1
|
Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 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. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
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.
Collapse
|
2
|
Yoshitani K, Ogata S, Kato S, Tsukinaga A, Takatani T, Kin N, Ezaka M, Shimizu J, Furuichi Y, Uezono S, Kida K, Seo K, Kakumoto S, Miyawaki H, Kawamata M, Tanaka S, Kakinohana M, Izumi S, Uchino H, Kakinuma T, Nishiwaki K, Hasegawa K, Matsumoto M, Ishida K, Yamashita A, Yamakage M, Yoshikawa Y, Morimoto Y, Saito H, Goto T, Masubuchi T, Kawaguchi M, Tsubaki K, Mizobuchi S, Obata N, Inagaki Y, Funaki K, Ishiguro Y, Sanui M, Taniguchi K, Nishimura K, Ohnishi Y. Effect of cerebrospinal fluid drainage pressure in descending and thoracoabdominal aortic repair: a prospective multicenter observational study. J Anesth 2023; 37:408-415. [PMID: 36944824 DOI: 10.1007/s00540-023-03179-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/06/2023] [Indexed: 03/23/2023]
Abstract
PURPOSE Cerebrospinal fluid drainage (CSFD) is recommended during open or endovascular thoracic aortic repair. However, the incidence of CSFD complications is still high. Recently, CSF pressure has been kept high to avoid complications, but the efficacy of CSFD at higher pressures has not been confirmed. We hypothesize that CSFD at higher pressures is effective for preventing motor deficits. METHODS This prospective observational study included 14 hospitals that are members of the Japanese Society of Cardiovascular Anesthesiologists. Patients who underwent thoracic and thoracoabdominal aortic repair were divided into four groups: Group 1, CSF pressure around 10 mmHg; Group 2, CSF pressure around 15 mmHg; Group 3, CSFD initiated when motor evoked potential amplitudes decreased; and Group 4, no CSFD. We assessed the association between the CSFD group and motor deficits using mixed-effects logistic regression with a random intercept for the institution. RESULTS Of 1072 patients in the study, 84 patients (open surgery, 51; thoracic endovascular aortic repair, 33) had motor deficits at discharge. Groups 1 and 2 were not associated with motor deficits (Group 1, odds ratio (OR): 1.53, 95% confidence interval (95% CI): 0.71-3.29, p = 0.276; Group 2, OR: 1.73, 95% CI: 0.62-4.82) when compared with Group 4. Group 3 was significantly more prone to motor deficits than Group 4 (OR: 2.56, 95% CI: 1.27-5.17, p = 0.009). CONCLUSION CSFD is not associated with motor deficits in thoracic and thoracoabdominal aortic repair with CSF pressure around 10 or 15 mmHg.
Collapse
Affiliation(s)
- Kenji Yoshitani
- Department of Transfusion, National Cerebral and Cardiovascular Center, 6-1 Kishibeshimmachi, Suita, Osaka, 564-8565, Japan.
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Soshiro Ogata
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Shinya Kato
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Akito Tsukinaga
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
- Department of Anesthesiology, School of Medicine, Yokohama City University, Yokohama, Japan
| | - Tsunenori Takatani
- Division of Central Clinical Laboratory, Nara Medical University, Kashihara, Nara, Japan
| | - Nobuhide Kin
- Department of Anesthesia, New Tokyo Hospital, Matsudo, Japan
| | - Mariko Ezaka
- Department of Anesthesia, New Tokyo Hospital, Matsudo, Japan
| | - Jun Shimizu
- Department of Anesthesiology, Sakakibara Heart Institute, Futyu, Japan
| | - Yuko Furuichi
- Department of Anesthesiology, Sakakibara Heart Institute, Futyu, Japan
| | - Shoichi Uezono
- Department of Anesthesiology, The Jikei University School of Medicine, Minato-ku, Japan
| | - Kotaro Kida
- Department of Anesthesiology, The Jikei University School of Medicine, Minato-ku, Japan
| | - Katsuhiro Seo
- Department of Emergency, Kokura Memorial Hospital, Fukuoka, Japan
| | - Shinichi Kakumoto
- Department of Anesthesiology, Kokura Memorial Hospital, Fukuoka, Japan
| | - Hiroshi Miyawaki
- Department of Anesthesiology, Kokura Memorial Hospital, Fukuoka, Japan
| | - Mikito Kawamata
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Satoshi Tanaka
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Manabu Kakinohana
- Department of Anesthesiology, Faculty of Medicine, University of Ryukyu, Nishihara, Japan
| | - Shunsuke Izumi
- Department of Anesthesiology, Faculty of Medicine, University of Ryukyu, Nishihara, Japan
| | - Hiroyuki Uchino
- Department of Anesthesiology, Tokyo Medical University, Shinjuku-ku, Japan
| | - Takayasu Kakinuma
- Department of Anesthesiology, Tokyo Medical University, Shinjuku-ku, Japan
| | - Kimitoshi Nishiwaki
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuko Hasegawa
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mishiya Matsumoto
- Department of Anesthesiology, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Kazuyoshi Ishida
- Department of Anesthesiology, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Atsuo Yamashita
