Current Trends in the Surgical Management of Thoracoabdominal Aortic Aneurysms

Czech version

Authors: P. Štádler; P. Zdráhal; P. Šebesta; L. Dvořáček; P. Vitásek; M. Šlais
Authors‘ workplace: Oddělení cévní chirurgie, Nemocnice Na Homolce, Praha, primář: doc. MUDr. Petr Štádler, Ph. D.
Published in: Rozhl. Chir., 2011, roč. 90, č. 1, s. 14-23.
Category: Monothematic special - Original

Overview

Introduction:
The authors present a group of patients, who underwent standard procedures on thoracic (TAA) and thoracoabdominal (TAAA) aortic aneurysms from 01-01-2009 to 15-09-2010.

Material and Methods:
During the above time period, a total of 29 patients were operated. The authors employed as many known organ protection procedures as possible, including reduced heparinization, mild hypothermia (32–34 °C), sequential aortic clamping cerebrospinal drainage, left heart bypass (a biopump) with non-ischemic canylation of the femoral artery, selective visceral blood perfusion (superior mesenteric artery and coeliac trunk) and renal arteries perfusion using cold crystallic solution. For technical reasons, monitoring of somatosensory and motor evoked potentials was used only twice. In the majority of TAAA procedures, the thoracoretroperitoneal approach was used.

Results:
During the studied period, the overall mortality rate was 24%. In 2009, a total of 16 patients were operated, out of which 14 subjects underwent elective procedures. Two subjects underwent urgent procedures for ruptures and both of them died. In 2009, the mortality rate was 21% for planned procedures. In the following year, from January to September 15, a total of 13 patients underwent surgery, out of whom 11 underwent elective and two urgent procedures. The group’s overall mortality rate was 15.4%, the moratlity rate in elective surgery patients was 9% . One patient undergoing urgent surgery survived and one exited. Postoperative paraplegia was reported in one subject (3,4%), postoperative dialysis due to postoperative renal insuficiency was used in 6.9% and other postoperative complications occurred in 10,3% of the subjects.

Conclusion:
Mortality and morbidity rates in the surgical management of thoracoabdominal aortic aneurysms remain considerably high, although new procedures of organ protection help to reduce it. These highly specialized procedures require a multispecialty approach and a well- coordinated surgical team, specialized in this problematics.

Key words:
thoracoabdominal aorta – surgical management – multispecialty approach – organ protection

Sources

1. Coselli, J. S., Bozinovski, J., Le Maire, S. A. Open surgical repair of 2286 thoracoabdominal aortic aneurysm. Ann. Thorac. Surg., 2007; 83: 862–864.

2. Clouse, W. D., Hallett, J. W., Schaff, H. V., Gayari, M. M., Ilstrup, D. M., Melton, L. J. Improved prognosis of thoracic aortic aneurysms: a population-based study. JAMA, 1998; 280: 1926–1929.

3. Wilmink, A. B., Quick, C. R. Epidemiology and potential for prevention of abdominal aortic aneurysm. Br. J. Surg., 1998; 85: 155–162.

4. Bickerstaff, L. K., Hollier, L. H., van Peenen, H. J., Melton, L. J., Pairolero, P. C., Cherry, K. J. Abdominal aortic aneurysms: the changing natural history. J. Vasc. Surg., 1984; 1: 6–12.

5. Wanhainen, A., Bjorck, M., Boman, K., Rutegard, J., Bergqvist, D. Influence of diagnostic criteria on the prevalence of abdominal aortic aneurysm. J. Vasc. Surg., 2001; 34: 229–235.

6. Bickerstaff, L. K., Pairolero, P. C., Hollier, L. H., Melton, L. J., van Peenen, H. J., Cherry, K. J. Thoracic aortic aneurysms: a population-based study. Surgery, 1982; 92: 1103–1108.

7. Perko, M. J., Norgaard, M., Herzog, T. M., Olsen, P. S., Schroeder, T. V., Petterson, G. Unoperated aortic aneurysm: a survey of 170 patients. Ann. Thorac. Surg., 1995; 59: 1204–1209.

8. Dapunt, O. E., Galla, J. D., Sadeghi, A. M., Lansman, S. L., Mezrow, C. K., de Asla, R. A. The natural history of thoracic aortic aneurysms. J. Thorac. Cardiovasc. Surg., 1994; 107: 1323–1332.

9. Etheredge, S. N., Yee, J., Smith, J. Successful resection of a large aneurysm of the upper abdominal aorta and replacement with homograft. Surgery, 1955; 38: 1071–1081.

