Thoracoabdominal aortic aneurysms associated with celiac, superior mesenteric, and renal artery occlusive disease: Methods and analysis of results in 271 patients

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Visceral and renal protection in thoracoabdominal aortic surgery

Ischemic renal failure and visceral ischemia are two serious complications of the surgery for thoracoabdominal aortic aneurysm. The introduction of left atrial bypass, partial bypass, total circulatory arrest, and selective visceral perfusion has reduced the incidence of these complications over the past two decades. Yet these complications still persist, suggesting the sub-optimal nature of the available strategies.

Splanchnic occlusive disease predicts for spinal cord injury after open descending thoracic and thoracoabdominal aneurysm repair

OBJECTIVE

In the present study, we sought to discern the effects of splanchnic occlusive disease (SOD; renal, superior mesenteric, and/or celiac axis arteries) on spinal cord injury (SCI; paraparesis or paraplegia) and major adverse events (MAE) after descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) open repair.

METHODS

Patients who had undergone DTA/TAAA repair at our institution were dichotomized according to the presence of SOD, which was investigated as a predictive factor of our primary (SCI) and secondary (operative mortality, myocardial infarction, stroke, tracheostomy, de novo dialysis, MAE, survival) endpoints. Risk adjustment used both propensity score matching and multivariable logistic regression.

RESULTS

From July 1997 to October 2019, 888 patients had undergone DTA/TAAA repair, of whom 19 were excluded from our analysis for missing data. SOD was absent in 712 patients and present in 157 patients. The patients with SOD had presented with a greater incidence of preoperative renal impairment (61 [38.9%] vs 175 [24.6%]; P < .01) and peripheral arterial disease (60 [38.2%] vs 162 [22.8%]; P < .01] and decreased left ventricular ejection fraction (45%; interquartile range, 10%; vs 50%; interquartile range, 4%; P < .01). The etiology of aortic disease was more frequently dissection in the SOD group (56.1% vs 43.7%) and more frequently nondissecting aneurysm in the non-SOD group (56.3% vs 43.9%; P < .01). Patients without SOD had presented with aneurysms more cranially located (DTA, 34.0% vs 7.6%; extent I TAAA, 44.0% vs 7.6%). In contrast, patients with SOD had presented with aneurysms more caudally located (extent II TAAA, 36.9% vs 8.6%; extent III TAAA, 30.6% vs 11.0%; extent IV TAAA, 17.2% vs 2.5%; P < .01). Propensity score matching led to 144 pairs, with SOD significantly associated with SCI (10 [6.9%] vs 2 [1.4%]; P = .03) and MAE (47 [32.6%] vs 26 [15%]; P < .01). Ten-year survival was reduced in those with SOD (31.5% vs 45.2%; P < .01). Conditional multivariable regression confirmed SOD to be a predictor of SCI in the matched sample (odds ratio, 6.60; P = .02).

CONCLUSIONS

Our results have shown that SOD is a significant predictor of SCI in patients undergoing open DTA/TAAA repair. The investigation of measures to prolong neuronal ischemia tolerance (eg, hypothermia) is warranted for such patients.

Aneurysmectomy for Crawford’s Type-I Thoracoabdominal Aortic Aneurysm using Gelatin Impregnated Woven Vascular Prosthesis under Mild Hypothermic Extracorporeal Circulation: A Video Presentation

Based on the risk of ischemic injury to the spinal cord and the risk of renal failure and mortality, Crawford and colleagues classified thoracoabdominal aortic aneurysms into four extents. Type I thoracoabdominal aortic aneurysms involved the descending thoracic aorta proximal to the level of 6th rib to above the renal arteries; type II extends from the proximal descending thoracic aorta above the level of T6 to below the renal arteries; type III extends from below the level of T6 in the descending aorta and a variable extent in the abdominal aorta; type IV thoracoabdominal aortic aneurysm involved the abdominal aorta without involvement of the descending aorta.

