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Hamelin T, Bouziane Z, Settembre N, Malikov S. Elective open repair with the debranch, perfuse, reconstruct technique to treat suprarenal or type IV thoracoabdominal aortic aneurysms. J Vasc Surg 2024:S0741-5214(24)01775-0. [PMID: 39181339 DOI: 10.1016/j.jvs.2024.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/19/2024] [Accepted: 08/11/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Open surgical repair of suprarenal abdominal aortic aneurysm (SRAAA) and type IV thoracoabdominal aortic aneurysm (TAAA) remains a surgical challenge because of the inducted intraoperative visceral and renal ischemia. We report a novel three-step technique named debranch, perfuse, reconstruct (DPR), using debranching and passive arterial shunt to decrease these ischemic complications. The main aim of this study was to evaluate the 30-day and 1-year mortality rates associated with these DPR technique. The secondary aim was to evaluate the impact on renal function and the primary patency of the repaired arteries. METHODS This retrospective study included all consecutive patients who underwent elective surgery for SRAAA or type IV TAAA using the DPR technique between January 2011 and June 2022. In debranching, using partial side clamping, a multibranch graft was implanted side-to-end into the descending thoracic aorta. The left renal artery was anastomosed end-to-end to the graft. As needed, the superior mesenteric artery (SMA), the celiac trunk, and the right renal artery could also be anastomosed to the graft. In the perfusion step, cannulas were connected to the last branch of the multibranch graft to perfuse other arteries during aortic cross-clamping. For repair, a tube or bifurcated graft was used for the aortic repair. The branch used as a passive temporary arterial shunt was ligated at the end of the intervention. Clinical, radiological, and biological preoperative and postoperative factors were reviewed using a standardized database. Procedural complications and reinterventions were analyzed, as well as artery patency. RESULTS There were 40 patients who underwent DPR technique. The mean patient age was 67 ± 13 years and two were women. Twenty-three patients presented with a SRAAA and 17 with a type IV TAAA. The 30-day and 1-year mortality rates were 2.5% (one patient). Two respiratory complications (5%) and three mesenteric ischemic complications (7%) have been recorded. No patient developed signs of cardiac or spinal cord dysfunction. We did not observe a significant change in postoperative renal function. The celiac trunk, superior mesenteric artery, left renal artery, and right renal artery bypass patency rates at 1 year were 95%, 100%, 90%, and 100%, respectively. CONCLUSIONS The SRAAA and type IV TAAA repair with DPR technique provides short visceral and renal ischemia times with a low mortality rate. This technique could be an option to consider for visceral and renal protection during open surgical repair.
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Affiliation(s)
- Thibaud Hamelin
- Department of Vascular Surgery, Nancy Regional University Hospital, Nancy, France.
| | - Zakariyae Bouziane
- Department of Vascular Surgery, Nancy Regional University Hospital, Nancy, France
| | - Nicla Settembre
- Department of Vascular Surgery, Nancy Regional University Hospital, Nancy, France; Université de Lorraine, INSERM UMR_S 1116 DCAC, Nancy, France
| | - Sergueï Malikov
- Department of Vascular Surgery, Nancy Regional University Hospital, Nancy, France; Université de Lorraine, INSERM UMR_S 1116 DCAC, Nancy, France
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Mohebali J, Latz CA, Cambria RP, Patel VI, Ergul EA, Lancaster RT, Conrad MF, Clouse WD. The Long-term Fate of Renal and Visceral Vessel Reconstruction After Open Thoracoabdominal Aortic Aneurysm Repair. J Vasc Surg 2021; 74:1825-1832. [PMID: 34171425 DOI: 10.1016/j.jvs.2021.05.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES In the ever-advancing era of endovascular thoracoabdominal aneurysm (TAAA) repair, understanding long-term patency of renovisceral reconstructions after open TAAA repair provides important benchmarks. METHODS Institutional open TAAA repair patient data were queried. Patients dying during index admission or with incomplete operative detail were excluded. Visceral and renal reconstructions were categorized as bypass, incorporation into a proximal or distal beveled aortic anastomosis, inclusion button, Carrel patch, or hybrid stent along with endarterectomy/stent adjuncts. Axial imaging or angiography determined long-term patency. Vessel event was defined as new occlusion or reintervention after repair. Overall time-to-event analysis was performed as well as separate analyses for each vessel (Celiac, SMA, right renal, left renal) by reconstruction type utilizing Kaplan-Meier methods. Log-rank testing was employed to compare reconstructive strategies. RESULTS Over 28-years, 604 repairs [Type I 106(18%), Type II 73(12%), Type III 195(32%), Type IV 230(38%)] were identified. Follow-up (median 500 days) was available in 410/570(72%) Celiac, 406/573(71%) SMA, 379/532(71.2%) right renal, and 370/515(72%) left renal reconstructions. There were five celiac, one SMA, eight right renal, and ten left renal events. No type of reconstruction or adjunct was significantly associated with event. Overall 5-year patency of all renal/visceral reconstructions was 94% (95%CI [90%-96%]). Estimated 5-year patency of the Celiac, SMA, left renal, and right renal were similar, and were 99%, 100%, 97%, and 96%, respectively (p = .09). CONCLUSIONS Visceral and renal long-term patency after open TAAA repair is excellent regardless of reconstructive technique. No differences are appreciated even when target vessel disease is addressed at the time of reconstruction. These findings continue to substantiate the effective long-term durability of open TAAA repair and are particularly germane to the ongoing evolution of endovascular strategies.
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Affiliation(s)
- Jahan Mohebali
- Massachusetts General Hospital Division of Vascular and Endovascular Surgery, Harvard Medical School, Boston, MA
| | - Christopher A Latz
- Massachusetts General Hospital Division of Vascular and Endovascular Surgery, Harvard Medical School, Boston, MA
| | - Richard P Cambria
- Divison of Vascular Surgery, Steward Medical Group, St. Elizabeth's Medical Center, Brighton, MA
| | - Virendra I Patel
- Divison of Vascular Surgery and Endovascular Interventions, Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY
| | - Emel A Ergul
- Massachusetts General Hospital Division of Vascular and Endovascular Surgery, Harvard Medical School, Boston, MA
| | - R Todd Lancaster
- Massachusetts General Hospital Division of Vascular and Endovascular Surgery, Harvard Medical School, Boston, MA
| | - Mark F Conrad
- Massachusetts General Hospital Division of Vascular and Endovascular Surgery, Harvard Medical School, Boston, MA
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
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Atkins MD, Reardon MJ. Commentary: There's more than one way to skin a cat (thoraco). JTCVS Tech 2021; 7:34-35. [PMID: 34318199 PMCID: PMC8312076 DOI: 10.1016/j.xjtc.2021.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 03/13/2021] [Accepted: 03/22/2021] [Indexed: 11/21/2022] Open
Affiliation(s)
- Marvin D. Atkins
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, Tex
| | - Michael J. Reardon
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, Tex
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Martelli E, Cho JS. Merits of and Technical Tips for Supra-Mesenteric Aortic Cross Clamping. Vasc Specialist Int 2019; 35:55-59. [PMID: 31297354 PMCID: PMC6609017 DOI: 10.5758/vsi.2019.35.2.55] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 11/20/2022] Open
Abstract
Supra-celiac aortic cross clamping is often utilized during aortic reconstruction for aneurysmal/occlusive disease involving the pararenal aorta. However, this may be accompanied a myriad of complications related to hemodynamic disturbances, cardiopulmonary compromise and hepatic ischemia. Supra-mesenteric aortic cross clamping may be an excellent option in selected patients with suitable anatomy to minimize or avoid these complications. Herein, the merits of and technical tips for supra-mesenteric aortic cross clamping are discussed.
