Surgical repair of thoracoabdominal aneurysms: patient selection, techniques and results

Repair of thoracoabdominal aortic aneurysms (TAAAs) continues to be a challenging task. Hemorrhagic shock, cardiac arrest and multisystem organ failures are the most frequent causes of death, and paraplegia and renal failure are the most devastating complications.

Flawless surgical technique and the use of adjuncts to protect key organs including the brain, heart, spinal cord, liver and kidneys affect outcome. Perfection in exposure and suturing technique decreases bleeding complications, shortens cross-clamp time and assures optimal, visceral, renal and lower extremity perfusion. Technical details include retroperitoneal abdominal aortic exposure, double thoracotomy for Type I and Type II aneurysms, and preservation of the diaphragm. The kidneys are protected by perfusion of iced lactated Ringers; visceral ischemia in Type I and Type II, aneurysms is diminished by using pulmonary vein-femoral artery pump with sequential clamping. Spinal cord protection is attempted by spinal fluid pressure monitoring and drainage, moderate general hypothermia, selective left heart bypass, reimplantation of critical intercostal arteries, monitoring somatosensory and somatomotor evoked potentials and epidural cooling of the spinal cord.

Outcome in 203 patients (Group I) who underwent repair of TAAAs without epidural cooling was compared with outcome in 97 patients, 27 with thoracic aortic aneurysms and 70 with TAAA (Group II) who underwent repair using epidural cooling. In Group II paraplegia/parapesis occurred in 11.6%, not different from the 8.9% in Group I. Thirty day mortality for elective cases decreased from 14.6% (Group I) to 7.2% (Group II, P<0.05).

Open surgical repair of TAAA carries elevated mortality and complication rates. The etiology of ischemic and reperfusion injury to the spinal cord is multifactorial and its prevention remains a formidable and as yet unresolved task. To select patients for surgical repair, the risk of TAAA rupture should be balanced against risks of perioperative mortality, paraplegia and renal failure.