proceedings

in Intensive Care
Cardiovascular Anesthesia

originAl ArticlE

45
management of thoracoabdominal
aortic aneurysms
R. Chiesa1, E. Civilini1, G. Melissano1, D. Logaldo1, F.M. Calliari1, L. Bertoglio1,
A. Carozzo2, R. Mennella2
1
Department of vascular surgery;
1
Cardiovascular Anesthesia, Università Vita-Salute San Raffaele, Milano

AbStrAct
Conventional treatment of thoracoabdominal aortic aneurysms (TAAAs) consists of graft replacement with
reattachment of the main aortic branches. over the past 20 years a multimodal approach has gradually evolved
to reduce the trauma of surgery by maximizing organ protection, allowing experienced surgical Centers to have
better outcomes than previously reported. However, mortality and morbidity associated to TAAA open repair
remain significant. Hybrid repair, consisting of open aortic debranching and revascularization followed by
endovascular exclusion of the aneurysm, may extend the indications of TAAA repair to high-risk patients that
cannot benefit from surgery, however results are still under evaluation. Aim of this paper is to illustrate the
management and results of thoracoabdominal aortic aneurysms surgery with open techniques of organ protec-
tion and hybrid approach in our Center.

Keywords: Thoracoabdominal aortic aneurysms, Vascular surgery, Surgery, Anesthesia.

introduction juncts to prevent end-organ ischemia (2).

The recent introduction of endovascular
A thoracoabdominal aortic aneurysm techniques may extend the indications of
(TAAA) is characterized by enlargement of TAAA repair to high-risk patients, whose
the aortic segment at the diaphragmatic cru- only alternative is now represented by the
ra and extends for variable distance proxi- best medical therapy.
mally and/or distally from this point (1).
Historically, open surgical repair of TAAAs
has involved greater operative risk than re- opEn rEpAir
pairs of aneurysms in other aortic segments.
The main sources of morbidity during op- Conventional treatment of TAAAs consists
erative repair of TAAAs are multiorgan of graft replacement with reattachment of
failure, paraplegia and respiratory, cardiac the main aortic branches. A multimodal
or renal complications. Experienced surgi- approach is currently used to reduce the
cal Centers now report lower mortality and trauma of surgery by maximizing organ
morbidity rates for TAAA repair than they protection. The surgical technique used, as
once did, largely because of the use of ad- the extension of the aneurysm, has a sig-
nificant impact on the outcome of the pro-
cedure.
Corresponding author:
Prof. Roberto Chiesa Thoracoabdominal incision and aortic
Chair of Vascular Surgery
“Vita-Salute” University exposure
Scientific Institute H. San Raffaele
Via olgettina, 60 - 20132 Milan, Italy
The patient is positioned with a beanbag
E-mail: r.chiesa@hsr.it in right lateral decubitus (shoulders 60°,
 R. Chiesa, et al.

46 pelvis 30°). The upper portion of the tho- Left Heart bypass (LHb)
racoabdominal incision is made through Cross-clamping of the descending thoracic
the 6th intercostal space; anterolaterally, aorta leads to several hemodynamic distur-
the incision curves gently as it crosses the bances, including severe afterload increase
costal margin, reducing the risk of tissue and organ ischemia. The rationale of LHB
necrosis. The pleural space is entered af- is providing flow to the spinal cord, viscera
ter single right-lung ventilation is initiated and kidneys during the aortic cross-clamp
(Figure 1). period together with the reduction of proxi-
Paralysis of the left hemidiaphragm by its mal hypertension and afterload to the heart
radial division to the aortic hiatus would (5). In preparation for LHB and aortic
contribute significantly to postoperative re- clamping, intravenous heparin (1 mg/kg) is
spiratory failure (3), hence after thoracoab- administered with a target ACT (Activated
dominal incision, a circumferential section Clotting Time) of 220-270 seconds.
of the diaphragm is routinely carried out, Proximal descending thoracic aorta, left
sparing the phrenic center. Under favorable atrium or pulmonary vein are usually can-
anatomic conditions, a limited phrenotomy nulated for arterial blood drain that is re-
is carried out to preserve the tendinous cen- infused through a centrifugal pump (Bio-
ter of the diaphragm; this has been shown medicus) into the subdiafragmatic aorta
to reduce respiratory weaning time (4). or the common left femoral artery. flow is
The upper abdominal aortic segment is ex- initially low (500 mL/min) to avoid retro-
posed via a transperitoneal approach; the grade embolization and then increased af-
retroperitoneum is entered lateral to the left ter aortic clamping to a mean distal aortic
colon, and medial visceral rotation is per- pressure of about 70 mmHg, a value that
formed so that the left colon, the spleen and is usually achieved using a flow between
the left kidney can be retracted anteriorly 1500 and 2500 mL/min. A “Y” bifurcation
and to the right. Transperitoneal approach is connected to the circuit and is provided
allows direct view of the abdominal organs with two occlusion/perfusion catheters for
to evaluate the efficacy of revascularization selective perfusion of visceral vessels (Fig-
at the end of aortic repair. ure 2).