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Affiliation(s)
- Eugenio Martelli
- Division of Vascular Surgery, Department of Medical, Surgical, and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Jae Sung Cho
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Review: perspectives on renal and visceral protection during thoracoabdominal aortic aneurysm repair. Indian J Thorac Cardiovasc Surg 2019; 35:179-185. [PMID: 33061084 DOI: 10.1007/s12055-018-0757-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 10/04/2018] [Accepted: 10/07/2018] [Indexed: 10/27/2022] Open
Abstract
Open repair of a thoracoabdominal aortic aneurysm (TAAA) is an extensive operation and associated with significant perioperative morbidities and mortality, in large part due to distal aortic ischemia secondary to aortic cross-clamping that is necessitated during repair. Distal aortic ischemia may manifest as complications of the kidneys and viscera. Postoperative renal complications range from temporarily elevated levels of creatinine resulting from impaired kidney function to acute renal failure necessitating dialysis that may persist after hospital discharge. Continued advances in the management and adjuncts associated with TAAA repair since the groundbreaking era of E.S. Crawford have led to improved postoperative outcomes following surgery, but the dramatic improvements seen in reducing rates of spinal cord deficits, mesenteric ischemia and other serious postoperative complications have not been seen in contemporary rates of postoperative renal failure. We provide an overview of the various surgical techniques and adjuncts as they relate to the management of visceral and renal ischemia.
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Durability of open surgical repair of type IV thoracoabdominal aortic aneurysm. J Vasc Surg 2019; 69:661-670. [DOI: 10.1016/j.jvs.2018.05.249] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 05/31/2018] [Indexed: 11/27/2022]
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Rasheed K, Stoner MC. Aortic endograft explantation in the setting of prior heterotopic renal allograft. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2018; 4:275-277. [PMID: 30547145 PMCID: PMC6282867 DOI: 10.1016/j.jvscit.2018.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/17/2018] [Indexed: 11/29/2022]
Abstract
It is rare to require explantation of an aortic endograft placed for endovascular aneurysm repair (EVAR). Sustained aneurysm growth in the setting of prior endovascular repair, despite secondary interventions and use of adjuncts, is the most common cause of EVAR explantation. An infected endograft and aneurysm rupture after EVAR represent more urgent or emergent indications for explantation and have a significantly greater associated morbidity and mortality. This case of endograft explantation is of even greater complexity, given the patient's specific history of aneurysm repair in the concomitant setting of a functioning renal allograft.
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Affiliation(s)
- Khurram Rasheed
- Division of Vascular Surgery, University of Rochester, Rochester, NY
| | - Michael C Stoner
- Division of Vascular Surgery, University of Rochester, Rochester, NY
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Monnot A, Dusseaux MM, Godier S, Plissonnier D. Passive Temporary Visceral Shunt from the Axillar Artery as an Adjunct Method during the Open Treatment of Thoracoabdominal Aortic Aneurysm. Ann Vasc Surg 2016; 36:127-131. [PMID: 27427350 DOI: 10.1016/j.avsg.2016.03.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 03/23/2016] [Accepted: 03/27/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Distal aortic retrograde perfusion systems like the left heart bypass or femoro-femoral extracorporeal circulation are the methods of reference for organ protection during direct approaches to thoracoabdominal aortic aneurysms. The aim of this work was to evaluate the use of a passive arterial shunt to reduce visceral ischemia during aortic operations when occlusive diseases of the iliac arteries make distal aortic retrograde perfusion inappropriate. METHODS Ten patients affected by a Crawford type III thoracoabdominal aneurysm (TAA) were operated on between January 2013 and January 2015 with the use of a temporary shunt inserted onto the left axillar artery that allows visceral perfusion immediately after the aorta is opened. The operation was performed after a single dose of heparin (50 UI/kg). The sera lactate levels were measured 2 hr after the last aortic clamp was removed and compared with those obtained from a group of 19 patients operated on for a Crawford type IV TAA during the same period without any arterial shunt. RESULTS Neither mortality nor paraplegia occurred. The sera lactate levels were lower in the group of patients operated on for a type III TAA (2.57 ± 1) than for a type IV TAA (3.68 ± 1) (P < 0.01, Student's t-test). CONCLUSION This method was effective for low mesenteric ischemia, easy to perform, and did not require high doses of anticoagulants.
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Affiliation(s)
- Antoine Monnot
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | | | - Sylvie Godier
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | - Didier Plissonnier
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France.
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Morrissey NJ, Kantonen I, Liu H, Sidiqui M, Marin ML, Hollier LH. Effect of Mesenteric Ischemia/Reperfusion on Spinal Cord Injury following Transient Aortic Occlusion in Rabbits. J Endovasc Ther 2016. [DOI: 10.1177/15266028020090s208] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To investigate in a rabbit model if prolonged periods of mesenteric ischemia followed by reperfusion may affect the rate of neurological complications. Methods: An infrarenal aortic snare, which consisted of a Silastic vessel loop whose ends were passed through plastic tubing, was placed in 50 male New Zealand white rabbits. In 40 of these animals, a similar but smaller device was placed around the superior mesenteric artery (SMA); all devices were exteriorized to allow vessel occlusion in the awake animal. The aorta was occluded for 12 minutes in the 10 control and 40 experimental animals, but the experimental rabbits also had occlusion of the SMA for varying intervals: 10 minutes (group 1), 12 minutes (group 2), and 18 minutes (group 3). To assess the hemodynamic effects of aortic and aortic/SMA occlusion, select control and test animals had blood pressure and heart rate monitoring via indwelling carotid catheters during the occlusion periods. The animals were euthanized, and spinal cords from paralyzed and normal rabbits were examined histologically Results: Neurological deficit occurred in 20% of controls and in 70%, 80%, and 100% in the experimental groups, respectively. There were no significant differences in systemic blood pressure at any time point during occlusion and reperfusion in the monitored control or test animals. There was no evidence of thrombosis of spinal arteries on histological analysis, nor was there evidence of bowel infarction at the time of sacrifice in animals undergoing combined aortic/SMA occlusion. Conclusions: Mesenteric ischemia/reperfusion worsens the neurological outcome in animals undergoing transient aortic occlusion. This observation is independent of hemodynamic influences and not the result of spinal artery thrombosis.
