[Perioperative Risk Management for Extensively Atheromatous Aortic Disease]

Extensive atheromatous disease of the thoracic aorta is a significant risk factor of lethal complications and remains an unsolved issue in patients undergoing cardiovascular surgery. The disease condition has been documented to be associated not only with high operative risk but also with relatively poor prognosis especially in patients with aortic replacement, due to the susceptibility to potential embolic events such as neurological deficits. To achieve favorable outcomes after surgical intervention, precise preoperative evaluation and meticulous surgical planning are important. 3-dimensional computed tomography (CT) can reveal detailed aortic lesions, graftable anastomotic sites, suitable cannulation sites, risk score related to thoracic endovascular aortic repair (TEVAR). Despite the tendency that atheromatous lesions are extensive and multiple, a selected treatment would better be targeted only for clinically significant pathologic site to minimize the risks associated with surgical intervention. In addition, realistic anticipation and subsequent preparation for potential second operation should also be planned. As for a representative aortic surgery, total aortic arch replacement has been the most frequently performed procedure in Japan. When extensive atheromatous lesions are encountered around the arch and supra-aortic branches, rapid switching over to isolation of neck vessels and selective cerebral perfusion is recommended rather than solely relying on the right axillar artery perfusion. Retrograde cerebral perfusion may also be employed in a case with hostile cervical arterial lesions. Besides surgical strategy, peri-operative managements including preservation of renal and gastrointestinal functions are of paramount importance, and definitely influence the post-operative quality of life in patients with extensive atheromatous disease.