Early Gastrointestinal Complications After Open Thoracoabdominal Aortic Aneurysm Repair

BACKGROUND

The present study was done to examine the incidence, predictors, and impact of early gastrointestinal (GI) complications after open thoracoabdominal aortic aneurysm repair.

METHODS

We retrospectively analyzed data from 3587 open thoracoabdominal aortic aneurysm repairs performed at our center from 1986 to 2019. We used univariate analyses and multivariable logistic regression to identify risk factors associated with GI complications, including bleeding, ischemia, obstruction, and acute pancreatitis. Adverse event was defined as operative death or persistent stroke, paraplegia, paraparesis, or renal failure necessitating dialysis.

RESULTS

Gastrointestinal complications developed after 213 repairs (5.9%). Gastrointestinal complications less often developed after extent I repair than after repairs that involved infrarenal abdominal aortic segments (ie, extent II to IV repairs; P = .003). Patients who had GI complications more often underwent endarterectomy, stenting, or bypass of visceral arteries (51.2% vs 42.2%; P = .01). Use of selective visceral perfusion did not differ between groups. Patients who had GI complications had higher rates of operative mortality (34.3% vs 6.6%) and adverse events (44.1% vs 13.2%) and had longer hospitalization (29 vs 11 days; P < .001 for all). Independent predictors of GI complications included incidental splenectomy, rupture, non-extent I repair, older age, and longer aortic cross-clamp time. Short-term, midterm, and long-term survival were poorer for patients who had GI complications (P < .001).

CONCLUSIONS

Although uncommon, early GI complications after open thoracoabdominal aortic aneurysm repair are associated with significant early and late morbidity and mortality. Development of perioperative strategies to mitigate these complications is warranted.

WITHDRAWN: Revisions to the ICD-10-CM Code Set for Aortic Aneurysms and Dissection Can Advance Clinical Research, Outcomes Reporting, and High-Value Health Care Delivery

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Renal protection in thoracoabdominal aortic aneurysm surgery

It is indisputable that open thoracoabdominal aortic aneurysm (TAAA) repair remains a highly complex and sophisticated surgical intervention. Despite advancements in the imaging modality, evolution of our understanding of the pathology afflicting the aorta, intraoperative brain and spinal cord monitoring, intraoperative organ protection, postoperative critical care and organ support, monitoring and the close follow-up of affected patients, this type of surgery remains a challenge to the surgeon and the patient. In this review, we will illustrate the recent evidence on renal protection and prediction during TAAA.

Organ Protection During Thoracoabdominal Aortic Surgery: Rationale for a Multimodality Approach

Surgical repair of thoracoabdominal aortic aneurysms (TAAAs) remains a technically challenging operation that requires a systematic approach to prevent ischemic complications and achieve excellent clinical outcomes. Techniques for organ protection have evolved substantially over the past 20 years. This review describes our current multimodality approach to organ protection during TAAA repair.

Extent II Thoracoabdominal Aortic Aneurysm Repair: How I Do It

The primary risks associated with thoracoabdominal aortic aneurysm (TAAA) repair-namely operative death, paraplegia, and renal failure necessitating dialysis-are commonly related to the distal ischemia that occurs during aortic clamping and the disruption of vital branching arteries. Our technique for open TAAA repair has evolved over the course of 3 decades, from the unheparinized, simple "clamp-and-sew" approach learned directly from E. Stanley Crawford himself to a contemporary, multimodal strategy that uses an array of surgical adjuncts. Today, our approach to TAAA repair is largely standardized and based on the Crawford extents of TAAA repair, but we have maintained flexibility to explore new techniques and to adapt to the specific needs of patients. To protect the spinal cord, we routinely use mild passive hypothermia, cerebrospinal fluid drainage, left heart bypass, and reimplantation of crucial intercostal or lumbar arteries. The renal arteries are perfused with cold solution to protect the kidneys from ischemic damage, and the celiac axis and superior mesenteric artery are perfused with isothermic blood from the left heart bypass circuit, which minimizes the duration of abdominal-organ ischemia. The most extensive repair, Crawford extent II repair, typically replaces the aorta from just beyond the left subclavian artery to the aortic bifurcation; unsurprisingly, it commonly poses greater operative risk than do less extensive TAAA repairs (extent I, III, and IV). Subsequently, most surgical adjuncts used today were developed to ameliorate risk in extent II repair. Here, we provide a detailed description of our approach to open extent II TAAA repair.