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Affiliation(s)
- Nicholas J. Morrissey
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai School of Medicine, New York, New York, USA
| | - Ilkka Kantonen
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai School of Medicine, New York, New York, USA
| | - Harry Liu
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai School of Medicine, New York, New York, USA
| | - Mohamed Sidiqui
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai School of Medicine, New York, New York, USA
| | - Michael L. Marin
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai School of Medicine, New York, New York, USA
| | - Larry H. Hollier
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai School of Medicine, New York, New York, USA
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Lim S, Halandras PM, Saqib NU, Ching YA, Villella E, Park T, Son H, Cho JS. Comparison of supramesenteric aortic cross-clamping with supraceliac aortic cross-clamping for aortic reconstruction. J Vasc Surg 2016; 64:941-7. [PMID: 27038834 DOI: 10.1016/j.jvs.2016.01.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 01/29/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Supraceliac aortic cross-clamping (SCXC) is routinely used during open aortic reconstruction (OAR) of pararenal aortic disease when suprarenal control is not feasible. On occasion, however, aortic control may be obtained at the supramesenteric level by supramesenteric cross-clamping (SMXC) between the superior mesenteric artery and the celiac axis. The purpose of this study was to compare outcomes between patients who had SMXC vs SCXC during OAR for both aneurysmal and occlusive diseases. METHODS A retrospective chart review identified 69 patients who underwent elective OAR requiring SMXC (n = 18) or SCXC (n = 51). All patients with thoracoabdominal aneurysms and those who had inframesenteric (suprarenal and infrarenal) aortic control were excluded. Propensity score-based matching was performed to adjust for confounding factors in a 1:1 ratio to compare outcomes. Late survival was estimated by Kaplan-Meier methods. RESULTS Propensity score-based matching was performed at a 1:1 ratio; 18 SMXC cases were matched with 18 SCXC cases. The average age was 66.7 years, and men constituted 72%. Baseline characteristics were matched, except for the incidence of peripheral vascular occlusive disease (72.2% in the SMXC group vs 33.3% in the SCXC group; P = .04). A majority (80.6%) of patients underwent OAR for aneurysmal disease (72.2% in the SMXC group, 88.9% in the SCXC group). Intraoperatively, there were no differences in operative times (325 minutes for SMXC vs 298 minutes for SCXC; P = .48), but the SMXC group had a longer renal ischemia time (40 minutes vs 28 minutes; P = .03). There were no significant differences in intraoperative blood loss (2.4 L vs 1.6 L; P = .2) or blood product transfusion requirements (packed red blood cells, 2.2 units vs 1.6 units [P = .5]; Cell Saver, 1.3 L vs 0.7 L [P = .09]). Overall complication rates did not differ significantly (27.8% for SMXC vs 44.4% for SCXC; P = .24). Thirty-day mortality rates did not differ between the two groups (0% for SMXC vs 5.6% for SCXC; P = 1). CONCLUSIONS In this study, there were no differences in early morbidity or mortality between SMXC and SCXC during aortic reconstruction. SMXC, however, can be performed safely and effectively in properly selected patients. A larger, multicenter prospective study would help elucidate the potential benefits.
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Affiliation(s)
- Sungho Lim
- Department of Surgery, Loyola University Medical Center, Maywood, Ill
| | - Pegge M Halandras
- Department of Surgery, Loyola University Medical Center, Maywood, Ill
| | - Naveed U Saqib
- Department of Cardiothoracic and Vascular Surgery, University of Texas Houston Medical Center, Houston, Tex
| | - Y Avery Ching
- Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Tex
| | - Edward Villella
- Department of Surgery, Loyola University Medical Center, Maywood, Ill
| | - Taeyoung Park
- Department of Applied Statistics, Yonsei University, Seoul, Korea
| | - Hyunju Son
- Department of Applied Statistics, Yonsei University, Seoul, Korea
| | - Jae S Cho
- Department of Surgery, Loyola University Medical Center, Maywood, Ill.
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Patel VI, Lancaster RT, Conrad MF, Cambria RP. Open surgical repair of thoracoabdominal aneurysms - the Massachusetts General Hospital experience. Ann Cardiothorac Surg 2013; 1:320-4. [PMID: 23977514 DOI: 10.3978/j.issn.2225-319x.2012.09.02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2012] [Accepted: 09/06/2012] [Indexed: 11/14/2022]
Affiliation(s)
- Virendra I Patel
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Lancaster RT, Conrad MF, Patel VI, Cambria MR, Ergul EA, Cambria RP. Further experience with distal aortic perfusion and motor-evoked potential monitoring in the management of extent I-III thoracoabdominal aortic anuerysms. J Vasc Surg 2013; 58:283-90. [DOI: 10.1016/j.jvs.2013.01.042] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 01/15/2013] [Accepted: 01/16/2013] [Indexed: 10/26/2022]
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Cytokine balance in hepatosplanchnic system during thoracoabdominal aortic aneurysm repair. J Artif Organs 2011; 14:192-200. [DOI: 10.1007/s10047-011-0577-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Accepted: 05/19/2011] [Indexed: 11/25/2022]
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Conrad MF, Ergul EA, Patel VI, Cambria MR, LaMuraglia GM, Simon M, Cambria RP. Evolution of operative strategies in open thoracoabdominal aneurysm repair. J Vasc Surg 2011; 53:1195-1201.e1. [DOI: 10.1016/j.jvs.2010.11.055] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Revised: 10/28/2010] [Accepted: 11/06/2010] [Indexed: 10/18/2022]
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Adams C, Zhen-Yu Tong M, Lawlor DK, DeRose G, Forbes TL. Recurrent aortic aneurysms in Behçet disease. Vascular 2010; 18:299-302. [PMID: 20822728 DOI: 10.2310/6670.2010.00041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The following is a case of a 22-year-old male with recurrent thoracic aneurysms with several constitutional symptoms, including gastrointestinal discomfort, irritable bowel syndrome, lactose intolerance, and a 2-week history of severe lower back pain. The patient underwent an initial thoracoabdominal repair of a visceral aneurysm followed by endovascular repair of a recurrent thoracic pseudoaneurysm. The etiology of the visceral aneurysm was initially hypothesized to be mycotic; however, further information revealed signs and symptoms consistent with the diagnostic criteria for Behçet disease (BD). We suggest that BD be considered in younger patients who present with an aortic aneurysm. Although open repair is the traditional approach for arterial lesions in BD, the role for endovascular intervention should be considered as it represents a surgical repair with a significant reduction in morbidity.
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Affiliation(s)
- Corey Adams
- Division of Vascular Surgery, London Health Sciences Centre, 800 Commissioners Road East, London, Ontario, Canada
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PJ34, a poly-ADP-ribose polymerase inhibitor, modulates visceral mitochondrial activity and CD14 expression following thoracic aortic ischemia-reperfusion. Am J Surg 2009; 198:250-5. [DOI: 10.1016/j.amjsurg.2008.09.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Revised: 09/10/2008] [Accepted: 09/10/2008] [Indexed: 11/18/2022]
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17
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Ockert S, Riemensperger M, von Tengg-Kobligk H, Schumacher H, Eckstein HH, Böckler D. Complex Abdominal Aortic Pathologies: Operative and Midterm Results after Pararenal Aortic Aneurysm and Type IV Thoracoabdominal Aneurysm Repair. Vascular 2009; 17:121-8. [DOI: 10.2310/6670.2009.00010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of the study was to describe the clinical outcome of pararenal aortic aneurysm (PAAA) and type IV thoracoabdominal aneurysm (TAAA) repair, with special consideration placed on disease-related complications and midterm follow-up. Data were collected retrospectively between 1997 and 2004 for patients with PAAA or type IV TAAA repair. Comorbidities, operative details, and early and late outcome were analyzed to predict disease-related complications. During the study period, 63 patients (33 PAAAs, 30 type IV TAAAs) underwent aortic repair. The 30-day mortality rate of 7.9% was acceptable for complex aortic entities compared with other series. The morbidity for cardiac events was 3.2%, for pulmonary complications 17.5%, and the need for reoperation was 14.3%. With regard to disease-related complications, two patients (3.2%) required dialysis and one patient (1.6%) developed paraplegia (spinal cord ischemia) after type IV TAAA repair. Complex aortic repair for PAAAs and type IV TAAAs showed acceptable perioperative mortality, morbidity, and midterm survival rates. Patients with type IV TAAAs suffered more major complications, such as postoperative dialysis or spinal cord ischemia.
