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Online ISSN 1827-1847
Loddo P., Degiudici A., Maxia A., Pibiri L., Pisu F., Ruiu G., Zanetti P. P.
Divisione Chirurgia Toraco-Vascolare, Dipartimento Cuore, Ospedale “G. Brotzu”, Cagliari
Aim. Surgical treatment of thoracoabdominal aneurysms (TAA) represents a burdensome problem for the vascular surgeon and may become a formable challenge in an emergency procedure. In patients with hemodynamic instability and prolonged low blood pressure, protective measures (cerebral spinal fluid drainage and/or Bio-pump) against spinal cord, visceral or renal ischemia may be ineffective or impracticable.
Methods. We report our experience with 28 emergency-operated patients with TAA out of 117 treated between 1994 and 2001; 23 were men and 5 were women (age range, 33-83 years; mean, 62 years); 57.1% presented with true aneurysms, 42.9% with dissecting aneurysms; 89.2% were hemodynamically unstable; 10.7% were hemodynamically stable. Based on findings from computed tomography scanning with contrast media, the TAA were evaluated by the Crawford classification as 9 type I, 9 type II, 8 type III, and 2 type IV. The surgical technique adopted in the emergency treatment of TAA is described.
Results. Overall mortality was 42.8% (12/28); 4 deaths occurred during the operation, 7 within 30 days and 1 within 60 days. Early deaths subdivided by Crawford TAA type were: 2/9 type I, 4/9 type II, 4/8 type III and 1/2 type IV. Out of 24 patients, 4 developed paraplegia/paraparesis (16.6%); spinal cord damage was permanent in 3 out of 4 and bilateral in 3 out of 4 patients. Type II TAA, which was present in 4 patients, of which 2 developed paraplegia/paresis (P/P), was found to be a high risk factor (p=0.02), as was prolonged intra- and postoperative low blood pressure (4 out of 4 patients), (p=0.01). Acute renal failure (ARF) was present in 16.6% of cases (4/24). Dialysis was found to be a risk factor for hospital mortality (p=0.03). Pulmonary insufficiency was present in 33.3% (8/24); 3 patients received tracheostomy, of which 2 died (p=0.04). Postoperative bleeding was present in 20.8% (5/24). Inferior laryngeal nerve palsy was present in 16.6% (4/24). The follow-up period comprised 12-60 months; the 6-year actuarial survival rate of the 16 patients discharged from the hospital was 50%.
Conclusion. The literature contains few studies on emergency treatment for TAA; the study data do not distinguish between hemodynamically stable and unstable patients. It is well known that the 2 different classes of patients are not comparable because hemodynamically patients do not differ from those who receive elective surgery. Wider studies are needed to shed light on the pathophysiology and surgical management of TAA, which are still being treated according to the individual surgeon’s experience.
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