- Department of Anesthesiology, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Michiaki Yamakage
- Department of Anesthesiology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yusuke Yoshikawa
- Department of Anesthesiology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yuji Morimoto
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hitoshi Saito
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takahisa Goto
- Department of Anesthesiology, School of Medicine, Yokohama City University, Yokohama, Japan
- Department of Anesthesiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Tetsuhito Masubuchi
- Department of Anesthesiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Masahiko Kawaguchi
- Department of Anesthesiology, Nara Medical University, Kashihara, Nara, Japan
| | - Kosuke Tsubaki
- Department of Anesthesiology, Nara Medical University, Kashihara, Nara, Japan
| | - Satoshi Mizobuchi
- Division of Anesthesiology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Norihiko Obata
- Division of Anesthesiology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshimi Inagaki
- Division of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Kazumi Funaki
- Division of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Yoshiki Ishiguro
- Department of Anesthesiology, The Jikei University School of Medicine, Minato-ku, Japan
- Department of Anesthesiology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | | | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshihiko Ohnishi
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| |
Collapse
|
3
|
Tanaka A, Nguyen H, Dhillon JS, Nakamura M, Zhou SF, Sandhu HK, Miller CC, Safi HJ, Estrera AL. Reappraisal of the role of motor and somatosensory evoked potentials during open distal aortic repair. J Thorac Cardiovasc Surg 2023; 165:944-953. [PMID: 34517983 DOI: 10.1016/j.jtcvs.2021.08.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 07/14/2021] [Accepted: 08/09/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Intraoperative motor and somatosensory evoked potentials have been applied to monitor spinal cord ischemia during repair. However, their predictive values remain controversial. The purpose of this study was to evaluate the impact of motor evoked potentials and somatosensory evoked potentials on spinal cord ischemia during open distal aortic repair. METHODS Our group began routine use of both somatosensory evoked potentials and motor evoked potentials at the end of 2004. This study used a historical cohort design, using risk factor and outcome data from our department's prospective registry. Univariate and multivariable statistics for risk-adjusted effects of motor evoked potentials and somatosensory evoked potentials on neurologic outcome and model discrimination were assessed with receiver operating characteristic curves. RESULTS Both somatosensory evoked potentials and motor evoked potentials were measured in 822 patients undergoing open distal aortic repair between December 2004 and December 2019. Both motor evoked potentials and somatosensory evoked potentials were intact for the duration of surgery in 348 patients (42%). Isolated motor evoked potential loss was observed in 283 patients (34%), isolated somatosensory evoked potential loss was observed in 18 patients (3%), and both motor evoked potential and somatosensory evoked potential loss were observed in 173 patients (21%). No spinal cord ischemia occurred in the 18 cases with isolated somatosensory evoked potential loss. When both signals were lost, signal loss happened in the order of motor evoked potentials and then somatosensory evoked potentials. Immediate spinal cord ischemia occurred in none of those without signal loss, 4 of 283 (1%) with isolated motor evoked potential loss, and 15 of 173 (9%) with motor evoked potential plus somatosensory evoked potential loss. Delayed spinal cord ischemia occurred in 12 of 348 patients (3%) with intact evoked potentials, 24 of 283 patients (8%) with isolated motor evoked potentials loss, and 27 of 173 patients (15%) with motor evoked potentials + somatosensory evoked potentials loss (P < .001). Motor evoked potentials and somatosensory evoked potentials loss were each independently associated with spinal cord ischemia. For immediate spinal cord ischemia, no return of motor evoked potential signals at the conclusion of the surgery had the highest odds ratio of 15.87, with a receiver operating characteristic area under the curve of 0.936, whereas motor evoked potential loss had the highest odds ratio of 3.72 with an area under the curve of 0.638 for delayed spinal cord ischemia. CONCLUSIONS Somatosensory evoked potentials and motor evoked potentials are both important monitoring measures to predict and prevent spinal cord ischemia during and after open distal aortic repairs. Intraoperative motor evoked potential loss is a risk for immediate and delayed spinal cord ischemia after open distal aortic repair, and somatosensory evoked potential loss further adds predictive value to the motor evoked potential.
