AB085. SOH26AB_0341. From sentinel event to system change: a quality improvement program for spinal cord protection in complex endovascular aortic repair

Background: Spinal cord ischaemia (SCI) is a rare but devastating complication of complex endovascular aortic repair (EVAR). Despite established spinal-cord-protection strategies, including strict mean arterial pressure (MAP) targets, optimisation of oxygen delivery, and multimodal neuromonitoring, perioperative neurological injury can still occur. An index case of acute paraplegia following urgent branched EVAR at University Hospital Limerick prompted a multidisciplinary review and the development of a targeted spinal cord protection quality improvement (QI) program. We describe the case and QI program.

Methods: A root-cause analysis of the index case, in which an adult male developed paraplegia within 12 hours of branched EVAR but demonstrated neurological improvement following cerebrospinal fluid (CSF) drainage, identified delayed lumbar drain insertion as the principal modifiable factor. Guided by local aortic aneurysm standard operating procedures (SOPs) and established spinal cord protection recommendations, a multidisciplinary team developed a standardised spinal cord protection pathway. Key QI interventions included: Routine pre-operative identification of high-risk patients (extensive aortic coverage, prior aortic repair, reduced collateral network, haemodynamic fragility). Planned pre-operative lumbar drain insertion for high-risk cases to allow controlled CSF pressure management from induction to the early postoperative period. Standardised MAP targets, positioning protocols, and structured neurological observation schedules.

Results: In the first post-implementation cycle, five consecutive high-risk patients underwent complex EVAR with planned pre-operative lumbar drains. No perioperative neurological deficits occurred in this cohort. Compliance with MAP targets, positioning instructions, and neurological monitoring exceeded 95%, demonstrating strong adoption of the pathway.

Conclusions: A single critical SCI event led to the development of a structured QI program for spinal cord protection in complex EVAR. Incorporating routine pre-operative lumbar drainage for clearly defined high-risk patients within a standardised care pathway has improved process reliability and was associated with zero SCI events in the initial cohort. Continued audit and iterative refinement will be essential to sustaining and expanding this improvement.

Keywords: Spinal cord ischaemia (SCI); complex endovascular aortic repair (complex EVAR); lumbar cerebrospinal fluid drainage (lumbar CSF drainage); quality improvement (QI); aortic repair