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Online ISSN 1827-1847
D’Addato M., Freyrie A., Paragona O., Spagnolo C. *, Kapelj S. *
From the Department of Surgery and Anesthesiology Vascular Surgery Department and Unit
* Anesthesia and Reanimation Department and Unit University of Bologna Policlinico S. Orsola - Bologna
Background. Thoracoabdominal aortic aneurysms (TAAA) surgery still presents a high incidence of perioperative mortality and morbidity. Numerous methods have been proposed to prevent ischemia secondary to clamping: in this context, the real value of extracorporeal circulation is still highly controversial. We report our personal experience of a series of TAAA patients treated without the use of distal perfusion.
Methods. Of a total of 94 TAAA operated between 1986 and July 2001, we included the last 74 cases (1994-2001) since they were treated using standardised pre-, intra- and postoperative protocols. In 62 cases the patients were male with a mean age of 65.6 years. With regard to the extent of aneurysms, 2 (2.7%) were type 1, 19 (25.6%) were type 2, 34 (45.9%) were type 3 and 19 (25.6%) were type 4. Chronic dissecting aneurysm was present in 6 cases (8.1%). The following methods were used to protect against ischemic spinal cord injury: intercostal artery re-attachment, serial clamping, cerebral spinal fluid drainage and systemic infusion of PGE1. Renal protection was provided by hypothermal perfusion of a solution containing PGE1. Wherever possible, type 4 forms were treated using left extrapleural access with removal of the 11th rib. The following parameters were evaluated: perioperative mortality (30 days) and the incidence of ischemic spinal cord injury and renal insufficiency.
Results. Perioperative mortality was 14 cases (18.9%). The highest number of deaths occurred in type 3 forms with 9 cases (26.4%). Mortality in type 2 TAAA was 21.15%, whereas it was 5.2% in type 4. Mortality was 0 in the 2 cases of type 1 TAAA. The most frequent causes of death were myocardial infarction and respiratory failure (each represented 28.5% of deaths). With reference to ischemic spinal cord injury, there were 3 cases of paraplegia (4%): 2 in type 2 TAAA (10.5%) and 1 in type 3 TAAA (2.9%). Postoperative renal insufficiency occurred in 11 cases (14.8%); chronic dialysis was only required in 4 cases. No postoperative respiratory deficiencies were reported in the 10 cases of type 4 TAAA undergoing surgery with left extrapleural access and removal of the 11th rib.
Conclusions. Treatment of TAAA still represents a major challenge to the surgical and anesthesia-reanimation teams. Although in this series perioperative mortality was still relatively high in types 2 and 3, the use of methods of spinal cord and renal protection lowered the incidence of severely disabling complications, such as paraplegia and renal insufficiency requiring dialysis. Cardiac and respiratory complications continue to be the main causes responsible for postoperative deaths.
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