Collapse
Affiliation(s)
- Akiko Tanaka
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth, Houston, Tex
| | - Hung Nguyen
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth, Houston, Tex
| | - Jaydeep S Dhillon
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth, Houston, Tex
| | - Masaki Nakamura
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth, Houston, Tex
| | - Shao-Feng Zhou
- Department of Anesthesiology, McGovern Medical School at UTHealth, Houston, Tex
| | - Harleen K Sandhu
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth, Houston, Tex
| | - Charles C Miller
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth, Houston, Tex
| | - Hazim J Safi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth, Houston, Tex
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth, Houston, Tex.
| |
Collapse
|
4
|
Bhatia M, Kumar PA. Con: Lumbar Drains Should Routinely Be Placed by a Landmark Approach and Not by Fluoroscopic Guidance for Elective Thoracic Aortic Repairs. J Cardiothorac Vasc Anesth 2023; 37:183-186. [PMID: 36280577 DOI: 10.1053/j.jvca.2022.09.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/24/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Meena Bhatia
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Priya A Kumar
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| |
Collapse
|
5
|
Tanaka A, Smith HN, Safi HJ, Estrera AL. Open Treatments for Thoracoabdominal Aortic Aneurysm Repair. Methodist Debakey Cardiovasc J 2023; 19:49-58. [PMID: 36910546 PMCID: PMC10000325 DOI: 10.14797/mdcvj.1178] [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: 10/20/2022] [Accepted: 11/22/2022] [Indexed: 03/09/2023] Open
Abstract
Thoracoabdominal aortic aneurysms (TAAA) represent a unique pathology that is associated with considerable mortality if untreated. While the advent of endovascular technologies has introduced new modalities for consideration, the mainstay of TAAA treatment remains open surgical repair. However, the optimal conduct of open TAAA repair requires careful consideration of patient risk factors and a collaborative team effort to mitigate the risk of perioperative complications. In this chapter, we briefly outline the history of treating TAAA, preoperative preparation and postoperative care, and our operative techniques for treatment.
Collapse
Affiliation(s)
- Akiko Tanaka
- McGovern Medical School at UTHealth Houston, Houston, Texas, US
| | - Holly N Smith
- McGovern Medical School at UTHealth Houston, Houston, Texas, US
| | - Hazim J Safi
- McGovern Medical School at UTHealth Houston, Houston, Texas, US
| | | |
Collapse
|
6
|
Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 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. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 397] [Impact Index Per Article: 198.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
| |
Collapse
|
7
|
Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 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. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
Collapse
|
8
|
Dias-Neto M, Tenorio ER, Baumgardt Barbosa Lima G, Baghbani-Oskouei A, Oderich GS. Postoperative management in patients with complex aortic aneurysms. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:587-596. [PMID: 35687066 DOI: 10.23736/s0021-9509.22.12359-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Patients with complex aortic aneurysms (CAA) are often high risk due to advanced age and widespread atherosclerosis affecting numerous vascular territories. Therefore, a thorough perioperative evaluation is needed prior to performing in any type of aortic repair, regardless of whether an endovascular or open surgical approach is selected. Because these operations are technically demanding and often result in end organ ischemia, it is not surprising that complex aortic repair carries significant risk of morbidity and mortality. Disabling complications such as dialysis, major stroke and paraplegia constitute the main limitation of complex aortic repair. The aim of this article was to review postoperative management to mitigate complications after CAA repair.