10. DeBakey, M. E., Cooley, D. A., Crawford, E. S. Clinical application of a new flexible knitted Dacron arterial substitute. Arch. Surg., 1957; 74: 713–724.

11. Crawford, E. S. Thoraco-abdominal and abdominal aortic aneurysms involving renal, superior mesenteric, celiac arteries. Ann. Surg., 1974; 179: 763–772.

12. Svensson, L. G., Crawford, E. S., Hess, K. R. Deep hypothermia with circulatory arrest. Determinants of stroke and early mortality in 656 patients. J. Thorac. Cardiovasc. Surg., 1993; 106: 19–28.

13. Engle, J., Safi, H. J., Miller, C. C. III. The impact of diaphragm management on prolonged ventilator support after thoracoabdominal aortic repair. J. Vasc. Surg., 1999; 29: 150–156.

14. Coselli, J. S., Le Maire, S. A., Conklin, L. D. Morbidity and mortality after extent II thoracoabdominal aortic aneurysm repair. Ann. Thorac. Surg.,2002; 73: 1107–1115.

15. Coselli, J. S. The use of left heart bypass in the repair of thoracoabdominal aortic aneurysms: current techniques and results. Semin. Thorac. Cardiovasc. Surg., 2003; 15: 326–332.

16. Coselli, J. S., Le Maire, S. A. Tips for successful outcomes for descending thoracic and thoracoabdominal aortic aneurysm procedures. Semin. Vasc. Surg., 2008; 21: 13–20.

17. Blaisdell, F. W., Cooley, D. A. The mechanism of paraplegia after temporary thoracic aortic occlusion and its relationship to spinal fluid pressure. Surgery, 1962; 51: 351–355.

18. Miyamoto, K., Ueno, A., Wada, T. A new and simple method of preventing spinal cord damage following temporary occlusion of the thoracic aorta by draining the cerebrospinal fluid. J. Cardiovasc. Surg., 1960; 16: 188–197.

19. Coselli, J. S., LeMaire, S. A., Köksoy, C. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. J. Vasc. Surg., 2002; 35: 631–639.

20. Safi, H. J., Hess, K. R., Randel, M. Cerebrospinal fluid drainage and distal aortic perfusion: reducing neurologic complications in repair of thoracoabdominalis aortic aneurysm types I and II. J. Vasc. Surg., 1996; 23: 223–228.

21. Cheung, A. T., Pochettino, A., Guvakov, D. V. Safety of lumbar drains in thoracic aortic operations performed with extracorporal circulation. Ann. Thorac. Surg., 2003; 76: 1190–1196.

22. Griepp, R. B., Grieb, E. B. Spinal cord perfusion and protection during descending thoracic and thoracoabdominalis aortic surgery: the collateral network concept. Ann. Thorac. Surg., 2007; 83: 865–869.

23. Coselli, J. S., LeMaire, S. A. Left heart bypass reduces paraplegia rates after thoracoabdominalis aortic aneurysm repair. Ann. Thorac. Surg., 1999; 67: 1931–1934.

24. Bavaria, J. E., Woo, Y. J., Hall, R. A. Retrograde cerebral and distal aortic perfusion during ascending and thoracoabdominal aortic operations. Ann. Thorac. Surg., 1995; 60: 345–352.

25. Svensson, L. G., Coselli, J. S., Safi, H. J., Hess, K. R., Crawford, E. S. Appraisal of adjuncts to prevent acute renal failure after surgery on the thoracic of thoracoabdominalis aorta. J. Vasc. Surg., 1989; 10: 230–239.

26. Safi, H. j., Harlin, S. A., Miller, C. C. Predictive factors for acute renal failure in thoracic and thoracoabdominalis aortic aneurysm surgery. J. Vasc. Surg., 1996; 24: 338–345.

27. Schmidt, C. A., Wood, M. N., Gan, K. A., Razzouk, A. J. Surgery for thoracoabdominal aortic aneurysms. A. Surg., 1990; 56: 745–748.

28. Levy, M. Oxygen consumption and blood flow in the hypothermic perfused kidney. Am. J. Physiol., 1959; 197: 1111–1114.

29. Hanley, M. J., Davidson, K. Prior mannitol and furosemide infusion in a model of ischemic acute renal failure. Am. J. Physiol., 1981; 241: 556–564.

