Abstract
Thoracoabdominal aortic aneurysm repair represents a continuing challenge for the
vascular surgeon. Although myocardial dysfunction and renal failure used to be worrisome
problems after this procedure, adequate diagnostic evaluation and simple intraoperative
maneuvers have dramatically reduced both potential complications. However, paraplegia,
intraoperative coagulopathy, and respiratory failure remain continuing problems.
Our approach represents a multimodality attempt to minimize the risks of this procedure.
Preoperative evaluation includes functional cardiac testing and duplex carotid screening.
Major occlusive lesions in either of these regions are corrected prior to thoracoabdominal
aneurysm repair. Patients with renal dysfunction are not excluded from thoracoabdominal
aneurysm repair; however, preoperative hydration is used and we routinely provide
for a delay between preoperative angiography and surgical repair, thus minimizing
the potential nephrotoxic effect of the angiogram contrast load. At the time of operation,
an intrathecal catheter is inserted for monitoring cerebral spinal fluid (CSF) pressure
and for drainage in order to keep the CSF pressure below 10 mmHg. CSF drainage is
also continued for 3 days postoperatively. A shunt or bypass is generally used for
patients with type I to type II thoracoabdominal aneurysm. An inlay technique is used
for graft replacement of the aneurysm and as many intercostal arteries as possible
are routinely reimplanted. No attempt is made to monitor spinal cord function during
repair. In order to minimize perioperative bleeding complications, visceral ischemia
time is kept to a minimum. Pharmacologic manipulation and systemic or regional cooling
is used to minimize the reperfusion injury. Using this multimodality approach, the
overall incidence of neurologic deficit in over 200 thoracoabdominal aneurysm repairs
is 4.4%. Intraoperative mortality is 2.5% and the incidence of reoperation for bleeding
is 4.8%. Thoracoabdominal aneurysm repair can be done safely and with acceptable morbidity
if appropriate attention is paid to preoperative evaluation, perioperative technique,
and postoperative care.