Collapse
Affiliation(s)
- Marina Dias-Neto
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Emanuel R Tenorio
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Guilherme Baumgardt Barbosa Lima
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Aidin Baghbani-Oskouei
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA
| | - Gustavo S Oderich
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Health Science Center at Houston, University of Texas, Houston, TX, USA -
| |
Collapse
|
9
|
Tenorio ER, Dias-Neto MF, Lima GBB, Baghbani-Oskouei A, Oderich GS. Lessons learned over two decades of fenestrated-branched endovascular aortic repair. Semin Vasc Surg 2022; 35:236-244. [DOI: 10.1053/j.semvascsurg.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/12/2022] [Accepted: 07/20/2022] [Indexed: 11/11/2022]
|
10
|
MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissection. J Thorac Cardiovasc Surg 2022; 163:1231-1249. [PMID: 35090765 DOI: 10.1016/j.jtcvs.2021.11.091] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 01/16/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Md
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| |
Collapse
|
11
|
MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery Clinical Practice Guidelines on the Management of Type B Aortic Dissection. Ann Thorac Surg 2022; 113:1073-1092. [PMID: 35090687 DOI: 10.1016/j.athoracsur.2021.11.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Texas
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
12
|
Awad H, Raza A, Saklayen S, Bhandary S, Kelani H, Powers C, Bourekas E, Essandoh M. Combined Stroke and Spinal Cord Infarction in Hybrid Type I Aortic Arch Debranching and TEVAR and the Dual Role of the Left Subclavian Artery. J Cardiothorac Vasc Anesth 2022:S1053-0770(22)00122-7. [PMID: 35339354 DOI: 10.1053/j.jvca.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/08/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Hamdy Awad
- Department of Anesthesiology at the Wexner Medical Center at the Ohio State University in Columbus, Columbus, OH.
| | - Arwa Raza
- Ohio State University College of Medicine in Columbus, Columbus, OH
| | - Samiya Saklayen
- Department of Anesthesiology at the Wexner Medical Center at the Ohio State University in Columbus, Columbus, OH
| | - Sujatha Bhandary
- Department of Anesthesiology at Emory University School of Medicine in Atlanta, Atlanta, GA
| | - Hesham Kelani
- Department of Anesthesiology at the Wexner Medical Center at the Ohio State University in Columbus, Columbus, OH
| | - Ciaran Powers
- Department of Neurosurgery at the Wexner Medical Center at the Ohio State University in Columbus, Columbus, OH
| | - Eric Bourekas
- Department of Radiology at Wexner Medical Center at the Ohio State University in Columbus, Columbus, OH
| | - Michael Essandoh
- Department of Anesthesiology at the Wexner Medical Center at the Ohio State University in Columbus, Columbus, OH
| |
Collapse
|
13
|
Ling X, Lu J, Yang J, Qin H, Zhao X, Zhou P, Zheng S, Zhu P. Non-Coding RNAs: Emerging Therapeutic Targets in Spinal Cord Ischemia-Reperfusion Injury. Front Neurol 2021; 12:680210. [PMID: 34566835 PMCID: PMC8456115 DOI: 10.3389/fneur.2021.680210] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 08/09/2021] [Indexed: 01/01/2023] Open
Abstract
Paralysis or paraplegia caused by transient or permanent spinal cord ischemia–reperfusion injury (SCIRI) remains one of the most devastating post-operative complications after thoracoabdominal aortic surgery, even though perioperative strategies and surgical techniques continue to improve. Uncovering the molecular and cellular pathophysiological processes in SCIRI has become a top priority. Recently, the expression, function, and mechanism of non-coding RNAs (ncRNAs) in various diseases have drawn wide attention. Non-coding RNAs contain a variety of biological functions but do not code for proteins. Previous studies have shown that ncRNAs play a critical role in SCIRI. However, the character of ncRNAs in attenuating SCIRI has not been systematically summarized. This review article will be the first time to assemble the knowledge of ncRNAs regulating apoptosis, inflammation, autophagy, and oxidative stress to attenuate SCIRI. A better understanding of the functional significance of ncRNAs following SCIRI could help us to identify novel therapeutic targets and develop potential therapeutic strategies. All the current research about the function of nRNAs in SCIRI will be summarized one by one in this review.