The effects of IL-18BP on mRNA expression of inflammatory cytokines and apoptotic genes in renal injury induced by infrarenal aortic occlusion

BACKGROUND

Renal injury is an important complication of infrarenal aortic occlusion (IAO), which is mainly encountered during the postoperative period. Aortic clamping procedure may lead to turbulent blood flow and eventually vasoconstriction at renal arterial level of the abdominal aorta. IL-18BP has well-known antioxidant and anti-inflammatory properties. In this study, we aimed to determine whether IL-18BP has anti-inflammatory, antiapoptotic, antioxidant, and protective effects on acute kidney damage induced by IAO rat model.

MATERIALS AND METHODS

A total of 30 adult male Wistar-Albino rats were equally and randomly separated to three groups as follows: SHAM laparotomy, ischemia-reperfusion (IR), and IR + IL-18BP. We applied 30-min IAO and 2-h reperfusion. Inflammatory cytokine levels (TNF-α, IL-1β, IL-18, IL-6, and IFN-γ) and oxidative stress parameters (TAS, TOS, and OSI) were measured. In addition to this, urea and creatinine levels, histopathology of kidney, mRNA expression levels of inflammatory cytokines, and apoptotic genes were investigated.

RESULTS

Urea and creatinine, tissue and serum levels of TNF-α, IL-6, IL-18, IFN-γ, and TOS, and oxidative stress index (OSI) were found significantly lower in IR + IL-18BP group, when compared to the IR group. Moreover, mRNA expression levels of inflammatory cytokines and apoptotic genes were prominently depressed in IR + IL-18BP pre-treatment group in histopathologic examination, there was a significant difference between the IR and other three groups (P < 0.001). These improvements were demonstrated with a total score of histopathologic damage. In our previous studies, we have demonstrated that IL-18BP has antioxidant, inflammatory, and protective effects on liver and spinal cord IR injury. Data established from the present study suggest that IL-18BP may exert anti-inflammatory, antiapoptotic, antioxidant, and protective effects on IAO-induced acute kidney injury in rats, and this would be the first study to be conducted in this field.

CONCLUSIONS

Data established from the present study suggest that IL-18BP may exert anti-inflammatory, antiapoptotic, antioxidant, and protective effects on IAO-induced acute kidney injury in rats.

The protective effects of resveratrol and L-NAME on visceral organs following aortic clamping

BACKGROUND

This study investigated the effect of temporary occlusion of the aorta on the development of ischemia-reperfusion (I/R) injury of the visceral organs, the optimal timing of administration of resveratrol, and its mechanism of protection via inhibiting nitric oxide (NO) release with an NO synthase inhibitor.

METHODS

Rabbits were divided into seven groups according to the administration period of resveratrol and/or N(G)-nitro-L-arginine methyl ester (L-NAME): control group; group 1, resveratrol during ischemic period; group 2, resveratrol during reperfusion period; group 3, L-NAME during ischemic period; group 4, L-NAME during reperfusion period; group 5, resveratrol during ischemic period and L-NAME during reperfusion period; group 6, L-NAME during ischemic period and resveratrol during reperfusion period. The infrarenal aorta was clamped for 30 min. Blood samples were taken for the biochemical assessment, and organ specimens were taken for pathological assessment at 24hr of reperfusion.

RESULTS

In groups 5 and 6, the renal I/R injury was comparatively milder (I/R injury score 1.04+/-0.29 in control group, 0.25+/-0.17 in group 5, and 0.33+/-0.13 in group 6 [p<0.05]). The I/R injury of bowel was milder in group 5 (I/R injury score 1.8+/-0.80 in control group vs. 0.0+/-0.0 in group 5 [p<0.05]).

