Spinal Cord Ischemia Following Endovascular Abdominal Aortic Aneurysm Repair: An Unpredictable Catastrophe

Abstract

Spinal cord ischemia (SCI) following endovascular abdominal aortic aneurysm (AAA) repair (EVAR) is a rare yet catastrophic complication. The underlying pathophysiological mechanism remains incompletely understood. We present the case of a 75-year-old man with a difficult left common iliac artery (CIA) anatomy that necessitated the coiling of his left internal iliac artery (IIA) to ensure proper sealing of his aortic stent graft. The patient complained of bilateral lower extremity weakness immediately following the procedure. The patient was diagnosed with SCI, which was later confirmed by magnetic resonance imaging (MRI). He was treated with cerebrospinal fluid drainage. The patient's neurological status mildly improved on follow-up one year later.

Keywords: endovascular abdominal aortic aneurysm repair; endovascular complications; neurologic injury; spinal cord ischemia; stent graft.

Figure 1. Abdominal aortic aneurysm: axial (panel A) and coronal (panel B) pre-procedural computed tomography angiograph slices showing the abdominal aortic aneurysm (white arrows).

Figure 2. Short left common iliac artery: coronal pre-procedural computed tomography angiography coronal slices showing the left common iliac artery (panel A) and bifurcation (panel B). Note the short left common iliac artery of less than 1 cm in length (white arrows).

Figure 3. Coiling of the internal iliac artery: multiple cook coils were deployed over a catheter to occlude the proximal portion of the internal iliac artery (white arrow).

Figure 4. Regain of blood flow: completion angiogram showing the regain of blood flow.

Figure 5. Follow-up MRI: magnetic resonance imaging sagittal (panel A) and axial (panel B) slices two weeks following discharge showing edema and expansion of the distal spinal cord with an abnormal signal on diffusion-weighted imaging concerning for ischemia of the conus medullaris (white arrows).