figure 1 - Type II thoracoabdominal aortic figure 2 - Left heart bypass and renal perfusion
aneurysm exposure through thoraco-phreno- catheters.
laparotomy.
 management of thoracoabdominal aortic aneurysms

47

figure 3 - Transection of the thoracic aorta and end-to-end anastomosis. Ligature of segmental
arteries is also shown.

Aortic repair tached to the graft by means of aortic patch

once the proximal aspect of the TAAA is or graft interposition. These arteries can be
isolated between clamps the descending tho- temporarily occluded with Pruitt catheters
racic aorta is transected and separated from to avoid blood steal phenomenon.
the esophagus (Figure 3). The proximal end The distal clamp is moved onto the distal
of the graft is sutured to the descending tho- abdominal aorta below the renal arteries
racic aorta using a 2/0 monofilament poly- and the upper abdominal aortic aneurysm is
propylene suture in a running fashion. The opened. Visceral hematic perfusion is then
anastomosis is reinforced with felt pledgets. maintained by the pump with occlusion/
The clamp is then removed and reapplied perfusion catheters (9 fr) inserted selec-
onto the abdominal aorta above the celiac tively into the celiac trunk and the superior
axis (sequential cross-clamping). mesenteric artery (400 mL/min). Selective
Reimplantation of intercostal arteries to the perfusion of renal arteries is performed
aortic graft plays a critical role in spinal cord with a cold crystalloid solution (Ringer 4°C
protection (6). Critical patent segmental + mannitol 18% 70 mL, 6-methylpredni-
arteries from T7 to L2 are selectively reat- solone 500 mg in 500 mL) (7).

figure 4 - Type II TAAA repair: aortic graft

replacement and visceral vessels reattachment
by means of Carrel patch (left) and Coselli
thoracoabdominal graft (above).
 R. Chiesa, et al.

48 incorporated in a beveled distal anastomo-

sis.