CONCLUSION

The protective effects of resveratrol on organs that have high metabolic rate like kidney and bowel was proven histopathologically. It may be beneficial to use different pharmacological medications in different periods of the I/R damage as they represent different characteristics with and without oxygen. The combination of resveratrol and L-NAME against I/R injury appears to be an effective option in the near future.

Repair of a pararenal abdominal aortic aneurysm with bilateral renal artery stenosis using a rapid infusion pump for renal perfusion: report of a case

A 73-year-old man with a history of hypertension and drug-induced hepatitis underwent surgical treatment of an enlarging pararenal abdominal aortic aneurysm (PRAAA) with bilateral renal artery stenosis, found on enhanced computed tomography (CT). His preoperative renal function was normal. We divided the right renal artery and used a 6-mm expanded polytetrafluoroethylene (ePTFE) tube graft for the anastomosis. Renal artery perfusion was achieved by a rapid infusion pump set at 200 ml/min. The left renal artery was reconstructed and perfused in the same way. The abdominal aorta was cross-clamped just distal to the superior mesenteric artery and a Y-graft was anastomosed. The ePTFE grafts were connected to the Y-graft and bilateral renal artery circulation was re-established. The renal ischemic time was 1 h 25 min and the urine output during reconstruction was 80 ml. Postoperatively, his serum blood urea nitrogen and serum creatinine levels increased slightly, but normalized within 3 days. This case report shows that this method of renal artery perfusion could prove useful for complex renal artery reconstructions.

Endovascular treatment of thoracoabdominal aortic aneurysms

OBJECTIVE

To establish the safety and efficacy of endovascular repair of thoracoabdominal aortic aneurysms.

METHODS

Between May 2004 and February 2006, patients with thoracoabdominal aneurysms considered high risk for conventional surgery were enrolled in a prospective trial to evaluate a novel endovascular grafting system. Devices were custom designed for each patient using high-resolution computed tomography. Patient data included mortality, morbidity, procedural details, and surrogate end points for endovascular repair. These were collected at hospital discharge and at 1, 6, and 12 months.

RESULTS

Seventy-three patients underwent endovascular repair of thoracoabdominal aortic aneurysms for type I, II, or III (n = 28), or for type IV (n = 45) thoracoabdominal aneurysms. Mean aneurysm size was 7.1 cm (range 4.5-11.3 cm). General anesthesia was used in 47% of patients and regional anesthesia in 53%. There were no conversions to open surgery nor ruptures post-treatment. Technical success was achieved in 93% of patients (68/73). Thirty-day mortality was 5.5% (4/73). Major perioperative complications occurred in 11 (14%) patients and included paraplegia (2.7%, 2/73), new onset of dialysis (1.4%, 1/73), prolonged ventilator support (6.8%, 5/73), myocardial infarction (5.5%, 4/73), and minor hemorrhagic stroke (1.4%; 1/72). A majority of patients had no complications. Mean length of stay was 8.6 days. At follow-up, 6 deaths had occurred. There were no instances of stent migration nor aneurysmal growth.

CONCLUSIONS

Endovascular repair of aortic aneurysms involving the visceral segment in nonsurgical candidates is feasible. Known complications of repair are not eliminated, but morbidity and mortality appeared low relative to the high-risk population studied. Further refinement of device design, delivery technique, and patient selection is ongoing. Assessment of durability will require longer follow-up.

Thoracoabdominal aortic aneurysm associated with abdominal aortic and visceral arterial occlusion in a hemodialysis patient

We report an extremely rare case of saccular thoracoabdominal aortic aneurysm associated with high abdominal aortic occlusion including the superior mesenteric and bilateral renal arteries in a patient requiring hemodialysis. Successful repair of the aneurysm and concomitant revascularization of the lower extremities was achieved using femoro-femoral bypass for perfusion of the lower body along with the visceral and intercostal arteries.

