A review of the literature on the management of thoracic aneurysm is presented. These patients have various comorbid conditions and need thorough work-ups. Aneurysms can be classified according to shapes and locations. Various methods to maintain hemodynamic stability with adequate endorgan perfusion are presented. The success of the operation depends upon preoperative anticipation and preparation for adequate organ perfusion and hemodynamic stability along with good communication between the anesthesiologist and the surgical team.
Get full access to this article
View all access options for this article.
References
1.
Norris EJ, Frank SM: Anesthesia for vascular surgery. In Miller RD, Cucchiara RF, Miller ED, et al (eds): Anesthesia, Vol 2. Philadelphia: Churchill Livingstone. pp 1849-1884, 2000.
2.
Banoub M: Anesthesia for thoracic aortic surgery. In Estafanous FG, Barash PG, Reves JG (eds): Cardiac Anesthesia Principles and Clinical Practice. Philadelphia: Lippincott Williams and Wilkins. pp 767-841, 2001.
3.
Ellis JE, Roizen MF, Mantha S, Wilke HJ: Anesthesia for vascular surgery. In Barash PG, Cullen BF, Stoelting RK (eds): Clinical Anesthesia, 3rd edition. Philadelphia: Lippincott Williams and Wilkins. pp 871-905, 1997.
4.
Banoub M: Anesthesia for thoracic aortic surgery. In Estafanous FG, Barash PG, Reves JG (eds): Cardiac Anesthesia Principles and Clinical Practice. Philadelphia: Lippincott Williams and Wilkins. pp 767-841, 2001.
5.
Crawford ES, Palamara AE, Saleh SA, et al: Aortic aneurysms: Current status of surgical treatment. Surg Clin North Am59:597-636, 1979.
6.
DeBakey ME, Henly WS, Cooley DA, Morris GC, Crawford ES, Beall AS: Surgical management of dissecting aneurysms of the aorta. J Thorac Cardiovasc Surg49:130-149, 1965.
7.
Gott VL, Cameron DE, Pyeritz RE, et al: Composite graft repair of Marfan aneurysm of ascending aorta: Results in 150 patients. J Card Surg9:482-489, 1994.
8.
Gott VL, Cameron DE, Reitz BA, et al: Current diagnosis and prescription for Marfan syndrome: Aortic root and valve replacement. J Card Surg9 (2 Suppl):177-181, 1994.
9.
Dapunt OE, Galla JD, Sadeghi AM, et al: The natural history of thoracic aortic aneuryms. J Thorac Cardiovasc Surg107:1323-1332, 1994.
10.
Gott VL, Gillinov AM, Pyeritz RE, et al: Aortic root replacement: Risk factor analysis of 17 years experience with 270 patients. J Thorac Cardiovasc Surg109:536-544, 1995.
11.
Pressler V, McNamara JJ: Aneurysm of thoracic aorta: Review of 260 cases. J Thorac Cardiovasc Surg89:50-54, 1985.
12.
Kouchoukos NT: Adjuncts to reduce the incidence of embolic brain injury during operations on aortic arch. Ann Thorac Surg57:243-245, 1994.
13.
Mori M, Chuma R, Kiichi Y, et al: Anesthetic management of a patient with thoracic aortic aneurysm that caused compression of the left main bronchus and right pulmonary artery. J Cardiothorac Vasc Anesth7:579-584, 1993.
14.
Penner C, Mycher B, Light RB: Compression of the left main bronchus between descending thoracic aortic aneurysm and enlarged right pulmonary artery. Chest106:959-961, 1994.
15.
Nishiwaki K, Komatsu T, Shimada Y, et al: Severe tracheal compression caused by false aneurysm arising from ascending aorta: successful airway management using induced hypotension and bronchoscopy. Anesthesiology73:1047-1049, 1990.
16.
Gorman RB, Merritt WT, Greenspun H, et al: Aneurysmal compression of trachea and right mainstem bronchus complicating thoracoabdominal aneurysm repair. Anesthesiology79:1424-1427, 1993.
17.
Stokland O, Miller MM, Ilebekk A: Mechanisms of hemodynamic responses to occlusion of descending thoracic aorta. Am J Physiol238:H423-H429, 1980.
18.
Pagani M, Pizzinelli P, Bergamaschi M, et al: A positive feedback sympathetic pressor reflex during stretch of aorta in conscious dogs. Circ Res50:125-132, 1982.
19.
Roberts AJ, Nora JD, Hughes WA, et al: Cardiac and renal responses to cross clamping of descending thoracic aorta. J Thorac Cardiovasc Surg86:732-741, 1983.
20.
O'Rourake K, Beattie C, Valman AT, et al: Acidosis during high cross clamp surgery. Anesthesiology65:266-266, 1985.
21.
