Despite a “dramatic” decrease in the use of prophylactic cerebrospinal fluid drains (CSFDs) for the prevention of spinal cord ischemia (SCI) in patients undergoing fenestrated and branched endovascular aortic repair (F/BEVAR), the rate of SCI has tracked a similarly dramatic decrease, according to the senior author of a new analysis of U.S. Aortic Research Consortium (ARC) data from 2011–2024.
Adam Beck, MD, the Holt A. McDowell Jr., MD, endowed chair of vascular surgery at the University of Alabama at Birmingham (UAB), described the data as likely practice-changing for many specialists who carry out complex repairs of thoracoabdominal aortic aneurysms (TAAAs) ahead of their presentation at the 2025 annual meeting of the Southern Association for Vascular Surgery (SAVS) in St. Thomas, the U.S. Virgin Islands (Jan. 22–25).
The retrospective analysis of the ARC registry—which encompasses 10 major medical centers with individual investigational device exemption (IDE) studies for complex aortic repairs—included 2,585 patients undergoing elective F/BEVAR. Eras of repair were divided into early (2011–2013), mid (2014–2021) and late (2022–2024) based on the publication of influential papers which changed ARC practices. Patient cohorts were separated by prophylactic (n=949), therapeutic (n=27) and no CSFD (n=1609) use. A composite variable consisting of any SCI, major CSFD complication or intracerebral hemorrhage was designated as the primary outcome.
The ARC data showed that 196 patients (7.6%) experienced the primary composite outcome and 160 (6.2%) experienced SCI. Presenting the data, Angela Sickels, MD, an integrated vascular surgery resident at UAB, told SAVS 2025: “The yearly incidence of the primary composite outcome and any SCI gradually declined over time, from a maximum of 25% [for both primary composite and SCI] in 2011 to 2.8% and 2.3%, respectively, in 2023.”
Meanwhile, the use of prophylactic CSFD declined from “being essentially universally done” in 2011 down to just 10.9% in 2023 “without any substantial increase in therapeutic CSFD use, which reached a maximum of just 3.5%,” Sickels said.
In high-risk patients (n=1026), 12.9% (n=132) and 10.6% (n=109) experienced the primary composite outcome or any SCI event, respectively, the data revealed. Rates of the primary composite outcome declined from 38.5% in 2013 to 3% in 2023. Prophylactic CSFD use in high-risk patients—while nearly universal (92.9–100%) until 2016—has also since been on a continuous decline, reaching a minimum of 22.6% in 2023, the research shows. “This subset of patients also saw no increase in therapeutic drain use, reaching a maximum of 5.9%,” Sickels added.
Speaking to Vascular Specialist about the significance of the findings, Beck noted how as experience of endovascular long-segment coverage of TAAAs over the last decade has expanded, discussion and education around SCI prevention protocols, too, have broadened at most large medical centers. “With implementation of defined protocols, the rate of SCI has dropped significantly over the last five or 10 years,” he said.
The ARC data, Beck said, shows a “rapid drop, especially over the last eight years or so, in the rate of SCI. In addition, interestingly people have been using less and less prophylactic spinal drains, and we think that that’s probably because the rate of SCI has dropped with the use of SCI prevention protocols and is almost equivalent to the risk of the placement of spinal drains.”
Beck continues: “Most of the surgeons who have been doing these procedures will have stories about complications associated with the drains, which can be anywhere from 5–10%. Now, the SCI rate is in that 5–10% range, so essentially the risk of SCI is almost equivalent to—or is equivalent to—the risk of putting a drain in, so there is clinical equipoise there.”
One question remains, added Beck. “If you were to randomize patients with an especially high risk of SCI to prophylactic drains or not, whether prophylactic drains would actually prevent SCI—we still do not know the answer to that question.”
Beck believes the education that the ARC research has yielded has led to better outcomes. “There is a learning curve to this and there has been a regression to the mean with how everyone is managing these patients,” he said. “Early on, some of us had well-defined SCI prevention protocols, and some of us were doing things that we thought reduced the risk but didn’t necessarily have a well-formed protocol for it. There has been a lot of conversation around this complication in our monthly ARC meetings and at national/international educational meetings, and I think the dissemination of information and everyone learning from each other has led to this decrease in SCI.”
The ARC researchers are now working on a propensity matched analysis that looks at similar patients with and without prophylactic CSFDs to help evaluate whether the drains help prevent SCI.
“This project was done in preparation for a randomized trial looking at patients with and without prophylactic drains. Given our findings, we are beginning to think that the trial may not be necessary or will be very difficult to complete because of the very low expected effect size of the prophylactic drains. This would necessitate a very large clinical trial, which may not be feasible,” Beck added.