Management of Thoracoabdominal Aneurysm Type IV

BACKGROUND

Thoracoabdominal aneurysm type IV (TAA IV) represents only a minority of aortic aneurysms, but as it is an entirely abdominally located aneurysm, vascular surgeons are likely to see such aneurysms in their practice. The current surgical management of TAA IV is reviewed.

METHODS

A PubMed/Medline-literature search for TAA IV.

RESULTS AND CONCLUSIONS

A detailed preoperative evaluation to determine the rupture and operative risk is required. A threshold size of 5.5-6 cm is recommended for elective repair of TAA IV, which then is adjusted for age and other risk factors. Operative simplicity with the clamp and sew approach to obtain a short aortic cross-clamp time seems to have most support in the literature. The necessity of adjunct treatment to prevent visceral and spinal cord ischemia seems to be needed rarely. Uncomplicated repair has a minimal risk of neurological injury and a low risk of renal failure requiring dialysis in patients without preoperative renal dysfunction or renal artery stenosis. The role of endovascular repair of these aneurysms remains to be established.

Activation of fibrinolytic pathways is associated with duration of supraceliac aortic cross-clamping

PURPOSE

The cause of the coagulopathy seen with supraceliac aortic cross-clamping (SC AXC) is unclear. SC AXC for 30 minutes results in both clotting factor consumption and activation of fibrinolytic pathways. This study was undertaken to define the hemostatic alterations that occur with longer intervals of SC AXC.

METHODS

Seven pigs underwent SC AXC for 60 minutes. Five pigs that underwent infrarenal aortic cross-clamping (IR AXC) for 60 minutes and 11 pigs that underwent SC AXC for 30 minutes served as controls. No heparin was used. Blood samples were drawn at baseline, 5 minutes before release of the aortic clamp, and 5, 30, and 60 minutes after unclamping. Prothrombin time, partial thromboplastin time, platelet count, and fibrinogen concentration were measured as basic tests of hemostatic function. Thrombin-antithrombin complexes were used to detect the presence of intravascular thrombosis. Fibrinolytic pathway activation was assessed with levels of tissue plasminogen activator antigen and tissue plasminogen activator activity, plasminogen activator inhibitor-1 activity, and alpha2-antiplasmin activity. Statistical analysis was performed with the Student t test and repeated measures of analysis of variance.

RESULTS

Prothrombin time, partial thromboplastin time, and platelet count did not differ between groups at any time. Fibrinogen concentration decreased 5 minutes (P =.005) and 30 minutes (P =.006) after unclamping in both SC AXC groups, but did not change in the IR AXC group. Thrombin-antithrombin complexes increased in both SC AXC groups, but were not significantly greater than in the IR AXC group. SC AXC for both 30 and 60 minutes produced a significant increase in tissue plasminogen activator antigen during clamping and 5 minutes after clamping. This increase persisted for 30 and 60 minutes after clamp release in the 60-minute SC AXC group. Tissue plasminogen activator activity, however, increased only in the 60-min SC AXC group during clamping (P =.02), and 5 minutes (P =.05) and 30 minutes (P =.06) after unclamping, compared with both control groups.

CONCLUSIONS

Thirty and 60 minutes of SC AXC results in similar degrees of intravascular thrombosis and fibrinogen depletion. Although SC AXC for both 30 and 60 minutes leads to activation of fibrinolytic pathways, only 60 minutes of SC AXC actually induces a fibrinolytic state. Fibrinolysis appears to be an important component of the coagulopathy associated with SC AXC, and is related to the duration of aortic clamping.

CLINICAL RELEVANCE

The coagulopathy frequently associated with thoracoabdominal aortic aneurysm repair is thought to revolt visceral ischemia-reperfusion. The nature of this coagulopathy is controversial. The current study demonstrates that the major hemostatic alteration associated with supraceliac aortic cross-clamping is activation of fibrinolytic pathways. The magnitude of this fibrinolytic response is directly related to the duration of supraceliac aortic occlusion. Future efforts to treat this coagulopathy may well include judicious use of autofibrinolytic agents.

