[Surgical management of thoracic aortic lesions. Aneurysm, dissection and traumatic rupture]

[Anesthesiologic procedure for elective aortic surgery]

Aortic aneurysms are frequent in the elderly who often suffer from relevant co-morbidities. In Germany it is estimated that approximately 250,000 patients suffer from an aortic aneurysm. Due to the high risk of cardiac or pulmonary complications operative management poses a challenge to the anesthesiologist. Especially hemodynamic management during aortic cross-clamping requires anesthesiologic know-how and an anticipatory use of vasodilators and catecholamines. Furthermore, the anesthesiologist has to protect renal function. In order to avoid paraplegia due to spinal ischemia cerebrospinal fluid drainage may be necessary in patients with aneurysms of the thoracic aorta. In recent years endovascular repair of aortic aneurysms has been established in addition to conventional open surgery. As a consequence in some patients aortic surgery can be performed under regional or local anesthesia. In special cases thoracic endovascular repair requires a medicinal induction of heart arrest or the reduction of aortic blood flow by overpacing.

[Traumatic thoracic aorta rupture: preclinical assessment, diagnosis and treatment options]

Traumatic aortic rupture is a life-threatening injury which is frequently associated with blunt thoracic trauma or found coincidentally in heavily traumatized patients. Depending on the degree of disruption of the damaged aortic wall, vascular injury is associated with a high primary mortality rate and a significant risk of secondary aortic rupture. Early clinical signs which may indicate a ruptured thoracic aorta are left sided thoracic pain, reduced ventilation, tachycardia and dyspnoe as well as hypotension in the lower extremities. The primary aim for emergency treatment is to maintain vital organ function and to hemodynamically stabilize the patient. Surgical treatment was previously performed by either direct aortic suture or segmental alloplastic graft interposition using the clamp and sew technique with or without extra-anatomic shunts or extracorporeal circulation. However, endovascular stent graft implantation has now become another treatment option for traumatic aortic rupture. According to the reported data and our own experience there is increasing evidence that endovascular aortic repair might become the treatment of choice for patients with traumatic aortic rupture, with the option of an early, less invasive intervention thus avoiding thoracotomy. Regular follow-up is necessary to detect possible stent graft migration or leakage which could require additional endovascular or open surgical re-interventions.

[Current concepts of polytrauma management: from ATLS to "damage control"]

In recent years, the implementation of standardized protocols for polytrauma management has led to a significant improvement in trauma care as well as to a decrease in post-traumatic morbidity and mortality. As such, the "Advanced Trauma Life Support" (ATLS) protocol of the American College of Surgeons for the acute management of severely injured patients has been established as a gold standard in most European countries since the 1990s. Continuative concepts to the ATLS program include the "Definitive Surgical Trauma Care" (DSTC) algorithm and the concept of "damage control" surgery for polytraumatized patients with immediate life-threatening injuries. These phase-oriented therapeutic strategies appraise the injured patient of the whole extent of the sustained injuries and are in sharp contrast to previous modalities of "early total care" which advocate immediate definitive surgical intervention. The approach of "damage control" surgery takes into account the influence of systemic post-traumatic inflammatory and metabolic reactions of the organism and is aimed at reducing both the primary and the secondary, delayed, mortality in severely injured patients. The present paper provides an overview of the current state of management algorithms for polytrauma patients, with a focus on the standard concepts of ATLS and "damage control".