Najafi H: Descending aortic aneurysmectomy without adjuncts to avoid ischemia: 1993 update. Ann Thorac Surg55:1042-1045, 1993.
Livesay JJ, Cooley DA, Ventemiglia RA, et al: Surgical experience in descending thoracic aneurysmectomy with and without adjuncts to avoid ischemia. Ann Thorac Surg39:37-46, 1985.
24.
Svensson LG, Crawford ES, Hess KR, et al: Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg17:357-368, 1993.
25.
Svensson LC, Crawford ES: Aortic dissection and aortic aneurysm surgery: Clinical observations, experimental investigations and statistical analyses. Part III Curr Problm Surg30:1-163, 1993.
26.
Janusz MT: Experience with thoracoabdominal aortic aneurysm resection. Am J Surg167:50-504, 1994.
27.
Bush HL Jr, Huse JB, Johnson WC, et al: Prevention of renal insufficiency after abdominal aortic aneurysm resection by optimal volume loading. Arch Surg116:1517-1524, 1981.
28.
Anto HR, Chou SY, Porush JG, et al: Infusion intravenous pyelography and renal function: Effect of hypertonic mannitorl in patients with chronic renal insufficiency. Arch Intern Med141:1652-1656, 1981.
29.
Svensson LG, Crawford ES, Hess KR, et al: Variables predictive of outcome in 832 patients undergoing repair of the descending thoracic aorta. Chest104:1248-1253, 1993.
30.
Collins GM, Green RD, Boyer D, et al: Protection of kidneys from warm ischemic injury; dosage and timing of mannitol administration. Transplantation29:83-84, 1980.
31.
Nicholson ML, Baker DM, Hopkinson BR, et al: Randomized controlled trial of the effect of mannitol on renal reperfusion injury during aortic aneurysm surgery. Br J Surg83:1230-1233, 1996.
32.
Grodin W, Scantlebury V, Warminton N: Dopaminergic stimulation of renal blood flow and renal function after transplantation (abstract). Anesthesiology61:A129-A129, 1984.
33.
Davis RF, Lappas DG, Kirklin JK, et al: Acute oliguria after CPAB: Renal functional improvement with low dose dopamine infusion. Crit Care Med10:852-856, 1982.
34.
Elliott WJ, Webber RR, Nelson KS, et al: Renal and hemodynamic effects of intravenous fenoldopam versus nitroprusside in severe hypertension. Circulation81:970-977, 1990.
35.
Lanier WL, Fleischer JE, Milde JH, et al: Post-ischemic neurologic recovery and cerebral blood flow using a compression model of complete bloodless cerebral ischemia in dogs. Resuscitation16:271-286, 1988.
36.
LeMay DR, Gehua L, Zelenock GB, et al: Insulin administration protects neurologic function in cerebral ischemia in rats. Stroke19:1411-1419, 1988.
37.
Hochachka PW: Defense strategies against hypoxia and hypothermia. Science231:234-241, 1986.
38.
Ergin MA, Griepp EB, Lansman SL, et al: Hypothermic circulatory arrest and other methods cerebral protection during operations on the thoracic aorta. J Card Surg9:525-537, 1994.
39.
Raskin SA, Fuselier VW, Reeves-Viets JL, et al: Deep hypothermic circulatory arrest with and without retrograde cerebral perfusion. Int Anesthesiol Clin34:177-193, 1996.
40.
Matsuda H, Nakano S, Shirakura R, et al: Surgery of aortic arch aneurysm with selective cerebral perfusion and hypothermic cardiopulmonary bypass. Circulation80 (Suppl I): II-243-II-248, 1989.
41.
Katoh T, Esato K, Gohra H, et al: Evaluation of brain oxygenation during selective cerebral perfusion by near-infrared spectroscopy. Ann Thorac Surg64:432-436, 1997.
42.
Mezrow CK, Midulla PS, Sadeghi AM, et al: Quantitative electroencephalography: A method to assess cerebral injury after hypothermic circulatory arrest. J Thorac Cardiovasc Surg109:925-934, 1995.
43.
Midulla PS, Gandsas A, Sadeghi AM, et al: Comparison of retrograde cerebral perfusion to antegrade cerebral perfusion and hypothermic circulatory arrest in a chronic porcine model. J Card Surg9:560-574, 1994.
44.
Mezrow CK, Gandsas A, Sadeghi AM, et al: Metabolic correlates of neurologic and behavioral injury after prolonged hypothermic circulatory arrest. J Thorac Cardiovasc Surg109:959-975, 1995.
45.
Cheung AT, Bavaria JE, Pochettino A, et al: Oxygen delivery during retrograde cerebral perfusion in humans. Anesth Analg88:8-15, 1999.
46.
Ganzel BL, Edmonds HL, Pank JR, et al: Neurophysiologic monitoring to assure delivery of retrograde cerebral perfusion. J Thorac Cardiovasc Surg113:748-755, 1997.
