be allergic to Chlorhexidine, and alternative ( Providine iodine) solution will be required.
Be aware: Chlorhexidine is considered an environmental allergen.
Refer to the asepsis guidance.

Management of cerebrospinal fluid (CSF) drainage systems in thoracic endovascular aneurysm repair (TEVAR) patients

Introduction

These guidelines are intended for use with patients who have a Cerebrospinal Fluid (CSF) drainage system following Thoracic Endovascular Aneurysm Repair (TEVAR) or thoraco-abdominal aortic stent grafting. A CSF drainage system is a closed sterile temporary system, which allows drainage of CSF from the lumbar subarachnoid space.

The common uses of CSF drainage systems within Vascular surgery and Vascular radiology include:

  • Post-operative TEVAR – used for the monitoring and treatment of neurological complications after aortic intervention.
  • Emergency cases of unexpected Spinal Cord Ischemia (SCI) following TEVAR

This is the 1st edition of the guidelines.

Back to top

Aims

The guidelines aim to provide a safe procedure for the management of CSF drainage devices within Vascular Surgery and Vascular Radiology.

Back to top

Objectives

To provide recommendations for insertion, management and removal of CSF drainage devices in Vascular surgical patients as well as to create a protocol of managing the most common complications of CSF drainage devices.

Back to top

Background

Paraplegia after TEVAR is a devastating complication of thoracic aorta stent grafting. The incidence varies between 2 and 6% with the cause of paraplegia likely as a result of inadequate spinal cord perfusion. Not all thoracic stent graft patients will require CSF drainage devices with only those deemed high risk having a planned CSF drainage device placed prophylactically.

This decision should be a collaborative MDT decision between surgeon, anaesthetist and interventional radiology.

The spinal cord is supplied by the Anterior Spinal Artery (ASA) and two Posterior Spinal Arteries (PSA) which form an anastomotic ring surrounding the cord. These arteries run the length of the cord. Blood flow is auto-regulated between 50-80mmHg mean arterial pressure above CSF pressure. Multiple radicular perforator arteries arise from the aorta to further supply the ASA and PSA; the number of perforators within the thoracic region is limited making it at risk of ischaemia at this level.

Spinal cord perfusion depends upon the difference between Mean Arterial Pressure (MAP) and mean intrathecal pressure. Thereby we may increase spinal cord perfusion by increasing systemic MAP or reducing the intrathecal pressure. Intrathecal pressure may rise as a result of spinal cord ischaemia during or after the interruption of its blood supply during or after TEVAR. Spinal cord ischaemia causes oedema of the spinal cord with resultant increase in the intrathecal pressure.

Selective CSF drainage is the standard of care in all centres performing TEVAR in the UK.

The highest risk to spinal cord perfusion comes at the time of TEVAR or within the first 48 hours. Only those deemed high risk will have a drain placed prophylactically at the time of the procedure.

Late onset spinal cord ischaemia is a possibility so rarely patients may require CSF drainage devices inserted as an emergency after a TEVAR.

Risk factors for spinal cord ischaemia following TEVAR:

  • Planned long-segment aortic coverage
  • Stent-graft length >200 mm
  • Coverage of Left Subclavian artery with graft
  • Occlusion of intercostal arteries
  • Occlusion of internal iliac arteries
  • Perioperative hypotension
  • Previous AAA repair

The Decision for elective spinal cord drainage is made by the MDT treating the patient prior to the procedure, based on assessment of risk using the risk factors above.

CSF Drainage Systems are used during TEVAR because the arterial blood supply to the spinal cord during the procedure can be compromised with interruption of intercostal and upper lumbar arteries.

The European Association for Cardio-Thoracic Surgery has recommended:

  1. CSF drainage should be considered in patients undergoing TEVAR at high risk for SCI.
  2. CSF drainage should be continued for at least 48 h after TEVAR or open thoracic/thoracoabdominal repair.

Etz CD, Weigang E, Hartert M, Lonn L, Mestres CA, Di Bartolomeo R et al. Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery. Eur J Cardiothorac Surg 2015;47:943–57.

