First-in-man endovascular preconditioning of the paraspinal collateral network by segmental artery coil embolization to prevent ischemic spinal cord injury

Objective: Spinal cord injury remains an invincible complication affecting up to 1 of 5 patients after thoracoabdominal aortic aneurysm repair. A staged surgical approach has been suggested to eliminate paraplegia by induction of arteriogenesis within the paraspinal collateral network; however, its clinical implementation was deferred because it required 2 major procedures. Methods: First-in-man experience with minimally invasive, selective segmental artery endovascular coil embolization before Crawford type II and III thoracoabdominal aortic aneurysm repair for arteriogenic preconditioning of the collateral network is reported. A 45-year-old man received bilateral elective minimally invasive, selective segmental artery endovascular coil embolization of 2 unilateral lumbar segmental arteries 4 weeks before open surgical repair. A 67-year-old woman who was planned for total endovascular treatment received minimally invasive, selective segmental artery endovascular coil embolization at the fourth lumbar level and coil embolization of the inferior mesenteric artery 8 weeks before endovascular repair. Results: Minimally invasive, selective segmental artery endovascular coil embolization was technically successful and did not result in any neurologic impairment. Both patients were discharged after 72 hours of clinical surveillance. Patient 1 returned for definite open single-stage thoracoabdominal aortic aneurysm repair after 4 weeks and left the hospital without any neurologic impairment on day 35 postoperatively. Patient 2 returned for total endovascular repair 8 weeks after she underwent minimally invasive, selective segmental artery endovascular coil embolization; she recovered well and was discharged without spinal cord injury 8 days after extensive single-stage endovascular thoracoabdominal aortic aneurysm repair. Both patients are alive with no neurologic injury at 1-year follow-up. Conclusions: Minimally invasive, selective segmental artery endovascular coil embolization for arteriogenic preconditioning of the paraspinal arterial collateral network is clinically feasible and may eventually eliminate ischemic spinal cord injury to enable safe open or endovascular repair of extensive thoracoabdominal aortic aneurysms and prevent paraplegia altogether in the near future.