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• W2582367887 abstract "Despite different surgical adjuncts, advanced anaesthesia, and improved critical care, mortality and morbidity rates following “open” repair of thoracoabdominal aneurysms (TAA) remain high, sometimes prohibitively. The mortality rate ranges from 4% to 30%, paraplegia/paraparesis (P/P) from 4% to 15%, acute renal failure (ARF) from 5% to 15%. With the promising results of endovascular repair of abdominal and thoracic aneurysm, several centres have developed a new option for treatment of thoracoabdominal aneurysm. The “hybrid” technique involves a primary phase with open revascularization of visceral and renal arteries, and subsequent endovascular grafting for the exclusion of the TAA. At the moment the indications for use of one or the other procedure represent a debatable question, particularly with regard to a population of patients more and more elderly, with co-morbidity present in a large number, and consequently unfit for “open” procedure, and, on the other hand, the need for continued development of endovascular technologies and increasing experience in the “hybrid” procedure, in order to obtain an alternative treatment option in patients with challenging TAA. The experience with pure endoluminal stent graft “fenestrated” or “branched” for treatment of TAA remains limited and purely experimental. In the light of our experience, based on 476 TAA treated from 1995 to 2007, we propose our surgical options, with reference to “open” versus “hybrid” surgery. “Open” surgical repair continues to be for us the standard therapy for thoracoabdominal aneurysms, evaluating the features of patients (age, smoker, ex-IMA) and of TAA (type I or II dissecting aneurysm). In fact for a patient less than 70 years old, ASA class type I or II, respiratory functionality not compromised, renal chronic failure with serum creatinine level less than 2 mg/dl, and absence of serious diabetes – all these factors favour “open” surgical treatment. In the same way, the “open” procedure is chosen for urgent presentations such as symptomatic or covered rupture of TAA, and much more in emergency, as in free rupture, and finally in all patients, in urgency or emergency, but haemodynamically unstable. Regarding TAA, all types, according Crawford’s classification, are treated with “open” procedure especially if it is the first operation, or in Marfan syndrome evaluating the aortic wall disorder evolution. Our current approach to TAA repair has evolved substantially during a 15-year period, but several aspects have remained consistent. Patients were anaesthetized and intubated using a double-lumen endotracheal tube. An arterial line and a pulmonary artery catheter monitored patient haemodynamics through central venous access. A catheter, placed in the third or fourth lumbar space, provided cerebrospinal fluid (CSF) drainage and monitoring of CSF pressure. The CSF pressure was maintained at less than 10 mm Hg., and the drainage was kept in place postoperatively for 3 days. Contraindication for CSF drainage use includes cases of free rupture, hypotension, sepsis or active bacteraemia, recent history of intracerebral haemorrhage or previous surgery. The surgical access is through a left thoraco-abdominal incision, and the thorax is entered between the V° and IX° intercostal space, according to TAA type. Routinely circumferential division of the diaphragm was utilized, but in a patient with poor respiratory function (FV1 <60%) only the muscle segment of the diaphragm was cut in order to obtain a quicker functional recovery. In our experience it is possible, in TAA type IV°, to have the aortic cross clamping without diaphragmatic section, only through the abdomen via cutting the left diaphragmatic pillar. The advantages to respiratory function, in post-operative time, are clear. Systemic heparin administration (1 mg/kg) was utilized in our experience, not mild, permissive hypothermia." @default.
• W2582367887 created "2017-02-03" @default.
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• W2582367887 date "2008-09-01" @default.
• W2582367887 modified "2023-09-27" @default.
• W2582367887 title "Thoracoabdominal aneurysm surgery. Update on open versus hybrid treatment and personal experience" @default.
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