30. Morishita, K., Yokoyama, H., Inoue, S., Koshino, T., Tamiya, Y., Abe, T. Selective visceral and renal perfusion in thoracoabdominal aneurysm repair. Eur. J. Cardiothorac. Surg., 1999; 15: 502–507.

31. Kashyap, V. S., Cambria, R. P., Davison, K., LęItalien, G. J. Renal failure after thoracoabdominal aortic surgery. J. Vasc. Surg., 1997; 26: 949–957.

32. Achouh, P. E., Madsen, K., Miller III, C. C., Estrera, A. L., Azizzadeh, A., Dhareshwar, J., Porat, E., Safi, H. J. Gastrointestinal complications after descending thoracic and thoracoabdominal aortic repairs: A 14-year experience. J. Vasc. Surg., 2006; 44: 442–446.

33. Cambria, R. P., Davison, J. K., Zannetti, S. Thoracoabdominal aneurysm repair: prospectives over a decade with the clamp-and-sew technique. Ann. Surg., 1997; 226: 294–303.

34. Svensson, L. G., Crawford, E. S., Hess, K. R., Coselli, J. S., Safi, H. J. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J. Vasc. Surg., 1993; 17: 357–368.

35. Jacobs, M. J., Mess, W., Mochtar, B., Nijenhuis, R. J., Statius, van Eps, R. G., Schurink, G. W. The value of motor evoked potentials in reducing paraplegia during thoracoabdominal aneurysm repair. J. Vasc. Surg, 2006; 43: 239–246.

36. Kawanishi, Y., Munakata, H., Matsumori, M., Tanaka, H., Yamashita, T., Nakagiri, K. Usefulness of transcranial motor evoked potentials during thoracoabdominal aortic surgery. Ann. Thorac. Surg., 2007; 83: 456–461.

37. Keyhani, K., Miller, C. C. III., Estrera, A. L., Wegryn, T., Sheinbaum, R., Safi, H. J. Analysis of motor and somatosensory evoked potentials during thoracic and thoracoabdominal aortic aneurysm repair. J. Vasc. Surg., 2009; 49: 36–41.

38. Miller, C. C. III., Grimm, J. C., Estrera, A. L., Azizzadeh, A., Coogan, S. M., Walkes, J. C. M., Safi, H. J. Postoperative renal function preservation with nonischemic femoral arterial cannulation for thoracoabdominal aortic repair. J. Vasc. Surg., 2010; 51: 38–42.

39. Melissano, G., Bertoglio, L., Civelli, V., Moraes Amato, A. C., Coppi, G., Civilini, E., Calori, G., De Cobelli, F., Del Maschio A., Chiesa, R. Demonstration of the Adamkiewicz artery by multidetector computed tomography angiography analysed with the open-source software osirix. Eur. J. Vasc. Endovasc. Surg., 2009; 37: 395–400.

40. Lin, P. H., El Sayed, H. F., Kougias, P. Endovascular repair of thoracic aortic disease: overview of current devices and clinical results. Vascular, 2007; 15: 179–190.

41. Mommertz, G., Sigala, F., Langer, S., Koeppel, T. A., Mess, W. H., Schurink, G. W. H., Jacobs, M. J. Thoracoabdominal aortic aneurysm repair in patients with Marfan syndrome. Eur. J. Vasc. Endovasc. Surg., 2008; 35: 181–186.

42. Chiesa, R., Tshomba, Y., Melissano, G., Marone, E. M., Bertoglio, L., Setacci, F., Calliari, F. M. Hybrid approach to thoracoabdominal aortic aneurysms in patients with prior aortic surgery. J. Vasc. Surg., 2007; 45: 1128–1135.

43. Anderson, J. L., Adam, D. J., Berce, M., Hartley, D. E. Repair of thoracoabdominal aortic aneurysms with fenestrated and branched endovascular stent grafts. J. Vasc. Surg., 2005; 42: 600–607.

44. Chiesa, R., Melissano, G., de Moura, M. R. L., Civilini, E., Tshomba, Y., de Moura, M. R. L., Magrin, S., Carozzo, A. Surgical treatment of thoracic and thoracoabdominal aortic aneurysms: technical notes and the use of left heart bypass. J. Vasc. Br., 2002; 1: 207–218.

45. Schlösser, F. J. V., Mojibian, H., Verhagen, H. J. M., Moll, F. L., Muhs, B. E. Open thoracic or thoracoabdominal aortic aneurysm repair after previous abdominal aortic aneurysm surgery. J. Vasc. Surg., 2008; 48: 761–768.