Ten years experience of thoracic and thoracoabdominal aortic aneurysm surgical repair: lessons learned

In the last few years, advances in surgical techniques and in organ protection adjuncts have improved outcomes in thoracic (TAA) and thoracoabdominal aortic aneurysm (TAAA) surgical repair, although mortality and morbidity are still noteworthy. The aim of the current retrospective study is to determine whether the use of adjuncts influenced mortality and morbidity rates. From 1993 to 2003 we performed 353 procedures for TAA (175 cases) and TAAA (178 cases). This series has been divided into two consecutive groups: in group I (from 1993 to 1997), distal aortic perfusion with left atriofemoral bypass and cerebrospinal fluid drainage were used selectively, and in group II (from 1998 to 2003), the adjuncts were used routinely (together with surgical techniques of less invasive approach in selected cases). Total in-hospital mortality rates were significantly different ( p < 0.05): 15.9% in group I and 8.6% in group II. The overall incidence of paraplegia or paraparesis in group I was 8.3% and in Group II it was 5.1%. Renal failure occurred in 9.6% of group I and in 4.1% of group II. The incidence of respiratory failure in group I was 28%, and was 17.9% in group II. Respiratory failure was significantly lower ( p < 0.05) in group II. The reduction in the incidence of renal failure and paraplegia in the two groups was nonsignificant. In conclusion, the use of adjuncts and our improved experience allowed us to achieve a significant improvement in mortality and major morbidity rates in the group of patients operated on after 1998.

Descending Thoracic and Thoracoabdominal Aortic Aneurysm Repair: 15-Year Results Using a Uniform Approach

This review presents the results of surgical repair of descending thoracic (DT) and thoracoabdominal aortic (TAA) aneurysms, using spinal drainage (SD) distal aortic perfusion (DAP), and other adjuncts intended to reduce complications. Records of patients undergoing repair of DT and TAA between 1986 and 2002 were reviewed. Elective operations were performed using single lung ventilation, invasive monitoring, SD, modest anticoagulation, permissive hypothermia (> or = 33 degrees F), liberal use of transaortic endarterectomy, and complete repair. Intercostal arteries were reimplanted when possible and DAP was used in DT and TAA types I, II, and III repair. Exceptions to this approach were noted. Some of these adjuncts were used in emergency cases. Actuarial survival was calculated. Fifty consecutive patients with DT (3) or TAA (47), type I (4), type II (16), type III (18), or type IV (9), aneurysms received elective (36) or emergency (14) repair between 1986 and 2002. Mortality was 2/36 (5.5%) in the elective group. In the emergency group, there were 2 intraoperative deaths and mortality was 4/14 (28.5%, p < 0.07). Overall survivor morbidity was 6/34 (17.6%) in elective and 7/10 (70%, p < 0.02) in emergency cases. Paraplegia occurred in one patient in the elective group (2.7%) with dissecting type II TAA aneurysm in whom the intercostal patch was sacrificed. Two of 12 initial survivors developed paraplegia in the emergency group (16.7%); one had SD but neither had DAP or intercostal reimplantation. Serious complications were associated with avoidable deviations from the approach. Five and 10-year survival for the entire series was 64.8% and 46.4%, respectively. These results parallel those in contemporary reports from centers where repair of descending and thoracoabdominal aortic aneurysm is frequently performed. Good long-term results can be achieved using spinal drainage and distal aortic perfusion, combined with other adjuncts as a means of reducing complications. When possible, the same approach should be used in emergency cases.

Thoracoabdominal aortic aneurysm repair after prior aortic surgery

PURPOSE

The purpose of this study was to determine whether the morbidity and mortality of surgery for thoracoabdominal aortic aneurysm (TAAA) in patients with prior aortic surgery are increased.

METHODS

The results for all patients undergoing operation for TAAA at a single institution were reviewed.