Back to top

Procedure

  1. Confirm patient identity and rule out contraindications to CSF drainage system placement. Explain the procedure to the patient (where possible), and complete the relevant consent form. Absolute contraindications include coagulopathy, infection at site, raised ICP/space occupying lesion and patient refusal. Relative contraindications include sepsis and antiplatelet/anticoagulant therapy. Ongoing Aspirin treatment should not prevent drain insertion.
  2. Prepare a CSF drainage system insertion trolley. The procedure is carried out in the presence of an assistant, who at the same time acts as a chaperone (refer to LTHT Chaperoning policy for more details).
  3. Place the patient in lateral decubitus position (sitting position is also possible), maximising flexion of the spine by bringing the knees up and flexing the neck. Maintain the patient's dignity at all times and only expose the area that is required for the procedure.
  4. Having washed hands with soap and water in accordance with LTHT Hand Hygiene Policy, establish the midline and the Tuffier's line (the line connecting the iliac crests that usually corresponds to the L3/4 interval or L4 spinous process). Estimate the level of insertion: L3/4 or L4/5 is usually preferred.
  5. At this stage, put on surgical hat and face mask, perform surgical scrub (using chlorhexidine or povidone iodine surgical soap) as detailed in LTHT Surgical Scrub, Gowning & Gloving Policy, and put on sterile gown and gloves aseptically.
  6. Clean the surgical site with chlorhexidine (0.5% in 70% alcohol); alternatively, alcoholic povidone iodine may be chosen where chlorhexidine is contraindicated (e.g. allergy). Currently no safety information is available regarding use of 2% chlorhexidine in procedures involving potential contact with CSF/neural tissues; for that reason, only 0.5% chlorhexidine in 70% alcohol solution should be employed.
  7. Cover the surgical site with a fenestrated drape. Sterility of the field is further facilitated by the use of additional adhesive drapes, where necessary.
  8. Lidocaine is the local anaesthetic of choice; 1% plain should be used (refer to British National Formulary for safe dosing). After checking the local anaesthetic with the assistant, infiltrate the skin using a 25G needle. Once the skin has been anaesthetised, administer the remaining anaesthetic to deeper tissues with a 21G needle, aspirating the syringe after each repositioning of the needle to ensure the tip is not within a vessel or the subarachnoid space.
  9. After checking that the skin has been adequately anaesthetised, ensure that the bevel of the spinal needle is directed towards the flank, and insert the needle. Continue to advance using a loss of resistance technique to saline to identify the epidural space.
  10. Remove the stylet. If no CSF is obtained, replace the stylet and advance the needle in increments, re-checking for CSF.
  11. As soon is CSF egress is achieved, insertion of the CSF drainage system has to be prompt to prevent excessive CSF losses. Tunnelling may be performed depending on the preferences of the Consultant responsible.
  12. The needle is rotated so that the bevel of the needle is directed cephalad. The stylet is then discarded, and 15-20 cm of the drain (estimated using the markings on the drain) is threaded in. The spinal needle is withdrawn. The tip protector is fed over the distal end of the drain, and the adaptor is attached.
  13. The area covered with appropriate clear dressing eg Tegaderm, and the drain is connected to a sterile closed drainage system.
  14. If the siting has been particularly bloody or difficult a discussion should occur about delaying the start for 30 mins or postponing surgery.

After procedure
Ensure the procedure is documented on the anaesthetic record and spinal drain summary (see appendix).

Back to top

Nursing care of the patient with a cerebrospinal fluid (CSF) drainage system

Patients following TEVAR with CSF Drainage Systems should be managed within a high dependency setting. Otherwise they can be managed on an appropriate critical care facility at the discretion of the senior intensive care medical/nursing staff. Staff should familiarise themselves with this document prior to caring for patients with a Cerebrospinal Fluid (CSF) Drainage System. Patients should not be managed on a non-critical care area.

Continuous assessment of both the patient and the drain is vital in preventing complications and in meeting the goal of lumbar drainage. The patient will normally be kept in bed while the drain is in place. CSF should be assessed hourly for colour, clarity and amount drained. Generally, the drain can be clamped for brief periods during care activities and patient movement.

The insertion site is assessed for signs and symptoms of infection or leakage at least twice every day. Dressing changes are usually carried out only if the dressing is soiled and replaced with a clear dressing (e.g. Tegaderm). The drainage bag is changed when full using aseptic technique and the 3-way-port proximal to the bag is clamped to prevent flow of CSF before change. 

