The 18 Delphi consensus questions and the level of importance and level of consensus
| Delphi questions: Open and endovascular aortic repair . | Median . | 1st Quartile . | 3rd Quartile . | IQR . | QD . | . |
|---|---|---|---|---|---|---|
| 1. CSF drainage should be used in all patients undergoing OPEN types I, II, III and V TAAA repair and should be considered in patients undergoing type IV repair if additional risk factors for symptomatic spinal cord injury are present. (Risk factors would be occlusion of 1 or more vascular territories feeding the collateral network.) | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 2. CSF drainage should be used in all patients undergoing ENDOVASCULAR types I, II, III and V repair and may be considered in patients undergoing type IV repair if additional risk factors for symptomatic spinal cord injury are present. (Risk factors would be occlusion of 1 or more vascular territories feeding the collateral network.) | 4.00 | 3.00 | 5.00 | 2.00 | 1.00 | High importance – no consensus |
| 3. In OPEN types I, II, III and V TAAA repair, despite CSF drainage, at least 1 additional method (MEPs, SEPs or paravertebral NIRS) to monitor spinal cord perfusion should be routinely used. | 4.00 | 3.50 | 5.00 | 1.50 | 0.75 | High importance – moderate consensus |
| 4. In ENDOVASCULAR types I, II, III and V TAAA repair, despite CSF drainage, at least 1 additional method (MEPs, SEPs or paravertebral NIRS) to monitor spinal cord perfusion should be considered. | 3.00 | 2.00 | 3.25 | 1.25 | 0.63 | Low importance – moderate consensus |
| 5. Cerebral NIRS should be used in all patients undergoing an OPEN type I or II TAAA repair. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 6. Cerebral NIRS should be considered in patients undergoing an OPEN type III or V TAAA repair | 4.00 | 3.00 | 4.00 | 1.00 | 0.50 | High importance – high consensus |
| 7. Staged OPEN or hybrid repair (TEVAR + OPEN repair of remaining downstream aortic segments) or preoperative minimally invasive segmental artery coil embolization (MISACE protocol) should be considered if feasible. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 8. Staged ENDOVASCULAR TAAA repair or preinterventional minimally invasive segmental artery coil embolization (MISACE protocol) should be considered, if appropriate, to minimize the risk of symptomatic spinal cord injury. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 9. In ENDOVASCULAR TAAA repair, an “intentional endoleak“ (branch that remains initially open) may be a useful option to prevent symptomatic spinal cord injury. | 4.00 | 3.75 | 5.00 | 1.25 | 0.63 | High importance – moderate consensus |
| 10. In case of a bloody puncture, the placement of the CSF drain should be discontinued and the operation should be rescheduled. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 11. In case of bloody puncture, delay of rescheduling the procedure and re-puncturing should be at least 24 hours. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 12. When puncturing for CSF drainage, initial puncture pressure should be monitored. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 13. Intraoperatively the CSF pressure should not exceed 10-15 mmHg. However, initial pressures should be used as a reference, and higher values might be accepted if preoperative CSF pressure was higher. | 4.00 | 3.75 | 5.00 | 1.25 | 0.63 | High importance – moderate consensus |
| 14. Postoperatively, in the absence of symptomatic spinal cord injury, the CSF pressure should be kept to preoperative levels but should not exceed 10–15 mmHg. However, initial pressures should be used as a reference and higher values might be accepted if preoperative CSF pressure was higher. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 15. If spinal cord injury is suspected intraoperatively, CSF pressure should be kept below preoperative CSF pressure. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 16. In the absence of symptomatic spinal cord injury, the CSF drain can be removed 48–72 hours after OPEN TAAA repair. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 17. In the absence of symptomatic spinal cord injury, the CSF drain can be removed 24–72 hours after ENDOVASCULAR TAAA repair. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 18. In case of symptomatic spinal cord injury, CSF drainage should be kept at least 2 days beyond when the diagnosis is established, even if CSF pressure has already returned to preoperative levels. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| Delphi questions: Open and endovascular aortic repair . | Median . | 1st Quartile . | 3rd Quartile . | IQR . | QD . | . |