47.
Cunningham JN, Laschinger JC, Spencer FC: Monitoring of somatosensory evoked potentials during surgical procedures on the thoracoabdominal aorta: IV. Clinical observations and results. J Thorac Cardiovasc Surg94:275-285,1987.
48.
Laschinger JC, Cunningham JN Jr, Baumann FG, et al: Monitoring of somatosensory evoked potentials during surgical procedures on the thoracoabdominal aorta: II. Use of somatosensory evoked potentials to assess adequacy of distal aortic bypass and perfusion following thoracic aortic cross-clamping. J Thorac Cardiovasc Surg94:266-270, 1987.
49.
Kaplan BJ, Friedman WA, Alexander JA, et al: Somatosensory evoked potential monitoring of spinal cord ischemia during aortic operations. Neurosurgery19:82-90, 1986.
50.
Kouchoukos NT, Wareing TH, Izumoto H, et al: Elective hypothermia cardiopulmonary bypass and circulatory arrest for spinal cord protection during operations on thoracoabdominal aorta. J Thorac Cardiovasc Surg99:659-654, 1990.
51.
O'Connor CJ, Rothenberg DM: Anesthetic considerations for descending thoracic aortic surgery: Part II. J Thorac Cardiovasc Anesth9:734-747, 1995.
52.
Wisselink W, Becker MO, Nguyen JH, et al: Protecting the ischemia spinal cord during aortic clamping: The influence of selective hypothermia and spinal cord perfusion pressure. J Vasc Surg19:788-795, 1994.
53.
Tabayashi K, Niibori K, Konno H, et al: Protection from post ischemic spinal cord injury by perfusion cooling of the epidural space. Ann Thorac Surg56:494-498, 1993.
54.
Marsala M, Vanicky I, Yaksh TL: Effect of graded hypothermia (27 degrees to 34 degrees C) on behavioral function, histopathology, and spinal blood flow after spinal ischemia in rat. Stroke25:2038-2046, 1994.
55.
Coles JG, Wilson GJ, Sima AF, et al: Intraoperative management of the thoracic aortic aneurysm: Experimental evaluation of perfusion cooling of the spinal cord. J Thorac Cardiovasc Surg85:292-299, 1983.
56.
Svensson LC, Stewart RW, Cosgrove DM, et al: Intrathecal papaverine for the prevention of paraplegia after operation of the thoracic or thoracoabdominal aorta. J Thorac Cardiovasc Surg96:823-829, 1988.
57.
Svensson LG, Grum DF, Bednarski M, et al: Appraisal of cerebrospinal fluid alterations during aortic surgery with intrathecal papaverine administration and cerebrospinal fluid drainage. J Vasc Surg11:423-429, 1990.
58.
Laschinger JC, Cunningham JN, Cooper MM, et al: Prevention of ischemic spinal cord injury following aortic cross-clamping: Use of corticosteroids. Ann Thorac Surg38:500-507, 1984.
59.
Braughler JM, Hall ED: Correlation of methylprednisolone levels in cat spinal cord with its effects on (N+ K +)ATPase, lipid peroxidation and alpha motor neuron function. J Neurosurg56:838-844, 1982.
60.
Faden AI, Jacobs TP, Smith MT: Evaluation of the calcium channel antagonist nimodipine in experimental spinal cord ischemia. J Neurosurg60:796-799, 1984.
61.
Guha A, Tator CH, Piper I: Increase in rat spinal cord blood flow with the calcium channel blocker nimodipine. J Neurosurg63:250-259, 1985.
Grabitz K, Freye E, Prior R, et al: Does prostaglandin E1 and superoxide dismutase prevent ischemic spinal cord injury after thoracic aortic cross-clamping?Eur J Vasc Surg4:19-24, 1990.
65.
Altura BT, Altura BM: Intersections of magnesium and potassium on cerebral vessels-aspects in view of stroke. Magnesium3:195-211, 1984.
66.
Mizrahi EM, Crawford ES: Somatosensory evoked potential during reversible spinal cord ischemia in man. Electroencephralogr Clin Neurophysiol58:120-126, 1984.
67.
Kurrek MM, Reed RL: Effect of hypothermia on enzymatic activity of thrombin and plasmin. Surg Forum38:221-223, 1987.
68.
Holmson H, Karpatkin S: Metabolism of platelet. In Williams WJ, Beutler E., Erslev AJ, et al: (eds) Hematology, 3rd ed.New York: McGraw-Hill. p 1157-1157, 1983.
69.
Aster RH: Thrombocytopenia due to sequestration of platelets. In Williams WJ, Beutler E, Erslev AJ, et al (eds): Hematology, 3rd ed.New York: McGraw-Hill. p 1338-1338, 1983.
