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Chapter 91. Thoracoabdominal Aneurysm

Ervant Nishanian, PhD, MD; Shahzad Shaefi, MD

  • Often associated with HTN, atherosclerosis, and connective tissue disorders such as Marfan syndrome
  • Best surgical series has 10% mortality
  • High risk of rupture along with aortic dissection. Untreated aortic dissection carries a 25–35% mortality within the first few days
  • Comorbidities
    • PVD
    • CAD
    • HTN
    • Chronic obstructive pulmonary disease (COPD) (smokers)
    • Renal impairment (independent predictor of postop renal failure and mortality)
  • Anticipate potential for rapid large blood loss and hemodynamic shifts. Successful outcome requires maintenance of adequate cardiac output and flow to vital organs including the spinal cord while avoiding hypertension and aortic rupture
  • Risk of paraplegia ≥3.5% blood as supply to the anterior spinal artery involved. Techniques to reduce incidence of paraplegia include:
    • Epidural cooling of the spinal cord during surgery
    • Cerebrospinal fluid drainage
    • Reimplantation of intercostal arteries
    • SSEP monitoring
    • Provision of distal aortic perfusion during surgery with the use of atriofemoral (left atrium) bypass to the distal aorta
  • Endovascular repairs are possible in patients that have appropriate anatomy. However, be prepared to convert to open procedure

Figure 91-1. Classification of Aortic Dissection and Thoracoabdominal Aneurysms
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Reproduced from Mathew JP, Swaminathan M, Ayoub CM. Clinical Manual and Review of Transesophageal Echocardiography. 2nd ed. Figure 16-4. Available at: www.accessanesthesiology.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.

  • Optimize comorbid conditions, anemia, renal function (consider HD if appropriate), pulmonary function (ideally stop smoking 4–6 weeks preop), and heart failure
  • Coronary artery revascularization before elective vascular surgery does not change outcome and is not recommended. However, a cardiac echo is useful to evaluate other cardiac pathology; β-blockade and statins as appropriate
  • The TAAA can distort the left mainstem bronchus; study CXR and CT-scan to predict difficulty with double-lumen ETT (DLETT) insertion
  • Notify blood bank for extra RBCs, FFP, and platelets to be available
  • Brief list of equipment and drugs to prepare besides usual GA setup:
    • DLETT (or Univent, or bronchial blocker), with fiberoptic scope to check placement
    • Lumbar drain kit, if CSF drainage intended (discuss with surgeon)
    • A-line, CVL/cordis, ±pulmonary artery catheter
    • TEE
    • Epidural kit
    • Cell saver
    • Rapid infuser device
    • Upper-body warming device only
    • Nitroprusside (50 mg in 250 mL: 200 μg/mL; 0.5–10 μg/kg/min)
    • Nitroglycerin (50 mg in 250 mL: 200 μg/mL; 0.5–10 μg/kg/min)
    • Esmolol (2,500 mg in 250 mL: 10 mg/mL; 50–200 μg/kg/min)
    • Norepinephrine (4 mg in 250 mL: 16 μg/mL; 1–10 μg/min)
    • Phenylephrine (20 mg in 250 mL: 80 μg/mL; 0.2–1 μg/kg/min)

  • Right radial artery and femoral or dorsalis pedis pressure monitoring
  • Internal jugular central line, large peripheral venous access with 7-Fr rapid infusion catheter (RIC), rapid infuser capable of 50 mL/min; consider a “double stick”, that is, placing two introducers in the same vein
  • Consider a pulmonary artery catheter if left ventricle (LV) systolic and diastolic function compromised
  • Intraoperative TEE for hemodynamic monitoring
  • When left atriofemoral (left heart) bypass to the distal aorta is used, a rapid infuser will keep up with the removal of blood from ...

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