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Affiliation(s)
- Stefan Ockert
- *Department of Vascular Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany; †Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany; ‡Department of Radiology, German Cancer Research Center, Heidelberg, Germany
| | - Marcel Riemensperger
- *Department of Vascular Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany; †Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany; ‡Department of Radiology, German Cancer Research Center, Heidelberg, Germany
| | - Hendrik von Tengg-Kobligk
- *Department of Vascular Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany; †Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany; ‡Department of Radiology, German Cancer Research Center, Heidelberg, Germany
| | - Hardy Schumacher
- *Department of Vascular Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany; †Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany; ‡Department of Radiology, German Cancer Research Center, Heidelberg, Germany
| | - Hans-Henning Eckstein
- *Department of Vascular Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany; †Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany; ‡Department of Radiology, German Cancer Research Center, Heidelberg, Germany
| | - Dittmar Böckler
- *Department of Vascular Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany; †Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany; ‡Department of Radiology, German Cancer Research Center, Heidelberg, Germany
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Type IV Thoracoabdominal Aneurysm Repair: Predictors of Postoperative Mortality, Spinal Cord Injury, and Acute Intestinal Ischemia. Ann Vasc Surg 2008; 22:822-8. [DOI: 10.1016/j.avsg.2008.07.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Accepted: 07/11/2008] [Indexed: 11/20/2022]
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Fehrenbacher JW, Hart DW, Huddleston E, Siderys H, Rice C. Optimal End-Organ Protection for Thoracic and Thoracoabdominal Aortic Aneurysm Repair Using Deep Hypothermic Circulatory Arrest. Ann Thorac Surg 2007; 83:1041-6. [PMID: 17307456 DOI: 10.1016/j.athoracsur.2006.09.088] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2006] [Revised: 09/25/2006] [Accepted: 09/26/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Despite the advent of numerous protective strategies, thoracic and thoracoabdominal aortic replacement remains a high risk. While mortality rates have improved over the last 15 years, the incidence of adverse outcomes (including stroke, renal failure, and paraplegia, as well as death) remains at 13% to 30% in all published series. The use of deep hypothermic cardiopulmonary bypass with circulatory arrest has been associated with high morbidity in the past; however, we report a single surgeon's experience of improved end-organ protection with low morbidity and mortality utilizing this technique. METHODS One hundred seventy-three consecutive patients with descending thoracic and thoracoabdominal aneurysms were operated on between April 1995 and March 2005. Hypothermic (15 degrees C) cardiopulmonary bypass with circulatory arrest and open proximal anastomosis were utilized in all subjects. Visceral arteries were uniformly reimplanted as an island while additional renal artery bypasses were performed as required. Lower intercostals and lumbar arteries were aggressively reimplanted or preserved at the aortic anastomosis. No other adjuncts for spinal cord protection were routinely employed. RESULTS Sixty-three patients with isolated descending thoracic aortic aneurysms and 27 patients with extent I, 49 with extent II, 20 with extent III, and 14 with extent IV thoracoabdominal aortic aneurysms underwent operative repair. Ninety percent of cases were elective while 10% were urgent or emergent. There were seven hospital deaths, and the hospital mortality was 4.0%. Operative complications included stroke in seven patients (4.1%), paraplegia in four (2.4%), including 0 of 62 ambulatory patients with isolated thoracic aneurysm repairs, and acute renal failure requiring dialysis in two of 168 operative survivors that were not dialysis-dependent before surgery. CONCLUSIONS Deep hypothermic circulatory arrest allows replacement of complex aortic pathology with low mortality. End-organ protection is excellent with lower incidences of dialysis-dependent renal failure and paraplegia than are reported with other currently used surgical techniques.
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Fehrenbacher J, Siderys H, Shahriari A. Preservation of Renal Function Utilizing Hypothermic Circulatory Arrest in the Treatment of Distal Thoracoabdominal Aneurysms (Types III and IV). Ann Vasc Surg 2007; 21:204-7. [PMID: 17349363 DOI: 10.1016/j.avsg.2006.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2005] [Revised: 07/14/2006] [Accepted: 08/10/2006] [Indexed: 10/21/2022]
Abstract
Although left heart bypass and hypothermia are often used in the performance of type I and type II thoracoabdominal aneurysms (TAAs), most of these more distal aneurysms are done utilizing the clamp and sew technique. Renal failure occurs between 8.6% to 39% in recent series of patients following surgery for type III and IV TAAs. The purpose of this study was to determine whether the use of hypothermic circulatory arrest in these cases would serve to protect renal function. All patients were operated on using hypothermic circulatory arrest. The kidneys were perfused with cold blood during the procedures, and renal artery bypasses were aggressively used (when stenoses greater than 50% were observed). The series describes 33 consecutive patients with type III and IV TAAs who were operated on utilizing hypothermic circulatory arrest with a core temperature of 15 degrees centigrade. All visceral and renal arteries were individually perfused; 20 patients had bypass grafts of their renal artery stenoses. Although six patients had renal failure preoperatively, only one developed postoperative renal failure. This was the patient who was operated on as an emergency for severe abdominal pain, back pain, and acidosis who was also the only hospital death. Of the remaining five patients with elevated creatinines preoperatively, four had postoperative decrease of the serum creatinine. One patient developed paraparesis and one developed a stroke. The median length of stay was 8 days. Consideration should be given to the use of hypothermic circulatory arrest in type III and IV TAAs for the preservation of renal function and improved overall results.
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Gawenda M, Aleksic M, Heckenkamp J, Reichert V, Gossmann A, Brunkwall J. Hybrid-procedures for the Treatment of Thoracoabdominal Aortic Aneurysms and Dissections. Eur J Vasc Endovasc Surg 2007; 33:71-7. [PMID: 17056286 DOI: 10.1016/j.ejvs.2006.09.002] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2006] [Accepted: 09/04/2006] [Indexed: 11/23/2022]
Abstract
AIM The conventional open repair of thoracoabdominal aneurysms and dissections remains complex and demanding and is associated with significant morbidity and mortality. We present our experience of hybrid open and endovascular treatment of thoracoabdominal aneurysms and dissections. METHODS Within an experience of 226 aortic stent-grafts between 1998 and April 2006, 6 of the patients (median age 60 years, range 35 to 68 years) with thoracoabdominal aneurysms (Crawford type I, II, III, and V) were treated with a combined endovascular and open surgical approach. Five men and one woman, with median aneurysm diameter of 75 mm (range 70-100 mm), received revascularization of the renal arteries, the superior mesenteric artery, and the coeliac trunk accomplished via transperitoneal bypass grafting. Aneurysmal exclusion was then performed by stent-graft deployment. RESULTS The entire procedure was technically successful in all patients. The patients were discharged a median of 9 days after the operation, while the postoperative studies revealed the patency of the vessels and no evidence of type I endoleak or secondary rupture of the aneurysm. During follow up (1 to 22 months) spiral-CT scanning revealed distinct shrinkage of the aneurysm, no graft migration or endoleak and patency of all revascularised vessels, except one renal artery in two patients. No patient experienced any temporary or permanent neurological deficit, and no dialysis was necessary. CONCLUSION The combined endovascular and open surgical approach is feasible, without cross clamping of the aorta and with minimized ischemia time for renal and visceral arteries, and seems to be an appropriate strategy for patients with a thoraco-abdominal aortic aneurysm or dissection.