Back to top

Patient pathway

  1. Not every TEVAR patient will require a CSF Drainage System. Only those deemed high risk for Spinal Cord Ischaemia (SCI) will have one sited prophylactically.
  2. Insertion of a CSF Drainage System can be undertaken within theatres, interventional radiology or within a high dependency setting only. The drain is inserted by a consultant anaesthetist or appropriately supervised trainee. It is possible to enlist the assistance of the neurosurgical interventional radiology consultant if siting is difficult.
  3. Physiological Targets:
    1. To maintain spinal cord perfusion pressure (SCPP = MAP – CSF Pressure)
    2. Maintain MAP to above 90mmHg using a vasopressor if necessary, at all times.
    3. Maximum CSF drainage of 20ml/hr.
    4. Ensure adequate volume/fluid status.
    5. Haemoglobin > 90g/L.
    6. Clotting normalised.
  4. Patient arrival on ICU/HDU Management – see section below
  5. Maintenance of CSF Drainage Systems on General ICU/HDU – see section below
  6. Removal of CSF Drainage Systems – see section below. Decision to remove lumbar drain should be in agreement between critical care, vascular surgical and vascular interventional radiological staff. Usually at 48-72hrs post procedure.
  7. Management of common complications – see section below. Initial responsibility for management is in collaboration between the anaesthetic intensive care staff and the Vascular team. Neurosurgery should be only consulted if complications are unable to be resolved by following these guidelines - this has been discussed and agreed by the lead clinician for Neurosurgery.

Back to top

Arrival on HDU management

Back to top

Management of cerebrospinal fluid (CSF) drainage systems on HDU

Any Problems – please contact the Vascular SpR (bleep 2031) to coordinate ongoing management

Back to top

Removal of cerebrospinal fluid (CSF) drainage systems

The CSF Drainage System is removed by the Critical care nursing staff. Strict adherence to LTHT Hand Hygiene, Standard Precautions and Asepsis policies and covered with an appropriate interactive dressing. Removal documentation must mention whether the tip of the drain was visualised.

  • Tips should only be sent for culture if infection is suspected. Discuss with Microbiology +/- neurosurgical referral if suspecting infection.
  • A Vascular surgeon must be informed immediately if the patient's neurological function deteriorates.

Any Problems – please contact the Vascular SpR (bleep 2031) to coordinate ongoing management

Back to top

The CSF Drainage System is removed by the Critical care nursing staff. Strict adherence to LTHT Hand Hygiene, Standard Precautions and Asepsis policies and covered with an appropriate interactive dressing. Removal documentation must mention whether the tip of the drain was visualised.