Collapse
Affiliation(s)
- Xiao Ling
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jun Lu
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jun Yang
- Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hanjun Qin
- Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xingqi Zhao
- Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Pengyu Zhou
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shaoyi Zheng
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Peng Zhu
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| |
Collapse
|
14
|
Awad H, Raza A, Saklayen S, Bhandary S, Kelani H, Powers C, Bourekas E, Stine I, Milner R, Valentine E, Essandoh M. Combined Stroke and Spinal Cord Ischemia in Hybrid Type I Aortic Arch Debranching and TEVAR and the Dual Role of the Left Subclavian Artery. J Cardiothorac Vasc Anesth 2021; 36:3687-3700. [PMID: 34538558 DOI: 10.1053/j.jvca.2021.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Hamdy Awad
- Department of Anesthesiology at the Wexner Medical Center at the Ohio State University, Columbus, OH.
| | - Arwa Raza
- Ohio State University College of Medicine, Columbus, OH
| | - Samiya Saklayen
- Department of Anesthesiology at the Wexner Medical Center at the Ohio State University, Columbus, OH
| | - Sujatha Bhandary
- Department of Anesthesiology at Emory University School of Medicine, Atlanta, GA
| | - Hesham Kelani
- Department of Anesthesiology at the Wexner Medical Center at the Ohio State University, Columbus, OH
| | - Ciaran Powers
- Department of Neurosurgery at the Wexner Medical Center at the Ohio State University, Columbus, OH
| | - Eric Bourekas
- Department of Radiology at Wexner Medical Center at the Ohio State University, Columbus, OH
| | - Ian Stine
- Department of Surgery at the University of Chicago, Chicago, IL
| | - Ross Milner
- Department of Surgery at the University of Chicago, Chicago, IL
| | - Elizabeth Valentine
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Michael Essandoh
- Department of Anesthesiology at the Wexner Medical Center at the Ohio State University, Columbus, OH
| |
Collapse
|
15
|
Miller LK, Patel VI, Wagener G. Spinal Cord Protection for Thoracoabdominal Aortic Surgery. J Cardiothorac Vasc Anesth 2021; 36:577-586. [PMID: 34366215 DOI: 10.1053/j.jvca.2021.06.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/15/2021] [Accepted: 06/20/2021] [Indexed: 01/06/2023]
Abstract
Open and endovascular repairs of the descending thoracic and thoracoabdominal aorta are associated with a substantial risk of spinal cord injury, namely paraplegia. Endovascular repairs seem to have a lower incidence of spinal cord injury, but there have been no randomized trials comparing outcomes of open and endovascular repairs. Paraplegia occurs when collateral blood supply to the anterior spinal artery is impaired. The risk of spinal cord injury can be mitigated with perioperative protocols that include drainage of cerebrospinal fluid, avoidance of hypotension and anemia, intraoperative neurophysiologic monitoring, and advanced surgical techniques. Drainage of cerebrospinal fluid using a spinal drain decreases the risk of spinal cord ischemia by improving spinal cord perfusion pressure. However, cerebrospinal fluid drainage has risks including neuraxial and intracranial bleeding, and these risks need to be carefully weighed against its potential benefit. This review discusses current surgical management of descending thoracic and thoracoabdominal aortic disease, incidence of and risk factors for spinal cord injury, and elements of spinal cord protection protocols that pertain to anesthesiologists, with a focus on cerebrospinal fluid drainage.
Collapse
Affiliation(s)
- Lydia K Miller
- Department of Anesthesiology, Columbia University, New York, NY
| | | | - Gebhard Wagener
- Department of Anesthesiology, Columbia University, New York, NY.
| |
Collapse
|
16
|
Oftadeh M, Ural N, LeVan P, Prabhu V, Haske M. The Evolution and Future of Spinal Drain for Thoracic Aortic Aneurysm Repair: A Review. J Cardiothorac Vasc Anesth 2021; 35:3362-3373. [PMID: 34154920 DOI: 10.1053/j.jvca.2021.04.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 11/11/2022]
Abstract
For decades, spinal drains for cerebrospinal fluid (CSF) pressure monitoring and drainage have been used as adjuncts to protect against spinal cord injury resulting from thoracic aortic aneurysm repair. There are many different approaches to placement and management of CSF drains, with no true consensus on best practice. Furthermore, the incidence of complications resulting from spinal drains largely has been stagnant. This review describes the history and rationale behind placement of CSF drains, explore various considerations, techniques, and equipment, and discuss potential considerations for developing more comprehensive protocols.
