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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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