hybrid rEpAir

Endovascular procedures may be an appeal-

ing less invasive approach to the thoraco-
abdominal aorta, however, the involvement
of the visceral segment of the aorta repre-
figure 5 - The Vascutek Triplex™ graft consists sents a major challenge for TAAA stent-
of three layers: an inner polyester graft, an outer graft repair.
ePTFE layer and a central layer of elastomeric Although total endovascular treatment
membrane. with branched stent-graft (8) has made it
technically feasible to preserve visceral per-
for visceral arteries reimplantation, a side fusion, the cost-efficacy and durability of
cut is tailored in the graft and the celiac these pioneering techniques are yet to be
trunk, superior mesenteric artery and renal fully assessed.
arteries are reattached by means of a Carrel Hybrid TAAA repair was first introduced
patch. This technique has been performed by Quiñones-Baldrich in 1999 (9) and
in 82.3% of the patients in our series. mainly consists of open aortic debranching
In 33.1% of the cases treated by Carrel and revascularization followed by endovas-
patch the left renal artery has been sepa- cular exclusion of the aneurysm.
rately reattached to the graft in a direct The inflow site for visceral grafts is a healthy
fashion or by graft interposition. When artery, usually the infrarenal aorta, the ili-
the relative distance of the visceral arteries ac arteries or an infrarenal graft. Visceral
would have required a large Carrel patch, and renal arteries are then ligated at the
a branched graft can be successfully used origin to avoid back-flow in the aneurysm
(Vascutek gelweave – Coselli thoracoab- and consequent type II endoleak. The open
dominal graft™) (Figure 4). This prosthesis
allows single vessel reattachment, reducing
the risk of recurrent aortic patch aneurysm.
In our series the Coselli branched graft has
been used in 10.5% of cases.
The Vascutek Triplex™ graft is a new vas-
cular prosthesis and consists of three lay-
ers: an inner polyester graft, an outer ePT-
fE layer and a central layer of elastomeric
membrane (Figure 5). In our preliminary
experience with this graft we found good
handling and tailoring performances and figure 6 - Preoperative CT of a patient with
actually a reduced bleeding from the suture type III TAAA (left). The hybrid procedure
lines. consisted of infrarenal aortic grafting with
finally, an end-to-end anastomosis with single visceral vessels revascularization (center).
the distal aorta is performed. In some cases Control angioCT demonstrated TAAA excusion
(TAAA type I) the visceral arteries can be and visceral bypasses patency (right).
 management of thoracoabdominal aortic aneurysms

surgical stage requires a laparotomy and a rESultS 49

transperitoneal or extraperitoneal access to
the visceral vessels; however, proximal aor- from literature, mortality and morbidity
tic cross-clamping, thoracotomy, aneurysm rates after TAAA conventional repair re-
exposure and monopulmonary ventilation main significant even in high-volume Cen-
are avoided (Figure 6). The surgical and en- ters (12-15) (Table 1 and 2).
dovascular procedures can be simultaneous These data could be not totally representa-
or staged. tive of the actual outcomes of TAAA surgi-
Hybrid TAAA repair may be indicated in cal repair. Cowan et al. (23) analized data
case of previous descending thoracic aortic from the nationwide Inpatient Sample
repair in which a redo left-sided thoracoto- (nIS), dividing Centers where TAAA surgi-
my may be associated with major bleeding, cal repair has been performed (1988-1998)
increased rate of postoperative respiratory in low volume (1-3 cases/year), medium
and organ failure and longer total aortic volume (2-9 cases/year) and high volume
clamping time. (5-31 cases/year). Annual surgeon volume
A further advantage of the hybrid treat- has been defined as low (1-2 cases) or high
ment is the possibility to reduce organ isch- (3-18 cases). Conclusions were that the re-
emic time and perform visceral protection sults of low-volume Centers and surgeons
techniques by selective cooling. were significantly different from those of
Hybrid repair is appealing in case of vis- high-volume Centers and surgeons. (Figure
ceral aortic patch (VAP) aneurysm after 7).
TAAA conventional repair (10). In particular, in a specific subset of high-
Moreover, VAP aneurysms have ideal risk patients, the outcomes are associated
straight and long “in-graft” proximal and to higher morbidity and mortality rates. As
distal necks where the stent-graft can be a result, these outcomes have encouraged
safely delivered (11). With this technique, some Centers to consider the hybrid repair
the aortic branches are anastomosed sepa- as the treatment of choice (24).
rately and virtually no native aortic rem- The data reported in literature regarding
nants are left in situ, thus avoiding the risk classification and extension of pathology,
of recurrences. patient’s overall clinical conditions, surgi-

table 1 - Morbidity and mortality after TAAA conventional repair in high-volume Centers.
30-day paraplegia/ 1-year
Author patients (n) mortality paraparesis dialysis (%) mortality
(%) (%) (%)

