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Giornale Italiano di Chirurgia Vascolare 2003 December;10(4):383-92


language: English, Italian

Extrapleural access with removal of the 11th rib in type IV thoracoabdominal aneurysms. Impact on postoperative management

Paragona O., Freyrie A., Ferri M., Testi G., D’Addato M.

Operating Unit of Vascular Surgery Department of Surgical and Anesthesiological Sciences Policlinico “S. Orsola” University of Bologna, Bologna, Italy


Aim. Postoperative res­pir­a­to­ry fail­ure is one of the ­most fre­quent com­pli­ca­tions of thor­a­coab­dom­i­nal aor­tic aneu­rysms (­TAAA): its occur­rence is main­ly ­linked to the ­extent of the sur­gi­cal ­access (tho­ra­co-phre­no-lap­a­rot­o­my). The aim of ­this ­study was to eval­u­ate the post­op­er­a­tive man­age­ment of Type 4 ­TAAA, pay­ing spe­cial atten­tion to res­pir­a­to­ry com­pli­ca­tions, ­with ­left extra­pleu­ral sur­gi­cal ­access and remov­al of the 11th rib.
Methods. Type IV ­TAAA treat­ed ­using ­left extra­pleu­ral sur­gi­cal ­access and remov­al of the 11th rib ­were exam­ined in a ret­ro­spec­tive ­study. The fol­low­ing param­e­ters ­were ana­lysed: pre­op­er­a­tive res­pir­a­to­ry (FEV1) and ­renal func­tion, post­op­er­a­tive intu­ba­tion ­time, ­length of inten­sive ­care ­unit ­stay, post­op­er­a­tive res­pir­a­to­ry com­pli­ca­tions, post­op­er­a­tive ­renal insuf­fi­cien­cy, per­i­op­er­a­tive mor­bid­ity and mor­tal­ity (30 ­days).
Results. The ­study was per­formed in 10 ­patients (9 ­males) ­with a ­mean age of 69 ­years (­range 60-75), diag­nosed ­with Type 4 ­TAAA ­whose ­upper prox­i­mal lim­it was the ­celiac tri­pod. None of the ­patients ­were ­obese; 90% of the ­patients ­were smok­ers. The pre­op­er­a­tive ­chest X-ray ­showed a suprael­e­va­tion of the ­left hem­i­di­aph­ragm in 2 cas­es. In 10 cas­es, FEV1 ­ranged ­from 57% to 144%. Preoperative ­renal insuf­fi­cien­cy was ­present in 2 cas­es (crea­ti­nine >2.0 mg
dl). Surgery was per­formed elec­tive­ly in all cas­es. In ­total, ­there ­were 2 cas­es of post­op­er­a­tive res­pir­a­to­ry fail­ure (post­op­er­a­tive intu­ba­tion ­time >12 ­hours). In the remain­ing cas­es ­mean post­op­er­a­tive intu­ba­tion ­time was 5.3 ­hours (­range: 4-8 ­hours). Both cas­es of res­pir­a­to­ry fail­ure ­were asso­ciat­ed ­with tran­sient ­renal insuf­fi­cien­cy. The ­mean ­length of inten­sive ­care ­unit ­stay was 3.5 ­days (­range: 0-15 ­days): a sin­gle day was suf­fi­cient in 50% of cas­es. Postope-­rative ­chest X-­rays ­revealed ­only 1 new ­case of suprael­e­va­tion of the ­left hem­i­di­aph­ragm (2 ­were ­already ­present pre­op­er­a­tive­ly), no ­case of pneu­moth­o­rax and no ­case of infec­tion. Two cas­es of tran­sient post­op­er­a­tive ­renal insuf­fi­cien­cy ­were ­observed: ­only 1 ­case ­required tem­po­rary hemo­di­al­y­sis. Redo sur­gery was nec­es­sary in 2 cas­es: in 1 ­case to emp­ty the ret­ro­per­i­to­neal hemat­o­ma and ­cross-­over sur­gery in 1 ­case due to throm­bo­sis of an ­iliac ­branch. There was no ­case of per­i­op­er­a­tive mor­tal­ity.
Conclusion. Based on ­these pre­lim­i­nary ­results, ­when prac­ti­cable, ­this sur­gi­cal ­access ­appears to pro­mote a ­more rap­id recov­ery of post­op­er­a­tive res­pir­a­to­ry func­tion.

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