RESULTS

Over a 10-year interval, 279 patients (136 women and 143 men) underwent aortic replacement for TAAA. The mean patient age was 68 years (range, 34-90). The extent of aortic replacement was relatively evenly distributed: type I (91), type II (54), type III (78), or type IV (56). Of these 279 patients, 76 (27%) had undergone prior aortic surgery. Prior infrarenal AAA was the most common prior procedure (56, 20%). Reoperation for prior failed TAAA repair was performed in 20 (7%) patients. A history of Marfan syndrome was highly associated with the need for remedial TAAA procedures (P <.0001). Overall 30-day mortality was 11.4% (32). Mortality was independent of prior aortic surgery (P =.98), prior AAA (P =.84), prior TAAA (P =.61), and gender (P =.18). Postoperative complications were seen in 67 (24%) patients and were more likely in patients who had undergone prior AAA surgery (P =.008). TAAA repair in patients with recurrent TAAA was not associated with higher morbidity (P =.33). Paraplegia (10) occurred in type I (3), type II (2), and type III (5) aneurysms but not in type IV (0), and its development was associated with higher mortality (P =.01). Prior aortic surgery was not found to be predictive of paraplegia (P =.90), although 30% of patients who developed paraplegia had a history of prior AAA repair.

CONCLUSIONS

Aortic reoperation for TAAA is required in a significant number of patients, particularly those with Marfan syndrome. Therefore, ongoing surveillance of the residual aorta is mandatory. Postoperative complications are more likely to occur in patients after prior infrarenal aortic replacement, but mortality is not significantly increased. Special technical considerations exist for remedial procedures after failed TAAA repair to provide protection for the spinal cord, kidneys, and viscera. Patients with failed TAAA procedures or progression of aneurysmal extent should be offered reoperation when indicated.

Acute renal failure in the surgical setting

Acute renal failure (ARF) is an unwelcome complication of major surgical procedures that contributes to surgical morbidity and mortality. Acute renal failure associated with surgery may account for 18-47% of all cases of hospital-acquired ARF. The overall incidence of ARF in surgical patients has been estimated at 1.2%, although is higher in at-risk groups. Mortality of patients with ARF remains disturbingly high, ranging from 25% to 90%, despite advances in dialysis and intensive care support. Appreciation of at-risk surgical populations coupled with intensive perioperative care has the capacity to reduce the incidence of ARF and by implication mortality. Developments in understanding the pathophysiology of ARF may eventually result in newer therapeutic strategies to either prevent or accelerate recovery from ARF. At present the best form of treatment is prevention. In this review the epidemiology, pathophysiology, diagnosis, treatment and possible prevention of ARF will be discussed.

Renal perfusion during thoracoabdominal aortic operations: cold crystalloid is superior to normothermic blood

BACKGROUND

Renal failure remains a common complication of thoracoabdominal aortic aneurysm repair. The purpose of this randomized clinical trial was to compare two methods of selective renal perfusion--cold crystalloid perfusion versus normothermic blood perfusion--and determine which technique provides the best kidney protection during thoracoabdominal aortic aneurysm repair.

METHODS

Thirty randomized patients undergoing Crawford extent II thoracoabdominal aortic aneurysm repair with left heart bypass had renal artery perfusion with either 4 degrees C Ringer's lactate solution (14 patients) or normothermic blood from the bypass circuit (16 patients). Acute renal dysfunction was defined as an elevation in serum creatinine level exceeding 50% of baseline within 10 postoperative days.

RESULTS

One death occurred in each group. One patient in the blood perfusion group experienced renal failure requiring hemodialysis. Ten patients (63%) in the blood perfusion group and 3 patients (21%) in the cold crystalloid perfusion group experienced acute renal dysfunction (p = 0.03). Multivariable analysis confirmed that the use of cold crystalloid perfusion was independently protective against acute renal dysfunction (p = 0.02; odds ratio, 0.133).