  1. Neurological deterioration
    1. If there is any change in sensory or motor function, inform medical staff and nurse in change immediately. Please contact the Vascular SpR (bleep 2031) to coordinate ongoing management.
    2. Check system is correctly aligned, set at prescribed level and that CSF is draining
    3. Ensure there are no kinks/blockages or disconnections of the system and the CSF Drainage System is still in situ
    4. Ensure MAP>90mmHg. Consider increasing MAP target >100mmHg. This may require fluids (dependent on volume status) or vasopressors (e.g. Phenylephrine)
    5. Reduce the CSF drainage pressure – reduce drainage pressure to 5cmH20 for 1 hour (allow a maximum 25ml/hr CSF drainage.)
    6. Reassess every 1 hour
    7. If symptoms not resolving reduce the CSF drainage pressure to 0 (zero) cmH20 and reassess in 1 hour.
    8. If resolution at any step above - keep the CSF drainage pressure at that level for next 6 hours then re-challenge the spinal cord at the higher incremental CSF drainage pressure while continuing permissive hypertension
    9. Consider early CT/MRI imaging of spine and brain +/- referral for advice from Neurosurgery if above steps not resolving symptoms
    10. If there is no CSF drainage system in situ either because it has been recently removed on ICU or the patient is on the ward and no drain was inserted prophylactically – consider insertion of spinal drain.
    11. Re-insertion of Cerebrospinal Fluid (CSF) Drainage System – within working hours Mon-Fri 08:00 – 18:00 discuss with Vascular Anaesthetists working in Theatre 2 Jubilee wing. Out of hours refer to neurosurgery - this has been agreed by the neurosurgical lead clinician.
  2. No flow
    1. When there is zero drainage in a 1 hour period – Check drain is zeroed to the entry site of the CSF drainage system (i.e. lower lumbar level)
    2. Ensure that the drain is set at the correct level – usually 10cmH20
    3. Check the line is free from kinks and the drainage 3 way tap system is set to “on”.
    4. Please contact the Vascular SpR (bleep 2031) to coordinate ongoing management.
    5. After 5 minutes, if there is no drainage lower to 5cmH20.
      1. If there is drainage at 5 cmH20 in 5 minutes, return to 10cmH20
      2. If there is NO drainage in 5 minutes at 5cmH20, inform the Vascular Consultant On-Call. The drain can, rarely, be set to 0 cmH20, but only after discussion with the consultant. If there is no drainage a risk benefit assessment for re-insertion should be made.
  3. Excessive flow
    1. If CSF flow is persistently high (i.e. >20ml/hr for 2 consecutive hours). CSF is produced at 20ml/hr so drainage greater than this constitutes a net decrease in the volume surrounding and supporting the brain/spinal cord and can lead to severe headaches and subdural haematomas.
    2. Check the level is aligned correctly (usually at 10 cmH20) and lie patient flat.
    3. Monitor neurological status and check for signs of headache.
    4. Inform ICU medical staff and nurse-in-charge. Please contact the Vascular SpR (bleep 2031) to coordinate ongoing management.
    5. The drain may be raised to 12cmH20.
    6. Observe for change in neurology.
    7. DO NOT CLAMP THE SYSTEM.
  4. CSF leaking from the drain site
    1. Remove dressing and examine the site.
    2. If no evidence of a leak, clean with chlorhexidine 2% and redress entry site with a transparent occlusive dressing.
    3. If leaking, inform ICU medical team and nurse-in-charge for ongoing management. Cover with a transparent occlusive dressing. Please contact the Vascular SpR (bleep 2031) to coordinate ongoing management.
  5. Break in the system
    1. If there is a disconnection in the system, clamp off both ends and clean with chlorhexidine 2%, wearing sterile gloves, wrap with sterile gauze and secure with sterile dressing such as tegaderm.
    2. There is risk bacteria will enter the CSF with further brain infections possible.
    3. Please contact the Vascular SpR (bleep 2031) to coordinate ongoing management.
    4. A decision at consultant level will decide on the relative risks of insertion of a new spinal catheter, reconnection of the disconnected drain or removal of the drain with neurological observation. Reconnection of the disconnected drain should only be considered in very high risk cases of spinal cord ischaemia in whom initial drain insertion was difficult.
    5. If removing a spinal drain please ensure no residual anticoagulation is in place and it is safe to do so (see guidance above).
  6. Visible blockage
    1. If visible blockage is seen, inform ICU medical staff and nurse-in-charge. Please contact the Vascular SpR (bleep 2031) to coordinate ongoing management.
    2. The blockage IS NOT to be flushed towards the patient.
    3. If it can be, any blockage will have to be carefully aspirated by medical staff. Only perform if competent to do so – if not refer to neurosurgery for advice. This has been agreed by the neurosurgical lead clinician.
  7. Visible blood
    1. If blood is seen on admission from vascular radiology, consult the accompanying anaesthetist for ongoing management. It is not uncommon to see blood staining of CSF due to microvascular bleeding and coagulopathy following TEVAR. The blood may also be the result of a traumatic insertion of the drain.
    2. If there is a new presentation of fresh blood inform the ICU medical staff and nurse-in-charge immediately. DO NOT CLAMP THE DRAINAGE SYSTEM. There could have been a subarachnoid bleed which can cause a sudden increase in pressure in the spinal column or block the drain. Both can lead to raised ICP, neurological deterioration and death.
    3. Please contact the Vascular SpR (bleep 2031) to coordinate ongoing management.
    4. CT/MRI may have to be ordered after discussion with ICU medical staff, Vascular Surgery and Interventional Radiology. Neurosurgical intervention maybe required - this has been agreed by the neurosurgical lead clinician.
  8. Infection
    1. Monitor for signs of infection: redness, swelling, leakage at entry site, pyrexia, stiff neck, photophobia, nausea and vomiting, confusion and agitation.
    2. Inform ICU medical staff and nurse-in-charge immediately. Please contact the Vascular SpR (bleep 2031) to coordinate ongoing management.
    3. Medical staff may need to take and send CSF samples from the drain by gently aspirating 1ml from the 3 way tap aseptically. Only perform if competent to do so – if not refer to neurosurgery for advice.
    4. Medical staff may need to take a lumbar puncture sample if drain already removed.
    5. Discuss with microbiology regarding management of possible infection.
    6. Consider discussion with Neurosurgery - this has been agreed by the neurosurgical lead clinician.