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Affiliation(s)
- M Gawenda
- Division of Vascular Surgery, Medical Centre, University of Cologne, Cologne, Germany.
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LeMaire SA, Voloyiannis T, Coselli JS. Images in vascular medicine. Aortic graft pseudo-pseudoaneurysms. Vasc Med 2006; 10:329. [PMID: 16444861 DOI: 10.1191/1358863x05vm632xx] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Scott A LeMaire
- The Texas Heart Institute at St Luke's Episcopal Hospital, Houston, TX, USA.
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Back MR, Bandyk M, Bradner M, Cuthbertson D, Johnson BL, Shames ML, Bandyk DF. Critical Analysis of Outcome Determinants Affecting Repair of Intact Aneurysms Involving the Visceral Aorta. Ann Vasc Surg 2005; 19:648-56. [PMID: 16052385 DOI: 10.1007/s10016-005-6843-3] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Visceral (mesenteric and/or renal) ischemia/reperfusion phenomena likely contribute to the greater operative risk associated with pararenal and lower thoracoabdominal aortic aneurysm (TAA) repair. To differentiate the relative adverse effects of aortic clamp level, visceral ischemic duration, and various pre- and perioperative factors shared with infrarenal aneurysm patients, a comparative analysis of early and late outcomes after open repair of intact infrarenal and visceral aortic aneurysms was undertaken. A retrospective review of our university experience from 1993-1999/2002 revealed 549 patients (mean age 70 +/- 8 years, 11% female) undergoing open repair of intact, degenerative aneurysms of the infrarenal (n = 391, 71%), juxtarenal (n = 78, 14%), suprarenal (n = 35, 7%), and type IV (n = 40, 7%) and type III (n = 5, 1%) TAA segments. All pararenal aneurysms required suprarenal (SR) or supravisceral (SV, above celiac or superior mesenteric artery) clamp placement. Concomitant renal reconstruction was done in 30% of visceral aortic and 3% of open infrarenal aneurysm repairs. Thirty-day adverse outcomes [death, renal failure (creatinine 2 x baseline or new dialysis), visceral (bowel, hepatic, renal, spinal cord, multiple organ dysfunction), and nonvisceral (cardiac, pulmonary, procedural) complications] were analyzed relative to patient and operative factors using univariate comparisons and multivariate stepwise logistic regression. Perioperative mortality rates varied significantly between aneurysm locations (infrarenal 2.1%, juxtarenal 2.6%, suprarenal 11.4%, TAA 13.3%; p < 0.01) and for clamp locations (infrarenal 2.1%, SR 3.0%, SV 10.8 %; p < 0.01) but were not different between juxtarenal (1.8% vs. 4.4 %) and SR (9.1% vs. 12.5%) aneurysms requiring SR or SV clamping, respectively. Visceral ischemic time (VIT) during SR or SV clamping, and not clamp location, was the only independent predictor of operative mortality [odds ratio (OR) = 10.8, 95% confidence interval (CI) 4-29]. Sensitivity analyses revealed VIT > 32 min to be the strongest predictor of early death. Visceral complication or renal failure affected 34% and 23% of visceral aortic (5% dialysis) and 7% and 5% (1% dialysis) of infrarenal repairs, respectively. VIT > 32 min, SV clamp placement, diabetes, and inflammatory aneurysm repair were each predictive of visceral complications and/or renal failure. Five-year survival rate was similar after visceral aortic (70%) and infrarenal (75%) repairs but negatively impacted only in patients with prior infrarenal abdominal aortic aneurysm repair and recurrent aneurysms (OR = 2.8, 95% CI 1.2-6.9). The high incidence of early adverse outcomes following repair of pararenal and lower thoracoabdominal aneurysms is primarily associated with excessive periods of renal and/or gut ischemia during visceral aortic clamp placement. However, nearly equivalent early and late survival was seen for visceral aortic and infrarenal repairs when VIT < 32 min was achieved.
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Affiliation(s)
- Martin R Back
- Division of Vascular and Endovascular Surgery, University of South Florida College of Medicine, Tampa, FL 33606, USA.
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Wahlgren CM, Wahlberg E. Management of Thoracoabdominal Aneurysm Type IV. Eur J Vasc Endovasc Surg 2005; 29:116-23. [PMID: 15649716 DOI: 10.1016/j.ejvs.2004.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2004] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- C-M Wahlgren
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, 171 76 Stockholm, Sweden.
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Affiliation(s)
- Wilton C Levine
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02214, USA
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Haithcock BE, Shepard AD, Raman SBK, Conrad MF, Pandurangi K, Fanous NH. Activation of fibrinolytic pathways is associated with duration of supraceliac aortic cross-clamping. J Vasc Surg 2004; 40:325-33. [PMID: 15297829 DOI: 10.1016/j.jvs.2004.04.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Benjamin E Haithcock
- Department of Surgery, Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI 48202, USA
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Eide TO, Romundstad P, Saether OD, Myhre HO, Aadahl P. A Strategy for Treatment of Type III and IV Thoracoabdominal Aortic Aneurysm. Ann Vasc Surg 2004; 18:408-13. [PMID: 15156360 DOI: 10.1007/s10016-004-0048-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The aim of this study was to describe the results of resection and graft replacement for type III and IV thoracoabdominal aortic aneurysm repair. In this retrospective study, 27 patients underwent resection and graft replacement for type III (10) or type IV (17) thoracoabdominal aortic aneurysms. Nine patients had rupture, 12 were symptomatic, and 6 were operated on electively. The "clamp-and-sew" technique was applied in six cases. In 12 patients with type IV aneurysm the proximal part of the vascular graft was beveled, including the orifices of the celiac, superior mesenteric, and one or both renal arteries in the proximal anastomosis. Finally, eight patients underwent surgical application of a shunt for perfusion of the celiac and superior mesenteric arteries. One patient was treated with a combination of open and endovascular surgery. There were four early deaths (14.8%), all following operations for rupture, which represents a 45% mortality rate in this subgroup of patients. Two patients with type III aneurysm had postoperative paraparesis. One was symptomatic whereas the other was operated on electively. Excluding the patients with rupture, the accumulated 5-year survival rate was 65%. These results indicate that direct cross-clamping of the aorta gives limited time for performing the necessary anastomoses without inducing mesenteric ischemia. Inclusion of the orifices of the visceral arteries in the upper anastomosis is a feasible method during surgery for type IV aneurysms. Finally, shunting of the celiac and the superior mesenteric arteries seems to be useful, especially during surgery for type III aneurysms.
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Affiliation(s)
- T O Eide
- Department of Surgery, St. Olavs Hospital, University Hospital of Trondheim, Trondheim, Norway
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28
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Giglia JS, Thompson JK. Repair of a thoracoabdominal aortic aneurysm in the presence of a left-sided inferior vena cava. J Vasc Surg 2004; 40:161-3. [PMID: 15218477 DOI: 10.1016/j.jvs.2004.02.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Venous anomalies are not infrequently encountered during aortoiliac reconstruction, because of the complexity of development of the venous system. Retroaortic left renal veins, duplicate inferior vena cava (IVC), and left-sided IVC are occasionally found. Left-sided IVC has been reported with infrarenal aortic aneurysms. We report successful repair of a thoracoabdominal aneurysm in a patient with a left-sided IVC. The embryology and intraoperative management are discussed.