CONCLUSIONS

When using left heart bypass during repair of extensive thoracoabdominal aortic aneurysms, selective cold crystalloid perfusion offers superior renal protection when compared with conventional normothermic blood perfusion.

Factors affecting outcome in proximal abdominal aortic aneurysm repair

Sixty-five consecutive patients undergoing nonemergent repair of an abdominal aortic aneurysm (AAA) originating above the visceral and/or renal arteries were studied to determine operative results and identify factors influencing outcome of proximal AAA repair. Factors associated with postoperative morbidity were analyzed using multivariate analysis. There were no postoperative deaths, paraplegia/paraparesis, or symptomatic visceral ischemia. Proximal AAA repair can be accomplished with acceptable mortality. If renal artery bypass or reimplantation is anticipated, cold renal perfusion may protect against renal dysfunction. Postoperative pulmonary dysfunction can be reduced by avoiding radial division of the diaphragm.

Short-term Arterial Blood Reperfusion of Normothermic Kidney in Renal Artery and Abdominal Aorta Reconstructive Surgery

OBJECTIVE

to prevent kidney injury in renal artery and juxta-renal aortic surgery. After 30 min of cross-clamping ischaemia, renal arterial inflow is temporary re-established for 3 min. The aim of the study was to retrospectively analyse the results of this original technique.

METHODS

between January 1987 and May 1999, 48 patients underwent kidney short-term arterial blood reperfusion, directly or through the Pruitt-Inahara shunt. The reperfusion was repeated every 30 min of ischaemia, whenever necessary. Fifty control patients underwent <30 min of kidney ischaemia. Patients were assessed by serum creatinine, digital angiography and radioisotope renography using technecium(99).

RESULTS

in the study group one patient developed an acute renal failure and died (2% (-95% CI: 0-11%)). In both study and control groups patients showed a similar and moderate but temporary decline in renal function, which returned to preoperative levels after 1 week.

CONCLUSIONS

the results of this study indicate that kidney short-term reperfusion may protect renal tissue from prolonged cross-clamping ischaemia (up to 100 min), also in patients considered at high risk for acute renal failure.

Percutaneous stenting of an latrogenic superior mesenteric artery dissection complicating suprarenal aortic aneurysm repair

PURPOSE

To report endovascular repair of an iatrogenic superior mesenteric artery (SMA) dissection caused by a balloon occlusion catheter.

CASE REPORT

A 68-year-old man with a suprarenal aortic aneurysm underwent conventional prosthetic replacement, during which visceral artery back bleeding was controlled with balloon occlusion catheters. Six hours postoperatively, the patient experienced an episode of bloody diarrhea with abdominal pain and tenderness and mild metabolic acidosis. Colonoscopy revealed colitis (grade I) without necrosis of the right and left colon. An emergent abdominal computed tomographic scan showed signs of mesenteric ischemia with bowel dilatation and SMA wall hematoma; angiography identified a dissection 1 cm distal to the SMA origin. An Easy Wallstent was deployed percutaneously, successfully reestablishing SMA patency. The postoperative course was uneventful, and the patient remains asymptomatic with a patent SMA stent and aortic graft at 1 year.

CONCLUSIONS

latrogenic SMA dissection should be suspected after suprarenal aortic aneurysm repair if signs of mesenteric ischemia arise. Prompt and thorough imaging studies are necessary to confirm the diagnosis and assess the potential for an endoluminal treatment.

A modified technique of atriofemoral bypass for visceral and distal aortic perfusion in thoracoabdominal aortic surgery

Modified atriofemoral bypass (AFB) was used for repair of thoracoabdominal aortic aneurysms (TAAA). The primary circuit consisted of a centrifugal pump and heat exchanger to perfuse and warm the systemic circulation. A parallel secondary circuit with a second heat exchanger perfused the viscera with cold blood. A progressive sequential cross-clamping technique was used. This technique offers theoretical hemodynamic and metabolic advantages and may prove to be useful in preventing ischemic and reperfusion injury to the spinal cord and kidneys.