|---|---|---|---|---|---|---|
| 1. CSF drainage should be used in all patients undergoing OPEN types I, II, III and V TAAA repair and should be considered in patients undergoing type IV repair if additional risk factors for symptomatic spinal cord injury are present. (Risk factors would be occlusion of 1 or more vascular territories feeding the collateral network.) | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 2. CSF drainage should be used in all patients undergoing ENDOVASCULAR types I, II, III and V repair and may be considered in patients undergoing type IV repair if additional risk factors for symptomatic spinal cord injury are present. (Risk factors would be occlusion of 1 or more vascular territories feeding the collateral network.) | 4.00 | 3.00 | 5.00 | 2.00 | 1.00 | High importance – no consensus |
| 3. In OPEN types I, II, III and V TAAA repair, despite CSF drainage, at least 1 additional method (MEPs, SEPs or paravertebral NIRS) to monitor spinal cord perfusion should be routinely used. | 4.00 | 3.50 | 5.00 | 1.50 | 0.75 | High importance – moderate consensus |
| 4. In ENDOVASCULAR types I, II, III and V TAAA repair, despite CSF drainage, at least 1 additional method (MEPs, SEPs or paravertebral NIRS) to monitor spinal cord perfusion should be considered. | 3.00 | 2.00 | 3.25 | 1.25 | 0.63 | Low importance – moderate consensus |
| 5. Cerebral NIRS should be used in all patients undergoing an OPEN type I or II TAAA repair. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 6. Cerebral NIRS should be considered in patients undergoing an OPEN type III or V TAAA repair | 4.00 | 3.00 | 4.00 | 1.00 | 0.50 | High importance – high consensus |
| 7. Staged OPEN or hybrid repair (TEVAR + OPEN repair of remaining downstream aortic segments) or preoperative minimally invasive segmental artery coil embolization (MISACE protocol) should be considered if feasible. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 8. Staged ENDOVASCULAR TAAA repair or preinterventional minimally invasive segmental artery coil embolization (MISACE protocol) should be considered, if appropriate, to minimize the risk of symptomatic spinal cord injury. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 9. In ENDOVASCULAR TAAA repair, an “intentional endoleak“ (branch that remains initially open) may be a useful option to prevent symptomatic spinal cord injury. | 4.00 | 3.75 | 5.00 | 1.25 | 0.63 | High importance – moderate consensus |
| 10. In case of a bloody puncture, the placement of the CSF drain should be discontinued and the operation should be rescheduled. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 11. In case of bloody puncture, delay of rescheduling the procedure and re-puncturing should be at least 24 hours. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 12. When puncturing for CSF drainage, initial puncture pressure should be monitored. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 13. Intraoperatively the CSF pressure should not exceed 10-15 mmHg. However, initial pressures should be used as a reference, and higher values might be accepted if preoperative CSF pressure was higher. | 4.00 | 3.75 | 5.00 | 1.25 | 0.63 | High importance – moderate consensus |
| 14. Postoperatively, in the absence of symptomatic spinal cord injury, the CSF pressure should be kept to preoperative levels but should not exceed 10–15 mmHg. However, initial pressures should be used as a reference and higher values might be accepted if preoperative CSF pressure was higher. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 15. If spinal cord injury is suspected intraoperatively, CSF pressure should be kept below preoperative CSF pressure. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 16. In the absence of symptomatic spinal cord injury, the CSF drain can be removed 48–72 hours after OPEN TAAA repair. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 17. In the absence of symptomatic spinal cord injury, the CSF drain can be removed 24–72 hours after ENDOVASCULAR TAAA repair. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 18. In case of symptomatic spinal cord injury, CSF drainage should be kept at least 2 days beyond when the diagnosis is established, even if CSF pressure has already returned to preoperative levels. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
CSF: cerebrospinal fluid; IQR: interquartile range; MEPs: motor evoked potentials; MISACE: minimally invasive segmental artery coil embolization; NIRS: near infrared spectroscopy; QD: quartile deviation; SEPs: somatosensory evoked potentials; TAAA: thoracoabdominal aortic aneurysm; TEVAR: thoracic endovascular aortic repair.
