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Open Thoracoabdominal Aortic Aneurysm Repair

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Principles and Practice of Anesthesia for Thoracic Surgery

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Abstract

Repair of a thoracoabdominal aortic aneurysm (TAAA) is among the most challenging cases for an anesthesiologist. The anesthetic technique is demanding and requires a high level of expertise, including proficiencies in managing one-lung ventilation, massive blood loss, coagulopathy, and cerebrospinal fluid drains. Specialized care from all members of the perioperative team has been shown to have a significant impact on outcomes.

The main complications include respiratory failure, renal failure, paraplegia, stroke, and major cardiac complications. To prevent spinal cord ischemia, different techniques may be used to achieve the same physiological goal of maintaining spinal cord perfusion pressure. Techniques to prevent and minimize spinal cord ischemia primarily focus on maximizing collateral flow by optimizing the spinal cord perfusion pressure while prolonging ischemic tolerance and reducing reperfusion injury with hypothermia and pharmacotherapy. The mainstay interventions to prevent renal injury include avoidance of nephrotoxic insults and selective cold renal perfusion.

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Author information

Authors and Affiliations

  1. Department of Anesthesia & Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand

    Helen A. Lindsay

  2. Department of Anesthesia, Toronto General Hospital, Toronto, ON, Canada

    Coimbatore Srinivas

  3. Division of Cardiovascular Surgery, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada

    Maral Ouzounian

Authors
  1. Helen A. Lindsay
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  2. Coimbatore Srinivas
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  3. Maral Ouzounian
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Corresponding author

Correspondence to Coimbatore Srinivas .

Editor information

Editors and Affiliations

  1. Department of Anesthesiology, University of Toronto, Toronto, ON, Canada

    Peter Slinger

Clinical Case Discussion

Clinical Case Discussion

A 40-year- old lady with Marfan syndrome has a Crawford type II TAAA which measures 6.4 cm. She is an ex-smoker with no other significant comorbidities.

  • Question 1. What are the major perioperative concerns?

  • Question 2: There is a suitable proximal clamp site just distal to the left subclavian artery. What are the options for perfusion management for this case?

  • Question 3: The patient develops weakness in both legs in ICU on the first postoperative day. How would you manage this situation?

  • Answer 1: For a complete discussion of these issues, see the section “Intraoperative Management” (from page 14)

    1. (a)

      Massive bleeding and coagulopathy

    2. (b)

      Spinal cord injury

    3. (c)

      Acute kidney injury

    4. (d)

      Acute lung injury due to prolonged OLV, surgical manipulation, and massive transfusion

  • Answer 2: For a complete discussion, see section “Surgical Technique” (from page 6)

    1. (a)

      Left heart bypass – preferred

    2. (b)

      Partial cardiopulmonary bypass

    3. (c)

      Deep hypothermic circulatory arrest

  • Answer 3: For a complete discussion, see sections “Spinal Cord Protection Strategies” and “Technical Specifics of Cerebrospinal Fluid Drainage” (specifically page 21)

    1. (a)

      Increase MAP to 90–100 mmHg

    2. (b)

      Increase CSF drainage to maintain ICP less than 10 mmHg

    3. (c)

      Raise the hemoglobin to over 90–100 g/dl

    4. (d)

      MRI/CT scan to rule out epidural hematoma

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Lindsay, H.A., Srinivas, C., Ouzounian, M. (2019). Open Thoracoabdominal Aortic Aneurysm Repair. In: Slinger, P. (eds) Principles and Practice of Anesthesia for Thoracic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-00859-8_41

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