Complications of Cerebrospinal Fluid Drainage in Thoracic and Complex Endovascular Aortic Repair

Cerebrospinal fluid drainage (CSFD) is widely used for neuroprotection during thoracic and complex endovascular aortic repair (TEVAR/cEVAR), yet its safety profile remains incompletely defined. This study evaluated the incidence, severity, and risk factors of CSFD-related complications in clinical practice.

This retrospective single-center study included consecutive patients undergoing TEVAR or complex EVAR with perioperative CSFD between January 2010 and October 2023. The indication for CSFD was based on institutional risk assessment, including extent of aortic coverage, prior aortic repair, and clinical presentation. Primary outcomes were CSFD-associated complications (major, minor, headache). Secondary outcomes included spinal cord ischemia and 30-day mortality. Multivariable logistic regression identified predictors of major complications.

A total of 251 patients were included (154 TEVAR, 97 cEVAR); CSFD was applied prophylactically in 239 patients only, therapeutically in 9 patients only, and both prophylactically and therapeutically in 3 patients. Median age was 69 years, and 53.8% had prior aortic surgery. Major CSFD-related complications occurred in 4.4% (11/251), all hemorrhagic, with mortality in 2 patients. Minor complications occurred in 16.7%, and headache in 7.2%. Spinal cord ischemia developed in 4.5% despite prophylactic drainage. In exploratory multivariable analysis, lower BMI was associated with major CSFD-associated complications (OR 0.82, 95% CI 0.69-0.97; p=0.022), while therapeutic CSFD was significant only in univariable analysis. Thirty-day mortality was 8.0%.

CSFD-associated complications were common, with hemorrhagic events accounting for all major complications. These findings emphasize the need for careful patient selection, standardized CSFD management, and close neurological monitoring when CSFD is used during complex endovascular aortic repair.