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Giornale Italiano di Chirurgia Vascolare 2001 March;8(1):53-67


language: English, Italian

Thoracoabdominal aneurysm surgery. Management of 82 patients

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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