Collapse
Affiliation(s)
- Mina Oftadeh
- Department of Anesthesiology, Loyola University Medical Center, Maywood, IL.
| | - Nil Ural
- Department of Anesthesiology, Loyola University Medical Center, Maywood, IL
| | - Pierre LeVan
- Department of Anesthesiology, Franciscan Health Olympia Fields, Olympia Fields, IL
| | - Vikram Prabhu
- Department of Anesthesiology, Loyola University Medical Center, Maywood, IL
| | - Michael Haske
- Department of Anesthesiology, Loyola University Medical Center, Maywood, IL
| |
Collapse
|
17
|
Menacho ST, Floyd C. Current practices and goals for mean arterial pressure and spinal cord perfusion pressure in acute traumatic spinal cord injury: Defining the gaps in knowledge. J Spinal Cord Med 2021; 44:350-356. [PMID: 31525138 PMCID: PMC8081322 DOI: 10.1080/10790268.2019.1660840] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Context: The mainstay of treatment for acute traumatic spinal cord injury (SCI) is to artificially elevate the patient's mean arterial pressure (MAP) to >85 mmHg to increase blood flow to the injured spinal cord for 7 days. However, the literature supporting these recommendations are only Class III evidence. In fact, the critical time window in which to elevate MAP after SCI and the optimal vasopressor to use are largely unknown, as is whether cerebrospinal fluid diversion has a role, and this leads to variability among practitioners. Also undefined is whether manipulating these parameters improves neurological outcome.Objective: Our goal is to better delineate current clinical practice and identify gaps in knowledge surrounding the care of patients with traumatic SCI.Methods: We undertook a systematic review of the current literature identified from PubMed on MAP elevation and spinal cord parenchymal pressure in acute SCI.Results: The 8 articles (6 human; 2 porcine) that met our inclusion criteria were all published within the last 6 years. Four were prospective, 1 was retrospective, and 3 were review articles. Only one study was randomized. All of these studies involved small sample sizes and varying lengths of MAP elevation. Choice of vasopressor was variable as well.Conclusions: From our literature review, we posit that norepinephrine may be the vasopressor of choice, that spinal parenchymal pressure monitors can be safely placed at the injury site, and that the combination of MAP elevation and cerebrospinal fluid drainage may improve neurologic outcome more than either intervention alone.
Collapse
Affiliation(s)
- Sarah T. Menacho
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Candace Floyd
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
18
|
Tanaka A, Estrera AL, Safi HJ. Open thoracoabdominal aortic aneurysm surgery technique: how we do it. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:295-301. [PMID: 33586937 DOI: 10.23736/s0021-9509.21.11825-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
More than four decades have passed since the modern principals to treat thoracoabdominal aortic aneurysm (TAAA) have been established. The historical challenges in repair of TAAA are represented by - and continue to be - multiorgan protection. Among all organs, the spinal cord remains one of the most vital and vulnerable. We described our current techniques of open extent II TAAA repair, including the following topics: anesthesia, intraoperative monitoring, skin incision, exposure of the TAAA, left heart bypass, graft replacement technique, intercostal artery reattachment, visceral/renal artery reconstructions, and postoperative care. We use cerebrospinal fluid drainage, distal aortic perfusion, mild passive hypothermia, sequential clamping, and visceral and renal perfusion using roller pump in all the cases for multiorgan protection. Both motor-evoked potentials and somatosensory-evoked potentials ere used to guide the conduct of intercostal artery reattachment. Our group demonstrated that the use of adjuncts has reduced the overall spinal cord ischemia rate after Extent I TAAA from 15% to less than 2% and after Extent II TAAA from 33% (50% with clamp time exceeding 40 minutes in "clamp and go" era) to less than 4%. The current standard practice of TAAA repair with adjuncts has improved outcomes, especially regarding spinal cord ischemia.