Coselli (16) 2755 4.7 3.6 5.1 no data

Svensson (17) 1509 10 16 9 no data

Rigberg (18) 1010 19 no data no data 31

Sandmann (19) 673 12.5 7.5/6.6 10 no data

Crawford (20) 605 8.9 6 17 21

Schepens (21) 500 11.4 no data no data 17

Conrad (22) 445 6.8 9.5/3.7 4.6 20

 R. Chiesa, et al.

50 table 2 - Results after TAAA conventional repair - Università Vita-Salute, Scientific Institute San Raffaele,
Milan, Italy.
total n (%) Elective n (%) Emergency n (%)
Total 345 286 59
Mortality 45 (13.3) 24 (8.6) 21 (35.6)
Paraplegia 34 (9.8) 23 (8.0) 11 (18.6)
Renal failure 23 (6.6) 15 (5.2) 8 (13.5)
Respiratory failure 67 (19.9) 43 (15.4) 24 (40.7)

cal technique and results of TAAA hybrid cern. Conrad et al. demonstrated the impact
repair are still very heterogeneous (Table of paraplegia/paraparesis on survival of
3). further studies are needed to assess the patients who underwent surgical or endo-
safety, efficacy and long-term survival asso- vascular TAAA repair: 5-year survival rate
ciated to the hybrid treatment of thoraco- was 25% in paraplegic/paraparetic patients
abdominal aortic aneurysms. versus 51% in patients with no spinal com-
plications. five-year survival rate was 41%
Spinal cord ischemia in paraparetic patients, while no paraple-
The etiology of spinal cord ischemia during gic patients survived for more than 5 years
thoracic aortic procedures is multifactorial, (28) (Figure 8).
and the risk of paraplegia is a debated con- Extensive coverage of the thoraco-abdom-

30 27.3% 30
25.6%

23.8%
25 25
in-hospital Mortality (%)

in-hospital Mortality (%)

20 20

15.0%
15 15
11.0%

10 10

5 5

0 0
Low Meduim High Low High

Annual Hospital Volume Annual Surgeon Volume

figure 7 - Graphs show in-hospital mortality rates in function of annual hospital volume (left) and
annual surgeon volume (right).
 management of thoracoabdominal aortic aneurysms

inal aorta could be identified as the cause 51

of a higher rate of spinal complications. 100
Greenberg et al. compared total stent-graft All ScI
no ScI
length in patients that did and did not de- 80

velope neurological deficit, demonstrating

% Survival
60
a significant association with the lenght of
aortic coverage (29). These findings were 40
confirmed by Carroccio et al. (30). p<0.001
20
Böckler et al. demonstrated that in the
animal model endovascular repair is as- 0
sociated to lower spinal cord ischemia and 0 1 2 3 4 5
Years
paraplegia rates than aortic cross-clamping
(31). 100 ScID I
During hybrid TAAA repair, the avoidance ScID II & III
of supraceliac clamping and the shortened 80
duration of visceral ischemia should lead to
% Survival

60
greater perioperative hemodynamic stabili-
ty compared with that during conventional 40 p<0.001

open repair of TAAA, and the risk of spinal

20
cord ischemia could be hypothesized to be
reduced (32). 0
0 1 2 3 4 5

open surgical repair of thoracoabdominal Years

aortic aneurysms has evolved significantly
over the last decades thanks to technical figure 8 - Graphs show the impact of paraple-
improvements, especially in the area of or- gia/paraparesis on survival of patients who un-
gan protection. However, despite adjunc- derwent surgical or endovascular TAAA repair
tive strategies, morbidity and mortality (SCI: spinal cord ischemia; SCID: spinal cord
rates are still not negligible. ischemia deficit; SCID I: flaccid paralysis; SCID
Patient selection has to be based on a care- II: muscle function <50%; SCID III: muscle func-
ful preoperative assessment and risk evalu- tion >50%)

table 3 - Morbidity and mortality after TAAA hybrid repair in the main series in literature.
paraplegia/ 30-day overall
patients complications
Author paraparesis rf (%) mortality mortality
(n) (%)
(%) (%) (%)
Black (24) 29 61 0 15.4 13 23
Böckler (31) 28 59 11 11 14.3 30
Wolf (25) 20 55 10 15 10 25
Resch (26) 13 53 15 2 23 38.5
Lee (27) 17 25 0 6 18 24
Chiesa 31 35.5 9.6 9.6 19.4 35.5
Jenkins* 89 19 8 3 13 no data
*Collaborative group
 R. Chiesa, et al.

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formed in high-volume Centers by experi- et al. Repair of type IV thoracoabdominal aneu-
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No conflict of interest acknowledged by the authors
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