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Affiliation(s)
- Joseph S Giglia
- Department of Surgery, University of Cincinnati Medical Center, Ohio, USA.
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29
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Eide TO, Myhre HO, Saether OD, Aadahl P. Shunting of the Coeliac and Superior Mesenteric Arteries during Thoracoabdominal Aneurysm Repair. Eur J Vasc Endovasc Surg 2003; 26:602-6. [PMID: 14603418 DOI: 10.1016/s1078-5884(03)00355-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe our experience with shunting of the coeliac and superior mesenteric arteries during thoracoabdominal aneurysm repair. DESIGN Retrospective study. MATERIAL Eight patients undergoing resection and graft replacement of Crawford type III (5) and type IV (3) thoracoabdominal aortic aneurysms were included in this series. One patient had rupture, four were symptomatic and three were operated on electively. METHODS A vascular graft with a sidearm was applied for the reconstructions. A T-shunt was connected to the sidearm. Following completion of the proximal anastomosis the shunt was inserted into the coeliac and superior mesenteric arteries. The anastomoses to these arteries and the renal arteries were then completed. Finally the distal anastomosis was performed. RESULTS There was no early mortality (30 days). One patient had postoperative paraparesis, but recovered quite well. Reoperation became necessary due to sigmoid necrosis in one patient and due to haemorrhage in another. During the follow-up period four patients died but the other patients are alive between 3 and 8 years after surgery. CONCLUSION The application of shunting of the superior mesenteric and coeliac arteries during thoracoabdominal aortic surgery is feasible and the results have been acceptable. Further investigation of the optimal blood flow needed to avoid intestinal ischaemia in a larger series of patients is desirable.
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Affiliation(s)
- T O Eide
- Department of Surgery, University Hospital of Trondheim, Norway
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30
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Giglia JS. Technique to decrease lower extremity and pelvic ischemia during thoracoabdominal aortic aneurysm repair. J Vasc Surg 2003; 38:401-2. [PMID: 12891130 DOI: 10.1016/s0741-5214(03)00229-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Joseph S Giglia
- Division of Vascular Surgery, University of Cincinnati, PO Box 670558, Cincinnati, OH 45267-0558, USA.
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31
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Carroccio A, Marin ML, Ellozy S, Hollier LH. Pathophysiology of paraplegia following endovascular thoracic aortic aneurysm repair. J Card Surg 2003; 18:359-66. [PMID: 12869184 DOI: 10.1046/j.1540-8191.2003.02076.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Alfio Carroccio
- Division of Vascular Surgery, Mount Sinai School of Medicine, New York, NY, USA
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32
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Ouriel K. The use of an aortoiliac side-arm conduit to maintain distal perfusion during thoracoabdominal aortic aneurysm repair. J Vasc Surg 2003; 37:214-8. [PMID: 12514606 DOI: 10.1067/mva.2003.72] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Thoracoabdominal aneurysm repair continues to be associated with a significant risk of operative complications, many of which are related to the prolonged period of aortic cross clamping inherent in the procedure. A variety of adjuvant techniques have been used in attempts to decrease morbidity, including atriofemoral extracorporal bypass, subarachnoid drainage, epidural cooling, and preliminary axillofemoral bypass. Herein is described a method to maintain distal perfusion with a side-arm conduit, originating from the most proximal aspect of the aortic graft and terminating on the left iliac artery. The technique has the potential to minimize hemodynamic instability while decreasing the period of pelvic and lower extremity ischemia and simplifying reattachment of aortic branch vessels. This method provides another option that can be considered in these technically demanding operative procedures.
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Affiliation(s)
- Kenneth Ouriel
- Department of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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33
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Cambria RP, Clouse WD, Davison JK, Dunn PF, Corey M, Dorer D. Thoracoabdominal aneurysm repair: results with 337 operations performed over a 15-year interval. Ann Surg 2002; 236:471-9; discussion 479. [PMID: 12368676 PMCID: PMC1422602 DOI: 10.1097/00000658-200210000-00010] [Citation(s) in RCA: 241] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To review perioperative results and late survival after thoracoabdominal aneurysm repair (TAA), in particular to assess the impact over time of epidural cooling (EC) on spinal cord ischemic complications (SCI). SUMMARY BACKGROUND DATA A variety of operative approaches and protective adjuncts have been used in TAA to minimize the major complications of perioperative death and SCI. There is no consensus with respect to the optimal approach. METHODS From January 1987 to November 2001, 337 consecutive TAA repairs were performed by a single surgeon. Clinical features included prior aortic grafts in 97 (28.8%) and emergent operation in 82 (24.6%), including rupture in 46 (13.6%) and dissection in 63 (19%). Operative management consisted of a clamp/sew technique with adjuncts in 93%. EC (since July 1993) to prevent SCI was used in 194 (57.6%) repairs. Variables associated with the end points of operative mortality and postoperative SCI were assessed with the Fisher exact test and logistic regression; late survival was estimated with the Kaplan-Meier method. RESULTS Operative mortality was 8.3% and was associated with nonelective operation, intraoperative hypotension, total transfusion requirement, and the postoperative complications of paraplegia, renal failure, and pulmonary insufficiency. Postoperative renal failure and transfusion requirement were independent correlates of mortality. SCI of any severity occurred in 38 of 334 (11.4%) operative survivors, with 22/38 (6.6% of cohort) sustaining total paraplegia. EC reduced the risk of SCI in patients with types I-III TAA (10.6% vs. 19.8%, =.04). Independent correlates of SCI over the entire study interval included types I/II TAA, rupture, cross-clamp duration, sacrifice of T9-L1 intercostal vessels, and intraoperative hypotension. Late survival rates at 2 and 5 years were 81.2 +/- 3% and 67.2 +/- 5%. CONCLUSIONS EC has decreased the risk of SCI after TAA repair. Decreasing the substantial proportion (nearly 25%) of patients requiring nonelective operation will improve results. Late survival is equal to that after routine AAA repair, indicating that the considerable resource expenditure required for TAA repair is worthwhile.
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Affiliation(s)
- Richard P Cambria
- Divisions of Vascular Surgery, Vascular Anesthesia and the Thoracic Aortic Center, Surgical and Anesthesia Services, Massachusetts General Hospital and the Harvard Medical School, Boston, Massachusetts 02114, USA.
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Morrissey NJ, Kantonen I, Liu H, Sidiqui M, Marin ML, Hollier LH. Effect of Mesenteric Ischemia/Reperfusion on Spinal Cord Injury Following Transient Aortic Occlusion in Rabbits. J Endovasc Ther 2002. [DOI: 10.1583/1545-1550-9.sp3.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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35
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Moriyama Y, Yotsumoto G, Hisatomi K, Matsumoto H, Toda R, Kaieda M. Thoracoabdominal aortic aneurysms repair under abdominal cavity cooling with visceral shunting technique--a case report. VASCULAR SURGERY 2001; 35:229-32; discussion 233. [PMID: 11452351 DOI: 10.1177/153857440103500312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Mild hypothermia induced by abdominal cavity cooling together with a selective visceral shunting technique can be a useful adjunct for thoracoabdominal aortic aneurysm repair. The authors adopted this combined technique for repair of selected Crawford type III and type IV aneurysms to reduce visceral ischemic damage and minimize the incidence of postoperative complications.
