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Online ISSN 1827-1847
Zanetti P. P.
From the Division of Thoracic and Vascular Surgery Hospital “G. Brotzu”, Cagliari Thoracic Aorta Surgery Center
From the Department of Heart Surgery, Turin University Centre of Thoracic Aorta Surgery, Asti, Italy
Background. Paraplegia and paraparesis (P/P) and acute kidney failure (AKF) represent the two most serious complications of thoracoabdominal aneurysm (TAA) surgery. Our results are compared with the latest literature in order to obtain correct indications for the treatment of this complex pathology.
Methods. A total of 82 patients were treated between 01.01.1994 and 31.12.1998 (48 males and 34 females), mean age 62 years (minimum 38, maximum 82). According to Crawford’s classification, 18 were Type 1, 10 were Type 2, 21 Type 3 and 33 Type 4. Fifty-eight cases were aneurysms and 24 aneurysms on dissection. 92.7% of lesions were treated electively and 7.3% underwent emergency surgery. Protective methods were applied in 6 cases using a subclavian-femoral shunt, in 12 cases with a C.E.C. F/F, in 33 cases using the “Clamp and Go” technique, and in 31 cases with a Bio-pump. Only the first 21 cases were treated with C.S.F.D., whereas the remaining 62 cases underwent open anastomosis. In the case of intercostal arteries, the failure to implant arteries in segment T8-L1 especially led to a significant percentage of P/P. Visceral ischemia time was treated in the first 20 cases only using Fogarty’s cold perfusion, whereas open-anastomosis was preferred in the remaining 62 cases.
Results. Mortality was 9.7% (8 cases) and by subdividing the deaths according to Crawford’s classification we note that Type 2 included 20% with 2/10. P/P affected 6.1% with 5/82 and again Crawford’s Type 2 accounted for 20% with 2/10. The percentage rose to 33.3% (2/6) in emergency surgery compared to 3.9% in elective cases (3/76). C.E.C. F/F with 0% of paraplegia was better than the 16.6% observed with inert shunts, 3.3% with C.S. and 9.6% with Bio-pump. The failure to reimplant intercostal arteries at the T8-L1 level caused 3/5 P/P, and likewise previous abdominal aortic surgery led to 20% of P/P (1/5). Prolonged hypotension (<60 mmHg) (3/5 P/P), clamping >50 minutes (4/5 P/P) and the closure of intercostal arteries T8-L1 (3/5 P/P) are regarded as the most frequent causes of medullary damage. AKF influenced 15% of cases, but only 5% required dialysis whereas 10%, with creatinine levels ≥3 mg/dl resolved spontaneously. Lung complications were involved in 36.5% (30/82) and in 4 cases resulted in tracheostomy, but reintubation was only required in 6 cases. Postoperative bleeding was reported in 2 cases (2.4%) who were treated using C.E.C. F/F in the first two years of this study.
Conclusions. In the light of our experience we can affirm that in thoracoabdominal aneurysm surgery P/P and AKF: 1) Do not depend on age. 2) Occur most frequently in Crawford’s Type 1 and Type 2. 3) Clamping time >50 minutes with intra- and postoperative episodes of hypotension (<60 mmHg) directly influence the onset. 4) The reimplantation of intercostal arteries especially at level T8-L1, but above all a valid medullary blood supply after graft replacement provides effective prevention against P/P. 5) No significant advantages emerged in favour of either method when comparing C.S.F.D. and open anastomosis. 6) Preoperative renal damage as well as protracted clamping time (> 50 min and intraoperative hypovolemic shock) are significant factors for AKF. 7) Lastly, the experience of the anesthesiological team influenced the mortality and morbidity rates, preventing episodes of embolism, haemorrhage and cardiopulmonary complications both during and after surgery.
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