Staging Strategies During Complex Endovascular Aortic Procedures to Minimize Spinal Cord Ischemia Rates: A Narrative Review

Endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) requires multidisciplinary expertise to minimize mortality and disabling complications. Despite satisfactory outcomes with this approach being common knowledge, extensive aortic coverage occurring in fenestrated/branched endovascular aortic repair (F/B-EVAR) carries a non-negligible risk of spinal cord ischemia (SCI). Recently, many authors have proposed different endovascular strategies to mitigate the risk of SCI; however, the real effectiveness of these maneuvers is not universally recognized due to a lack of standardized protocols among individual centers. Several adjuncts have been proposed to obtain staged occlusion of segmental aortic branches to promote spinal cord preconditioning. These strategies include proximal thoracic aortic repair (PTAR), temporary aneurysm sac perfusion (TASP), and minimally invasive staged segmental artery coil embolization (MIS2ACE). The present paper aims to provide an overview of the most advanced staging strategies used in high-volume aortic centers, pointing out that it takes meticulous preoperative planning to face every clinical scenario.