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Affiliation(s)
- Y Moriyama
- Second Department of Surgery, Kagoshima University, Faculty of Medicine, Sakuragaoka 8-35-1, Kagoshima City 890, Japan
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Fink MP. Thoracoabdominal aortic aneurysm repair: a human model of ischemia/reperfusion-induced cytokine-driven multiple organ dysfunction syndrome. Crit Care Med 2000; 28:3356-7. [PMID: 11009005 DOI: 10.1097/00003246-200009000-00044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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37
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Cambria RP, Davison JK, Carter C, Brewster DC, Chang Y, Clark KA, Atamian S. Epidural cooling for spinal cord protection during thoracoabdominal aneurysm repair: A five-year experience. J Vasc Surg 2000; 31:1093-102. [PMID: 10842145 DOI: 10.1067/mva.2000.106492] [Citation(s) in RCA: 137] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We developed and applied a method for providing regional spinal cord hypothermia with epidural cooling (EC) during thoracoabdominal aneurysm (TAA) repair. Preliminary results indicated significant reduction in spinal cord ischemic complications (SCI), compared with historical controls, and a 5-year experience with EC was reviewed. METHODS From July 1993 to September 1998, 170 patients with thoracic aneurysms (n = 14; 8.2%) or TAAs (types I and II, n = 83 [49%]; type III, n = 66 [39%]; type IV, n = 7 [4.1%]) were treated with EC. An earlier aneurysm resection was noted in 44% of patients, an emergent operation was noted in 20% of patients, and an aortic dissection was noted in 16% of patients. The EC was successful (mean cerebrospinal fluid [CSF] temperature at cross-clamp, 26.4 +/- 3 degrees C) in 97% of cases, with all 170 patients included in an intention-to-treat analysis. The operation was performed with a clamp/sew technique (98% patients) and selective (T(9) to L(1) region) reimplantation of intercostal vessels. Clinical and EC variables were examined for association with operative mortality and SCI by means of the Fischer exact test, and those variables with a P value less than.1 were included in multivariate logistic regression analysis. RESULTS The operative mortality rate was 9.5% and was weakly associated (P =.07) with SCI; postoperative cardiac complications (odds ratio [OR], 35. 3; 95% CI, 5.3 to 233; P <.001) and renal failure (OR, 32.2; 95% CI, 6.6 to 157; P <.001) were the only independent predictors of postoperative death. SCI of any severity occurred in 7% of cases (type I/II, 10 of 83 [12%]; all other types, 2 of 87 [2.3%]), versus a predicted (Acher model) incidence of 18.5% for this cohort (P =. 003). Half the deficits were minor, with good functional recovery, and devastating paraplegia occurred in three patients (2.0%). Independent correlates of SCI included types I and II TAA (OR, 8.0; 95% CI, 1.4 to 46.3; P =.021), nonelective operation (OR, 8.3, 95% CI, 1.8 to 37.7; P =.006), oversewn T(9) to L(2) intercostal vessels (OR, 6.1; 95% CI, 1.3 to 28.8; P =.023), and postoperative renal failure (OR, 23.6; 95% CI, 4.4 to 126; P <.001). These same clinical variables of nonelective operations (OR, 7.7; 95% CI, 1.4 to 41.4; P =.017), oversewn T(9) to L(2) intercostal arteries (OR, 9.7; 95% CI, 1.5 to 61.2; P =.016), and postoperative renal failure (OR, 20.8; 95% CI, 3.0 to 142.1; P =.002) were independent predictors of SCI in the subgroup analysis of high-risk patients, ie, patients with type I/II TAA. CONCLUSION EC has been effective in reducing immediate, devastating, total paraplegia after TAA repair. A strategy that combines the neuroprotective effect of regional cord hypothermia, avoiding the sacrifice of potential spinal cord blood supply, and postoperative adjuncts (eg, avoidance of hypotension, CSF drainage) appears necessary to minimize SCI after TAA repair.
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Affiliation(s)
- R P Cambria
- Division of Vascular Surgery and Vascular Anesthesia, Department of Surgery and Anesthesia, Massachusetts General Hospital and the Harvard Medical School, Boston 02114, USA
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Martin GH, O'Hara PJ, Hertzer NR, Mascha EJ, Krajewski LP, Beven EG, Clair DG, Ouriel K. Surgical repair of aneurysms involving the suprarenal, visceral, and lower thoracic aortic segments: early results and late outcome. J Vasc Surg 2000; 31:851-62. [PMID: 10805874 DOI: 10.1067/mva.2000.106481] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study is to review our experience with surgical repair of lower thoracoabdominal and suprarenal aortic aneurysms to determine early and late survival rates and identify factors influencing morbidity and survival among these patients. MATERIALS From 1989 through 1998, 165 consecutive patients underwent repair of 108 thoracoabdominal (55 group III and 53 group IV) and 57 suprarenal aneurysms. The study group consisted of 109 men and 56 women with a mean age of 70 years (median, 70 years; range, 29-89 years). Mean aneurysm diameter was 6.9 cm (median, 6.5 cm; range, 4-12 cm). There were 125 aneurysms (76%) repaired electively; 40 repairs (24%) were nonelective. The cause of 12 aneurysms (7%) was chronic aortic dissection; the remaining 153 (93%) were degenerative aneurysms. RESULTS The early postoperative (30-day) mortality rates were 7% (9/125) for elective and 23% (9/40) for nonelective operations (P =.016). For both elective and urgent procedures, early mortality was 1.8% (1/57) for suprarenal aneurysm repair, 11% (6/53) for group IV thoracoabdominal aneurysms, and 20% (11/55) for group III thoracoabdominal aneurysms (P =.013, suprarenal vs group III). Spinal cord ischemia occurred after 6% (10/165) of aneurysm repairs (4% paraplegia, 2% paraparesis). None of the 57 suprarenal aneurysm repairs were complicated by spinal cord ischemia, whereas it occurred in 2% (1/53) of group IV thoracoabdominal aneurysms and 16% (9/55) of group III thoracoabdominal aneurysms (P =.001, suprarenal vs group III; P =. 016, group IV vs group III). Three (25%) of the 12 patients with dissection developed spinal cord ischemia; this compared with seven (5%) of 153 patients with degenerative aneurysms (P =.027). The cumulative 3-year survival rate for the entire series was 71% (95% CI, 64%-79%), and 5-year survival was 50% (95% CI, 40%-60%). CONCLUSIONS Aneurysms involving the suprarenal, visceral, and lower thoracic aorta may be repaired with acceptable perioperative mortality and late survival rates. The risk of spinal cord ischemia is increased for patients with aortic dissection and may be stratified according to the proximal extent of the aneurysm.