Collapse
Affiliation(s)
- Akiko Tanaka
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Anthony L Estrera
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Hazim J Safi
- McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA -
| |
Collapse
|
19
|
Perioperative care after thoracoabdominal aortic aneurysm repair: The Baylor College of Medicine experience. Part 2: Postoperative management. J Thorac Cardiovasc Surg 2021; 161:699-705. [DOI: 10.1016/j.jtcvs.2019.11.143] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/01/2019] [Accepted: 11/21/2019] [Indexed: 01/16/2023]
|
20
|
Tanaka A, Sandhu HK, Afifi RO, Miller CC, Ray A, Hassan M, Safi HJ, Estrera AL. Outcomes of open repairs of chronic distal aortic dissection anatomically amenable to endovascular repairs. J Thorac Cardiovasc Surg 2021; 161:36-43.e6. [PMID: 31699416 DOI: 10.1016/j.jtcvs.2019.09.083] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 09/12/2019] [Accepted: 09/15/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To review short-term outcomes and long-term survival and durability after open surgical repairs for chronic distal aortic dissections in patients whose anatomy was amenable to thoracic endovascular aortic repair (TEVAR). METHODS Between February 1991 and August 2017, we repaired chronic distal dissections in 697 patients. Of those patients, we enrolled 427 with anatomy amenable to TEVAR, which included 314 descending thoracic aortic aneurysms (DTAAs) and 105 extent I thoracoabdominal aortic aneurysms (TAAAs). One hundred eighty-five patients (44%) had a history of type A dissection, and 33 (7.9%) had a previous DTAA/TAAA repair. Variables were assessed with logistic regression for 30-day mortality and Cox regression for long-term mortality. Time-to-event analysis was performed using Kaplan-Meier methods. RESULTS Thirty-day mortality was 8.4% (n = 36). In all, 22 patients (5.2%) developed motor deficit (paraplegia/paraparesis), and 17 (4.0%) experienced stroke. Multivariable analysis identified low estimated glomerular filtration rate (eGFR; <60 mL/min/1.73 m2), previous DTAA/TAAA repair, and chronic obstructive pulmonary disease (COPD) as associated with 30-day mortality. Patients without all 3 risk factors had a 30-day mortality rate of 2.6%. During a median follow-up of 6.5 years, 160 patients died. The survival rate was 81% at 1 year and 61% at 10 years. Cox regression analysis identified preoperative aortic rupture, eGFR <60 mL/min/1.73 m2, previous DTAA/TAAA repair, COPD, and age >60 years as predictive of long-term mortality. Forty-five patients required subsequent aortic procedures, including 8 reinterventions to the treated segment. Freedom from any aortic procedures was 85% at 10 years, and aortic procedure-free survival was 45% at 10 years. Hereditary aortic disease was the sole predictor for any aortic interventions (hazard ratio, 3.2; P = .004). CONCLUSIONS Open surgical repair provided satisfactory low neurologic complication rates and durable repairs in chronic distal aortic dissection. Patients without low eGFR, redo, and COPD are the low-risk surgical candidates and may benefit from open surgical repair at centers with similar experience to ours. Patients with hereditary aortic disease warrant close surveillance.
Collapse
Affiliation(s)
- Akiko Tanaka
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Harleen K Sandhu
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Rana O Afifi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Charles C Miller
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Amberly Ray
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Madiha Hassan
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Hazim J Safi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex.
| |
Collapse
|
21
|
Chatterjee S, Preventza O, Orozco-Sevilla V, Coselli JS. Critical care management after open thoracoabdominal aortic aneurysm repair. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 62:220-229. [PMID: 33307646 DOI: 10.23736/s0021-9509.20.11712-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Thoracoabdominal aortic aneurysm repair is technically demanding for the surgeon and physiologically demanding on the patient. As such, it requires diligent multidisciplinary perioperative care to maximize the likelihood of a successful outcome. In this article, we discuss key principles for managing patients after open thoracoabdominal aortic aneurysm repair, which we have learned over the course of performing more than 3500 of such procedures. These principles address patient handoff between the operating room and Intensive Care Unit, resuscitation, prevention and management of spinal cord deficits, and important neurological, respiratory, cardiovascular, renal, gastrointestinal, and hematological considerations. Understanding the expected postoperative course allows for earlier recognition of deviations from that course and increases the likelihood of successful rescue of patients from adverse outcomes. Achieving positive outcomes after thoracoabdominal aortic aneurysm repair requires attention to detail across the perioperative, intraoperative, and postoperative phases of care.
