Renal and visceral protection in thoracoabdominal aortic surgery

Open thoracoabdominal aortic aneurysm (TAAA) repair traditionally carries substantial perioperative morbidity and mortality, primarily from distal aortic ischemia. Advances in surgical techniques, adjuncts, and strategies have greatly improved outcomes.

We analyzed outcomes of 1267 open consecutive TAAA repairs between January 2005 and September 2013. We provided cold crystalloid renal perfusion whenever the renal ostia were accessible; according to extent of repair, we selectively used left heart bypass and provided isothermic blood to the celiac axis and superior mesenteric artery. Repair was extensive (Crawford extent I and II) in 717 cases (57%). Left heart bypass was used in 645 (51%) cases, cold crystalloid renal perfusion in 987 (78%), and isothermic visceral perfusion in 318 (25%). Additional patient-specific surgical adjuncts included endarterectomy of renal or visceral vessels, open stent placement within these vessels, or use of both techniques; at least one was used in 447 repairs (35%).

Thirty-day survival was 95% (1198/1267); overall operative mortality was 8% (104/1267). Acute renal dysfunction occurred in 155 (12%), renal failure requiring hemodialysis at hospital discharge in 84 (7%), and bowel ischemia in 9 (<1%). Extent II and III TAAA repairs carried the highest risks of postoperative renal dysfunction and renal failure requiring hemodialysis at hospital discharge.

Contemporary protective strategies allow open TAAA repair with substantially fewer renal and visceral ischemic complications. Although bowel ischemia is uncommon, renal failure remains a concern, especially in extent II and extent III TAAA repairs. Additional studies are needed to identify and improve renal protection strategies.