Thoracic aortic aneurysms and dissections: endovascular treatment

How Would I Treat My Own Thoracoabdominal Aortic Aneurysm: Perioperative Considerations From the Anesthesiologist Perspective

A thoracoabdominal aortic aneurysm (TAAA) can be potentially life-threatening due to its associated risk of rupture. Thoracoabdominal aortic aneurysm repair, performed as endovascular repair and/or open surgery, is the recommended therapy of choice. Hemodynamic instability, severe blood loss, and spinal cord or cerebral ischemia are some potential hazards the perioperative team has to face during these procedures. Therefore, preoperative risk assessment and intraoperative anesthesia management addressing these potential hazards are essential to improving patients' outcomes. Based on a presented index case, an overview focusing on anesthetic measures to identify perioperatively and manage these risks in TAAA repair is provided.

Anesthetic Management for Endovascular Repair of the Thoracic Aorta

Thoracic endovascular aneurysm repair (TEVAR) is fast becoming the primary treatment of thoracic aortic aneurysms, thoracic aortic dissections, acute aortic injuries, and other conditions affecting the thoracic aorta. Patients scheduled for TEVAR tend to have a host of comorbid conditions, including coronary artery disease, diabetes, and chronic obstructive pulmonary disease. Intraoperative management should optimize end-organ perfusion, facilitate neuromonitoring, and adjust hemodynamic management. Complications include spinal cord injury, peripheral vascular injury, contrast-induced nephropathy, postimplantation syndrome, and endoleaks. Patients who undergo TEVAR require care in a postoperative environment where these complications can be rapidly detected and aggressively treated.

Treatment of serious complications following endovascular aortic repair for type B thoracic aortic dissection

Objective

This study aimed to describe treatment of serious complications after primary thoracic endovascular aortic repair (TEVAR) in type B aortic dissection.

Methods

From June 2008 to March 2016, serious complications occurred in 58 patients without Marfan syndrome who received TEVAR for type B aortic dissection.

Results

Complications included endoleak, distal true lumen collapse, retrograde dissection, stroke, stent–graft (SG) migration and mistaken deployment, lower limb ischaemia, and SG fracture. Treatment included endovascular repair, surgical procedures, or conservative medication. Forty-six patients recovered from complications. Twelve patients were not cured. The median follow-up time was 29.5 months (2–61 months). The overall 30-day mortality rate was 1.7% (1/58) and the total mortality rate following secondary complications was 8.6% (5/58). The causes of death were stroke and aortic rupture.

Conclusion

Some treatments need to be performed after TEVAR because of severe complications. A reduction in these complications can be achieved by optimal evaluation of patients, selection of SGs, and specialized endovascular manipulation.