Collapse
Affiliation(s)
- Subhasis Chatterjee
- Division of General Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA - .,Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA -
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA.,Department of Cardiovascular Surgery, CHI St Luke's Health - Baylor St Luke's Medical Center, Houston, TX, USA
| | - Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA.,Department of Cardiovascular Surgery, CHI St Luke's Health - Baylor St Luke's Medical Center, Houston, TX, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA.,Department of Cardiovascular Surgery, CHI St Luke's Health - Baylor St Luke's Medical Center, Houston, TX, USA
| |
Collapse
|
22
|
Permissive Hypertension and Collateral Revascularization May Allow Avoidance of Cerebrospinal Fluid Drainage in Thoracic Endovascular Aortic Repair. Ann Thorac Surg 2020; 110:1469-1474. [PMID: 32535042 DOI: 10.1016/j.athoracsur.2020.04.101] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 04/04/2020] [Accepted: 04/17/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The utility of cerebrospinal fluid drainage (CSFD) for prevention of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) remains unclear. We previously published our institutional algorithm restricting preoperative CSFD to patients deemed high risk for SCI. Since that publication, our algorithm has evolved with preoperative CSFD avoided in all patients undergoing isolated descending TEVAR with or without arch involvement (+/- arch TEVAR). This study evaluated the updated algorithm in a contemporary cohort. METHODS Patients who underwent TEVAR for descending aortic +/-arch pathology between February 2012 and September 2018 at a single center were identified from an institutional aortic surgery database. The algorithm includes left subclavian artery (LSA) revascularization in cases of coverage with no preservation of antegrade flow, permissive hypertension, and use of evoked potential monitoring. The primary end points were SCI or postoperative CSFD. RESULTS During the study interval, 225 patients underwent descending +/- arch TEVAR. CSFD was used before TEVAR in 2 patients (0.9%) in violation of the algorithm, and they were excluded from the study cohort. Endograft coverage below T6 occurred in 81%. The LSA was fully covered in 100 patients (47%), all of whom underwent LSA revascularization. Following the updated algorithm, the incidence of temporary or permanent SCI was 0%. No patient required postoperative CSFD. CONCLUSIONS A restrictive lumbar CSFD algorithm, including permissive hypertension and LSA revascularization in the setting of descending +/- arch TEVAR, appears safe, with a 0% incidence of SCI in 223 consecutive patients treated during a 6.5-year interval. We recommend consideration of further prospective study to evaluate this algorithm.
Collapse
|
23
|
Tanaka A, Al-Rstum Z, Leonard SD, Gardiner BD, Yazij I, Sandhu HK, Miller CC, Safi HJ, Estrera AL. Intraoperative Intercostal Nerve Cryoanalgesia Improves Pain Control After Descending and Thoracoabdominal Aortic Aneurysm Repairs. Ann Thorac Surg 2020; 109:249-254. [DOI: 10.1016/j.athoracsur.2019.07.083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 07/09/2019] [Accepted: 07/26/2019] [Indexed: 10/26/2022]
|
24
|
Open Descending and Thoracoabdominal Aortic Repairs in Patients Younger Than 50 Years Old. Ann Thorac Surg 2019; 108:693-699. [DOI: 10.1016/j.athoracsur.2019.03.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 03/05/2019] [Accepted: 03/18/2019] [Indexed: 11/22/2022]
|
25
|
Thoracic Endovascular Aortic Repair for Aneurysm: How I Teach It. Ann Thorac Surg 2018; 106:646-650. [PMID: 30028984 DOI: 10.1016/j.athoracsur.2018.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 06/04/2018] [Indexed: 11/24/2022]
|
26
|
Tanaka A, Safi HJ, Estrera AL. Current strategies of spinal cord protection during thoracoabdominal aortic surgery. Gen Thorac Cardiovasc Surg 2018; 66:307-314. [DOI: 10.1007/s11748-018-0906-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 03/05/2018] [Indexed: 10/17/2022]
|
27
|
To reattach or not to reattach, that is not the question. J Thorac Cardiovasc Surg 2018. [PMID: 29526362 DOI: 10.1016/j.jtcvs.2018.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
28
|
Minatoya K. Keep Alert Eyes on Delayed Paraplegia. Semin Thorac Cardiovasc Surg 2017; 29:S1043-0679(17)30303-9. [PMID: 29217482 DOI: 10.1053/j.semtcvs.2017.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| |
Collapse
|