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A Journal on Vascular and Endovascular Surgery

Official Journal of the Italian Society of Vascular and Endovascular Surgery
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Giornale Italiano di Chirurgia Vascolare 2002 March;9(1):47-64

language: English, Italian

Treatment of thoracoabdominal aortic aneurysms without extracorporeal circulation

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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