The 18 Delphi consensus questions and the level of importance and level of consensus
| Delphi questions: Open and endovascular aortic repair . | Median . | 1st Quartile . | 3rd Quartile . | IQR . | QD . | . |
|---|---|---|---|---|---|---|
| 1. CSF drainage should be used in all patients undergoing OPEN types I, II, III and V TAAA repair and should be considered in patients undergoing type IV repair if additional risk factors for symptomatic spinal cord injury are present. (Risk factors would be occlusion of 1 or more vascular territories feeding the collateral network.) | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 2. CSF drainage should be used in all patients undergoing ENDOVASCULAR types I, II, III and V repair and may be considered in patients undergoing type IV repair if additional risk factors for symptomatic spinal cord injury are present. (Risk factors would be occlusion of 1 or more vascular territories feeding the collateral network.) | 4.00 | 3.00 | 5.00 | 2.00 | 1.00 | High importance – no consensus |
| 3. In OPEN types I, II, III and V TAAA repair, despite CSF drainage, at least 1 additional method (MEPs, SEPs or paravertebral NIRS) to monitor spinal cord perfusion should be routinely used. | 4.00 | 3.50 | 5.00 | 1.50 | 0.75 | High importance – moderate consensus |
| 4. In ENDOVASCULAR types I, II, III and V TAAA repair, despite CSF drainage, at least 1 additional method (MEPs, SEPs or paravertebral NIRS) to monitor spinal cord perfusion should be considered. | 3.00 | 2.00 | 3.25 | 1.25 | 0.63 | Low importance – moderate consensus |
| 5. Cerebral NIRS should be used in all patients undergoing an OPEN type I or II TAAA repair. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 6. Cerebral NIRS should be considered in patients undergoing an OPEN type III or V TAAA repair | 4.00 | 3.00 | 4.00 | 1.00 | 0.50 | High importance – high consensus |
| 7. Staged OPEN or hybrid repair (TEVAR + OPEN repair of remaining downstream aortic segments) or preoperative minimally invasive segmental artery coil embolization (MISACE protocol) should be considered if feasible. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 8. Staged ENDOVASCULAR TAAA repair or preinterventional minimally invasive segmental artery coil embolization (MISACE protocol) should be considered, if appropriate, to minimize the risk of symptomatic spinal cord injury. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 9. In ENDOVASCULAR TAAA repair, an “intentional endoleak“ (branch that remains initially open) may be a useful option to prevent symptomatic spinal cord injury. | 4.00 | 3.75 | 5.00 | 1.25 | 0.63 | High importance – moderate consensus |
| 10. In case of a bloody puncture, the placement of the CSF drain should be discontinued and the operation should be rescheduled. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 11. In case of bloody puncture, delay of rescheduling the procedure and re-puncturing should be at least 24 hours. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 12. When puncturing for CSF drainage, initial puncture pressure should be monitored. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 13. Intraoperatively the CSF pressure should not exceed 10-15 mmHg. However, initial pressures should be used as a reference, and higher values might be accepted if preoperative CSF pressure was higher. | 4.00 | 3.75 | 5.00 | 1.25 | 0.63 | High importance – moderate consensus |
| 14. Postoperatively, in the absence of symptomatic spinal cord injury, the CSF pressure should be kept to preoperative levels but should not exceed 10–15 mmHg. However, initial pressures should be used as a reference and higher values might be accepted if preoperative CSF pressure was higher. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 15. If spinal cord injury is suspected intraoperatively, CSF pressure should be kept below preoperative CSF pressure. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 16. In the absence of symptomatic spinal cord injury, the CSF drain can be removed 48–72 hours after OPEN TAAA repair. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 17. In the absence of symptomatic spinal cord injury, the CSF drain can be removed 24–72 hours after ENDOVASCULAR TAAA repair. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 18. In case of symptomatic spinal cord injury, CSF drainage should be kept at least 2 days beyond when the diagnosis is established, even if CSF pressure has already returned to preoperative levels. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| Delphi questions: Open and endovascular aortic repair . | Median . | 1st Quartile . | 3rd Quartile . | IQR . | QD . | . |
|---|---|---|---|---|---|---|
