Title: Modern Strategies for SCI Prevention after Aortic Repair: Are We Winning the Battle?

Spinal cord ischemia (SCI) remains one of the most feared complications of thoracoabdominal aortic repair, particularly as endovascular techniques have expanded the scope and complexity of disease we treat. This Grand Rounds will review the evolution of endovascular thoracoabdominal aneurysm repair, highlighting how advances in device design and procedural strategy have shifted—but not eliminated—the risk of neurologic injury.

The talk will examine the pathophysiology and established risk factors for SCI, including anatomic extent, collateral network disruption, perioperative hemodynamics, and patient-specific vulnerabilities. Current prevention strategies—such as cerebrospinal fluid drainage, permissive hypertension, staging strategies, collateral preservation, and perioperative monitoring—will be critically reviewed with an emphasis on evidence rather than dogma.

Finally, outcomes from the largest contemporary global experiences will be presented to assess whether modern strategies have meaningfully reduced SCI rates. The session will conclude with a discussion of future directions, including refined risk stratification, procedure staging, device innovation, and systems-based approaches aimed at further improving neurologic outcomes after complex aortic repair.

Learning Objectives

By the end of this session, participants will be able to:

1. Describe the historical evolution of endovascular thoracoabdominal aortic repair and its impact on spinal cord ischemia risk.
2. Identify key patient-, anatomic-, and procedure-related risk factors for spinal cord ischemia and the evidence supporting current prevention strategies.
3. Evaluate contemporary SCI rates from large international experiences and discuss emerging strategies aimed at further reducing neurologic complications, modern techniques and future directions