Back to top

Cerebrospinal fluid (CSF) drainage system insertion guide

  1. Preliminaries
    1. Consent – discuss procedure including complications
    2. Rule out contraindications:
      1. Absolute – coagulopathy, infection at site, raised ICP/space occupying lesion, patient refusal
      2. Relative – sepsis, antiplatelet/anticoagulant therapy (as per epidural insertion guidance)
    3. Document baseline neurology and current anticoagulant status
    4. Strict asepsis best achieved in theatre/interventional radiology setting
    5. Postoperative care must be within a critical care setting

2. Equipment check

  1. Spinal drain kit
  2. Compatible spinal drain system (Medtronic lumbar drainage kit – available in JW Th 5)
  3. Epidural insertion pack
  4. Other – sterile saline, local anaesthetic

3. Patient position

  1. Lateral decubitus with legs flexed preferred - reduces risk of excessive CSF loss
  2. Awake vs asleep. Both are practiced within this hospital
  3. Insertion level ideally below L2/3

4. Preparation

  1. Full aseptic technique as per neuro-axial anaesthesia
  2. Skilled assistant essential
  3. Familiarise yourself with equipment
    1. 14G tuohy needle, wingless, with no markings
    2. Spinal drain catheter – soft silicone tube with multiple holes proximal to tip and black markings
    3. Standard epidural insertion pack
  4. Level of insertion – as per spinal (L3/4)

5. Inserting spinal drain

  1. Advance 14G Tuohy LOR Saline
  2. Advance slowly 1mm at a time until free flow of CSF, a typical give can usually be felt once the subarachnoid space is reached.
  3. Replace the Stylet or Syringe to stop excessive CSF loss and rotate the needle so that it is pointing cephalad
  4. Pass the spinal catheter through the Tuohy needle
    NB – Catheter markings begin at 10cm

6. Needle removal

Advance catheter 15-20cm and then slowly withdraw the spinal needle.
The tip protector is fed over the distal end of the drain, and the adaptor is attached.
NB – do not use excessive force – this may result in a fractured catheter.
NB – check for adequate CSF flow – this may initially be blood stained but should clear with continued drainage.

7. Post insertion care

  1. Secure spinal catheter with a transparent occlusive dressing.
  2. Lumbar drainage system should be de-aired and flushed with saline aseptically
  3. Connect the spinal drain to the drainage system
  4. Zero to the reference point at the level of the insertion level (i.e. Lower Lumbar Level) and set the CSF Drainage System to 10cmH20 as shown in the picture.
  5. Make sure CSF flows easily from the catheter into the drainage system

8. Hints and tips

  1. The spinal drain catheter can be quite flexible, some anaesthetists find a more cephalad angulation can help with threading into the subarachnoid space.
  2. If there is difficulty with insertion please communicate with the consultant vascular surgeons and interventional radiologists to discuss to benefits/risks of continuing or postponing surgery.
  3. If you struggle finding the intrathecal space, Interventional Neurosurgical Radiology have previously been of assistance but no formal agreement is in place.
  4. If CSF flow is good but the spinal catheter won’t feed, a standard epidural catheter can be used, especially if the drain is felt to be essential. The alternative would be to use a standard epidural kit and catheter which would be acceptable if unable to site a lumbar drain kit.

9. Bloody taps

  1. If bloody Epidural tap – consider siting at the space above. Avoid Heparin for at least 1 hour post insertion.
  2. If the vascular procedure is expected to be complex and drain essential, consider delaying surgery for 30 minutes, it may be necessary to postpone surgery.
  3. If CSF blood tinged - this is acceptable especially if it clears. Consider delaying surgery for 30 minutes.
  4. If CSF frank blood – procedure should be abandoned and consider postponing surgery, Neuro-imaging may be necessary.