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Affiliation(s)
- G H Martin
- Department of Vascular Surgery, Cleveland Clinic Foundation, Ohio, USA
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Hafez HM, Berwanger CS, McColl A, Richmond W, Wolfe JH, Mansfield AO, Stansby G. Myocardial injury in major aortic surgery. J Vasc Surg 2000; 31:742-50. [PMID: 10753282 DOI: 10.1067/mva.2000.102325] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE The purpose of this study was to examine the effects of major aortic surgery and its associated oxidative stress and injury on the myocardium. METHODS Plasma from 27 patients who underwent thoracoabdominal aortic aneurysm (TAAA) repair and 17 patients who underwent infrarenal aortic aneurysm (AAA) repair was collected at incision, aortic crossclamping, and reperfusion and 1, 8, and 24 hours thereafter. Samples were assayed for the myocardial specific protein troponin-T, total antioxidant status, and lipid hydroperoxides. RESULTS Ten patients experienced cardiac dysfunction in the first 24 hours after surgery (eight patients in the TAAA group and two patients in the AAA group). Immediately after reperfusion, total antioxidant status levels dropped in all patients with TAAA and with AAA; this was more marked in patients with TAAA, leading to a significant difference between the two groups at this time point and for up to 1 hour thereafter (P <.01). Patients with TAAA showed a sharp rise in lipid hydroperoxide levels immediately after reperfusion, and levels were significantly higher than in patients with AAA (P =.0007). In patients with AAA, no significant change in troponin-T was observed throughout the study period; whereas in patients with TAAA, levels were significantly elevated at 8 and 24 hours after reperfusion (P <.01). Troponin-T levels significantly correlated with total antioxidant status (r = -0.5) and lipid hydroperoxides (r = 0.78) but not with systolic blood pressure. CONCLUSION Supracoeliac aortic crossclamping is associated with a significant release of the myocardial injury marker troponin-T. This seems to correlate with the severity of oxidative rather than hemodynamic stresses. Ameliorating oxidative injury during TAAA surgery may therefore have a cardioprotective effect.
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Affiliation(s)
- H M Hafez
- Academic Surgical and Regional Vascular Unit, Division of Surgery and Anaesthetics, Imperial College Medical School at St Mary's Hospital, UK
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Wu X, Siegemund M, Seeberger M, Studer W. Systemic and mesenteric hemodynamics, metabolism, and intestinal tonometry in a rat model of supraceliac aortic cross-clamping and declamping. J Cardiothorac Vasc Anesth 1999; 13:707-14. [PMID: 10622654 DOI: 10.1016/s1053-0770(99)90125-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To describe systemic and mesenteric hemodynamics, metabolism, and intestinal tonometry in a rat model of supraceliac aortic cross-clamping and declamping. DESIGN Prospective, randomized, experimental study. SETTING University cardiovascular research laboratory. PARTICIPANTS Twelve male anesthetized and ventilated Sprague-Dawley rats. INTERVENTION Supraceliac aortic cross-clamping was performed for 30 minutes, followed by declamping and reperfusion for 180 minutes or sham clamping and sham declamping. MEASUREMENTS AND MAIN RESULTS Mean arterial blood pressure; abdominal aortic, superior mesenteric, and carotid artery blood flow; intestinal mucosal tonometry; hemoglobin; lactate; and blood gases were measured before and after 30 minutes of aortic cross-clamping and 15, 30, 60, 120, and 180 minutes after declamping during reperfusion. Aortic cross-clamping induced an increase in mean arterial pressure (117+/-20 mm Hg to 147+/-12 mm Hg), an increase in right atrial hemoglobin saturation(66%+/-11% to 81%+/-6%), an increase in lactate levels (1.7+/-0.7 mmol/L to 4.3+/-1.3 mmol/L), and an increase in tonometric PCO2 (49.6+/-5.0 mm Hg to 75.6+/-8.6 mm Hg). Three hours of reperfusion after declamping resulted in significantly decreased mean arterial pressure (38+/-10 mm Hg); decreased aortic (101+/-12 mL/min/kg to 57+/-32 mL/min/kg), mesenteric (19+/-4 to 13+/-6 mL/min/kg), and carotid (12+/-4 mL/min/kg to 5+/-3 mL/min/ kg) blood flows; and elevated lactate levels (4.2+/-2.0 mmol/L). Tonometric PCO2 had normalized to baseline levels (51.9+/-3.8 mm Hg), but PCO2 gap was significantly higher than in sham clamped rats (17.9+/-7.8 mm Hg v. 7.0+/-2.6 mm Hg). CONCLUSIONS Hemodynamic and metabolic effects of aortic cross-clamping and declamping known from large animal models are reproducible using a rat model. Intestinal tonometry indicated mesenteric ischemia during aortic cross-clamping, which was reversible to preclamp values within 30 minutes of reperfusion after declamping.
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Affiliation(s)
- X Wu
- Department of Anesthesia and Research, University of Basel, Switzerland
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Cambria RP. Thoracoabdominal aortic aneurysm repair: how I do it. CARDIOVASCULAR SURGERY (LONDON, ENGLAND) 1999; 7:597-606. [PMID: 10519667 DOI: 10.1016/s0967-2109(99)00038-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
There remains no consensus on the operative management of Thoracoabdominal aortic aneurysm (TAA). Our approach emphasizes operative expediency and simplicity (without circulatory assist techniques), avoiding anticoagulation and systemic hypothermia. The technique involves a fundamental clamp/sew method with specific adjuncts directed against the principle complications: epidural cooling (introduced in 1993) for spinal cord protection, regional renal hypothermia, and in-line mesenteric shunting to minimize visceral ischemia. In a cohort of over 200 TAA patients (50% Types I & II) treated during the past decade perioperative mortality has been 8% and paraparesis/paraplegia occured in 7%. These figures are halved for patients treated in elective circumstances.
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Affiliation(s)
- R P Cambria
- Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston 02114, USA
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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; 15:502-7. [PMID: 10371129 DOI: 10.1016/s1010-7940(99)00075-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Whether or not selective visceral and renal perfusion during thoracoabdominal aortic aneurysm (TAAA) repair has a protective effect on visceral and renal function remains unknown. The aim of this study was to clarify if selective perfusion has such an effect. METHODS From May 1982 to December 1997, 82 consecutive patients underwent TAAA repair. Patients receiving hypothermic circulatory arrest or cooling of the kidney using Ringer's lactate solution were excluded, thus 73 patients were enrolled into this study. They were divided into three groups: those in whom selective visceral and renal perfusion was performed using a roller pump (n = 41), those in whom it was performed using a centrifugal pump with a reduced heparin regimen (n = 22) and those who underwent simple aortic clamping alone (n = 10). RESULTS Serum creatinine, total bilirubin and alanine aminotransferase levels were elevated postoperatively in patients undergoing simple cross-clamp repair, but remained almost within normal limits in patients undergoing TAAA repair with selective visceral and renal perfusion. Urine output was more in selective perfused patients than in non-perfused patients. Renal dysfunction, defined by requirement of hemodialysis or by a serum level of creatinine above 3 mg/dl, occurred in four patients (10%) of the roller pump group and in two patients (9%) of the centrifugal pump group, while in four patients (40%) of the simple cross-clamping group. CONCLUSION Our experience suggests that selective visceral and renal perfusion has a protective effect on hepato-renal function during TAAA repair.
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Affiliation(s)
- K Morishita
- Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, Japan
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Stanley JC. Vascular surgery. J Am Coll Surg 1999; 188:202-14. [PMID: 10024166 DOI: 10.1016/s1072-7515(98)00311-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- J C Stanley
- Department of Surgery, University of Michigan Medical School, Ann Arbor, USA
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