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Giornale Italiano di Chirurgia Vascolare 2003 September;10(3):255-67


language: English, Italian

Emergency surgery in thoracoabdominal aneurysms repair. Clinical outcome

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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