Provenance

Record: 5712
Objective:

To provide recommendations for insertion, management and removal of CSF drainage devices in Vascular surgical patients as well as to create a protocol of managing the most common complications of CSF drainage devices.

Clinical condition:

Handling Cerebrospinal Fluid (CSF) Drainage Systems

Target patient group: Any patient undergoing insertion of Cerebrospinal Fluid (CSF) Drainage System in Vascular Surgical patients
Target professional group(s): Secondary Care Doctors
Adapted from:

Evidence base

Evidence base

Evidence level:
Supported use from the European Association for Cardio-thoracic Surgery
IIa - Weight of evidence/opinion is in favour of usefulness/efficacy
C - Consensus of opinion of experts and/or small studies, retrospective studies, registries.

References:

  • D. A. Scott, M. J. Denton; Spinal cord protection in aortic endovascular surgery, BJA: British Journal of Anaesthesia, Volume 117, Issue suppl_2, 1 September 2016, Pages ii26–ii31.
  • Etz CD, Weigang E, Hartert M, Lonn L, Mestres CA, Di Bartolomeo R et al. Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery. Eur J Cardiothorac Surg 2015;47:943–57.
  • Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: Results of a randomized clinical trial. Coselli, Joseph S. et al. Journal of Vascular Surgery , Volume 35 , Issue 4 , 631 – 639.
  • Khan SN, Stansby G. Cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery. Cochrane Database of Systematic Reviews 2012, Issue 10.
  • Contemporary Single-Center Experience With Prophylactic Cerebrospinal Fluid Drainage for Thoracic Endovascular Aortic Repair in Patients at High Risk for Ischemic Spinal Cord Injury. Mazzeffi M, Abuelkasem E, Drucker CB, Kalsi R, Toursavadkohi S, Harris DG, Rock P, Tanaka K, Taylor B, Crawford R. J Cardiothorac Vasc Anesth. 2017 Dec 6. pii: S1053-0770(17)30987-4.
  • A systematic review of spinal cord injury and cerebrospinal fluid drainage after thoracic aortic endografting. Wong CS, Healy D, Canning C, Coffey JC, Boyle JR, Walsh SR. J Vasc Surg. 2012 Nov;56(5):1438-47.
  • Effects of preemptive cerebrospinal fluid drainage on spinal cord protection during thoracic endovascular aortic repair. Song, Seungjun; Song, Suk-Won; Kim, Tae Hoon; Lee, Kwang-Hun; Yoo, Kyung-Jong Source Journal of thoracic disease; Aug 2017; vol. 9 (no. 8); p. 2404-2412.
  • Intraoperative neuroprotective interventions prevent spinal cord ischemia and injury in thoracic endovascular aortic repair.
Acher, Charles; Acher, C W; Marks, Erich; Wynn, Martha
Source Journal of vascular surgery; Jun 2016; vol. 63 (no. 6); p. 1458-1465.
  • Results of adjunctive spinal drainage and/or left subclavian artery bypass in thoracic endovascular aortic repair.
Arnaoutakis DJ; Arnaoutakis GJ; Beaulieu RJ; Abularrage CJ; Lum YW; Black JH Source Annals of vascular surgery; Jan 2014; vol. 28 (no. 1); p. 65-73.
  • Fate of patients with spinal cord ischemia complicating thoracic endovascular aortic repair. DeSart K; Scali ST; Feezor RJ; Hong M; Hess PJ; Beaver TM; Huber TS; Beck AW Source Journal of vascular surgery; Sep 2013; vol. 58 (no. 3); p. 635-42.e2.
  • Results with selective preoperative lumbar drain placement for thoracic endovascular aortic repair.
Hanna JM; Andersen ND; Aziz H; Shah AA; McCann RL; Hughes GC
Source The Annals of thoracic surgery; Jun 2013; vol. 95 (no. 6); p. 1968.
  • Spinal cord protection with a cerebrospinal fluid drain in a patient undergoing thoracic endovascular aortic repair.
Lam CH; Vatakencherry G
Source Journal of vascular and interventional radiology: JVIR; Sep 2010; vol. 21 (no. 9); p. 1343-1346.
  • Açikbaş SC, Akyüz M, Kazan S, Tuncer R. Complications of closed continuous lumbar drainage of cerebrospinal fluid. Acta Neurochir (Wien). 2002 May;144(5):475-80.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.