| 1. CSF drainage should be used in all patients undergoing OPEN types I, II, III and V TAAA repair and should be considered in patients undergoing type IV repair if additional risk factors for symptomatic spinal cord injury are present. (Risk factors would be occlusion of 1 or more vascular territories feeding the collateral network.) | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 2. CSF drainage should be used in all patients undergoing ENDOVASCULAR types I, II, III and V repair and may be considered in patients undergoing type IV repair if additional risk factors for symptomatic spinal cord injury are present. (Risk factors would be occlusion of 1 or more vascular territories feeding the collateral network.) | 4.00 | 3.00 | 5.00 | 2.00 | 1.00 | High importance – no consensus |
| 3. In OPEN types I, II, III and V TAAA repair, despite CSF drainage, at least 1 additional method (MEPs, SEPs or paravertebral NIRS) to monitor spinal cord perfusion should be routinely used. | 4.00 | 3.50 | 5.00 | 1.50 | 0.75 | High importance – moderate consensus |
| 4. In ENDOVASCULAR types I, II, III and V TAAA repair, despite CSF drainage, at least 1 additional method (MEPs, SEPs or paravertebral NIRS) to monitor spinal cord perfusion should be considered. | 3.00 | 2.00 | 3.25 | 1.25 | 0.63 | Low importance – moderate consensus |
| 5. Cerebral NIRS should be used in all patients undergoing an OPEN type I or II TAAA repair. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 6. Cerebral NIRS should be considered in patients undergoing an OPEN type III or V TAAA repair | 4.00 | 3.00 | 4.00 | 1.00 | 0.50 | High importance – high consensus |
| 7. Staged OPEN or hybrid repair (TEVAR + OPEN repair of remaining downstream aortic segments) or preoperative minimally invasive segmental artery coil embolization (MISACE protocol) should be considered if feasible. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 8. Staged ENDOVASCULAR TAAA repair or preinterventional minimally invasive segmental artery coil embolization (MISACE protocol) should be considered, if appropriate, to minimize the risk of symptomatic spinal cord injury. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 9. In ENDOVASCULAR TAAA repair, an “intentional endoleak“ (branch that remains initially open) may be a useful option to prevent symptomatic spinal cord injury. | 4.00 | 3.75 | 5.00 | 1.25 | 0.63 | High importance – moderate consensus |
| 10. In case of a bloody puncture, the placement of the CSF drain should be discontinued and the operation should be rescheduled. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 11. In case of bloody puncture, delay of rescheduling the procedure and re-puncturing should be at least 24 hours. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 12. When puncturing for CSF drainage, initial puncture pressure should be monitored. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 13. Intraoperatively the CSF pressure should not exceed 10-15 mmHg. However, initial pressures should be used as a reference, and higher values might be accepted if preoperative CSF pressure was higher. | 4.00 | 3.75 | 5.00 | 1.25 | 0.63 | High importance – moderate consensus |
| 14. Postoperatively, in the absence of symptomatic spinal cord injury, the CSF pressure should be kept to preoperative levels but should not exceed 10–15 mmHg. However, initial pressures should be used as a reference and higher values might be accepted if preoperative CSF pressure was higher. | 4.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 15. If spinal cord injury is suspected intraoperatively, CSF pressure should be kept below preoperative CSF pressure. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 16. In the absence of symptomatic spinal cord injury, the CSF drain can be removed 48–72 hours after OPEN TAAA repair. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 17. In the absence of symptomatic spinal cord injury, the CSF drain can be removed 24–72 hours after ENDOVASCULAR TAAA repair. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
| 18. In case of symptomatic spinal cord injury, CSF drainage should be kept at least 2 days beyond when the diagnosis is established, even if CSF pressure has already returned to preoperative levels. | 5.00 | 4.00 | 5.00 | 1.00 | 0.50 | High importance – high consensus |
CSF: cerebrospinal fluid; IQR: interquartile range; MEPs: motor evoked potentials; MISACE: minimally invasive segmental artery coil embolization; NIRS: near infrared spectroscopy; QD: quartile deviation; SEPs: somatosensory evoked potentials; TAAA: thoracoabdominal aortic aneurysm; TEVAR: thoracic endovascular aortic repair.
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