Chapter 77 - TAAA open repair

Question 1

Adam’s 1954 paraplegia rate in TAAA open repair

Answer 1

25%

Question 2

DeBakey 1964 mortality rate in TAAA

Answer 2

50%

Question 3

Crawford 1974 series of TAAA open repair

Answer 3

Mortality 8% paralysis 16% much improved since then

Question 4

% of TAAA ruptures under 6 cm

Answer 4

13% rarely below 5.5 cm

Question 5

Extracorporeal circulation in TAAA repair

Answer 5

Assisted circulation (left heart bypass): left atrial/left pulmonary cannula –> femoral artery Hypothermic cardiac arrest: femoral artery –> femoral vein/right atrium + left ventricular sump drain Cool pt to 16-18C Gott shunt: passive flow from aorta to aorta distally Axillofemoral bypass: passive flow

Question 6

Anesthetic drug use in TAAA open repair

Answer 6

1) nitroprusside and hydralazine avoided for spinal ischemia 2) sodium bicarb when aorta occluded (0.05 meq/kg/min) 3) methylprednisolone after induction and naloxone after surgery 4) amnnitol before aortic occlusion and after renal reperfusion

Question 7

Temperature for cooling during surgery

Answer 7

31-34 C

Question 8

Spinal fluid pressure

Answer 8

< 6 mm during aortic occlusion

Question 9

MAP during surgery

Answer 9

> 90 mm Hg

Question 10

TAAA open surgery patient position

Answer 10

Lateral decubitus with left side up Shoulder vertical with pelvix tilted to access left femoral vessels

Question 11

Rib space for different pathologies

Answer 11

Arch aneurysm = 5th Craford 1-2 = 5-6th Descending = 4th - 7th Type 3-4 = 8th or 9th space

Question 12

Recurrent laryngeal nerve injury rate in TAAA repair

Answer 12

10% especially when proximal anast is proximal to left subclavian

Question 13

TAAA exposure

Answer 13

1) cut through rib space as previously determined 2) cut diaphragm at aortic hiatus 3) spare phrenic nerve 4) ligate lumbar vein of left renal 5) retroperitoneal lift up kidney

Question 14

Dose with hypothermic circulatory arrest heparin

Answer 14

400 units/kg

Question 15

Condition before cross clamping

Answer 15

1) SBP < 100 2) temp < 34 3) spinal fluid pressure < 6 mmHg 4) MAP > 100

Question 16

Cooling solution for kidney

Answer 16

300-400 ml of 4C renal perfusion solutio 12.5g mannitol and 1000 Units heparin/L of lactated ringers

Question 17

Visceral renal reattachment in TAAA

Answer 17

Carrel patch keep narrow to avoid aneurysm SMA-CELIAC +/- right renal left renal alone Coselli branched graft for individual attachment - in connective tissue disease

Question 18

Dye to test renal perfusion

Answer 18

Indigo carmine given IV to see in urine production

Question 19

Number of intercostals to reimplant

Answer 19

2-4

Question 20

Suturing dacron to endograft technique

Answer 20

FIGURE 77.12

Question 21

Treatment of delayed weakness/paralysis

Answer 21

1) increase MAP 2) drain more spinal fluid 3) restart neuroprotective medication 4) maintain cardiac index

Question 22

Greater radiculary

Answer 22

Arises from Artery of Adamkiewicz between T8-L2 (85%)

Question 23

Factors associated with increased spinal paralysis

Answer 23

1) Cardiac index low 2) dissection etiology 3) C2 pathology 4) acute 5) age

Question 24

Risk of paralysis by age after TAAA mortality

Answer 24

< 60 yo: 1.4% > 60 yo 5.7% MORTALY 0.7% 8.9%

Question 25

Mathematical model for calculating expected paraplegia based on extent of aortic repair

Answer 25

BELOW FIGURE 77.15

Question 26

Pulmonary complication after TAAA

Answer 26

27% 8-10% need trach

Question 27

Mortality after TAAA by age

Answer 27

TABLE 77.3

Question 28

Mortality by clamping modality and adjuncts in TAAA

Answer 28

TABLE 77.4

Question 29

Mortality improvements TAAA elective vs urgent and age

Answer 29

Elective < 60 yo 0% > 80 yo 5.7% Urgent < 60 yo 1.6% > 80 yo 42.9% (with renal failure 67%)

Question 30

Mortality improvements over time in TAAA

Answer 30

Era 1 - 11.34% Era 2 - 7.99% mostly improved because of paraplegia improvement

Question 31

Post-taaa mortality due to renal failure

Answer 31

50-60%

Question 32

Rate of permanent dialysis after TAAA with normothermic vs hypothermic

Answer 32

15% normothermic 0.8% hypothermic

Question 33

Survival after TAAA

Answer 33

69-78% 1 year 45-68% 5 years