Aortic Vascular surgery (TAAA, ascending and arch aneurysms))

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DeBakey type I TAAA

Originates in the ascending aorta, propagates at least tot he aortic arch and often beyond it distally

DeBakey Type II TAAA

originates in and is confined to the ascending aorta

DeBakey Type III TAAA

Originates in the descending aorta and extends distally down the aorta or rarely retrograde into the aortic arch and ascending aorta

Stanford Type A TAAA

All dissections involving the ascending aorta regardless of the site of origin

Stanford Type B TAAA

All dissections not involving the ascending aorta

3 categories of thoracoabdominal disease

acute dissection
subacute dissection
stable TAAA

characteristics of acute dissections

ruptured
transactions usually emergent

characteristics of subacute dissections

expending aneurysms usually urgent

characteristics of stable TAAA

may be elective surgery
usually an incidental finding

3 indications for a TAAA

symptomatic
greater than 6cm
growing at a rate of greater than 1cm/yr

what is a class s/s of TAAA

back pain

What are 4 areas that must be focused on the the pre-op TAAA pt.

cardiac
renal
pulmonary
esophageal

What are considerations pre-op for the TAAA pt.

prepare for blood loss
might need DLT, deep hypothermic arrest, partial or full heart bypass, descending spinal drain
poss. mediastinal mass

What is the mortality rate for descending TAAA and dissections

22%

What systems are most involved with TAAA complications

cardiopulmonary and renal

What approach is often used for descending TAAA

thoracotomy approach

What are 5 considerations for the TAAA patient

large blood loss
a-line on right side
cvc
TEE
positioning

Why is there are high risk for paralyzation in the TAAA patient

Because there is lack of perfusion to the spinal nerves

What are 3 surgical approaches to the open TAAA

simple clamp and sew
gott shunt
partial left-sided heart bypass

Name 3 characteristics of the simple clamp and sew method

leads to ischemia distal to the cross clamp
used for short and emergency procedures
exaggerated response to clamping and unclamping

4 characteristics of the gott shunt

proximal to distal aorta shunting
additional fem. a-line to assess perfusion
partial anti-coagulation required
partial anti-coagulation

2 characteristics of partial left-sided heart bypass

occurs if aneurysm is proximal enough to the aortic arch or aorta too calcified
full anticoagulation

What do you want to avoid during induction of the TAAA patient

minimize an increase or a precipitous drop in blood pressure

What would be the DOC for hypertensive episode during induction of the TAAA pt.

esmolol or other beta blockers

What % if patients get spinal ischemia during TAAA cross clamping above the diaphragm

3-30%

What supplies anterior 2/3 of spinal cord

anterior spinal artery

What supplies the posterior 1/3 of spinal cord

posterior spinal artery

Artery of Adamkiewicz t9-t12

75%

artery of Adamkiewicz t8-t13

15%

artery of Adamkiewicz L1-L2

10%

What are 4 risk factors for spinal ischemia in the TAAA patient

duration of cross clamp
hypotension
presence of dissection
surgical technique

2 types of spinal ischemia

immediate
delayed onset

pt paraplegic on awakening from anesthesia that is usually irreversible

immediate

pt several hours to days after end of surgery might be reversed

delayed onset

With descending TAAA and dissections, what can be done to alleviate increase in CSF

CSF drain (lumbar drain in place)
placed if pressure exceeds 10mmHg
left in for 24hours

What is necessary to pull lumbar drain

normal coagulation studies

What are 6 complications of spinal drain complications placed for the TAAA patient

brain herniation
epidural hematoma
meninigitis
headache
spinal cord injury
back pain

What are 4 drugs that have been used to help protect the spinal cord

glucocorticoids
thiopental
mannitol
magnesium

Treatment regimen for delayed onset spinal cord ischemia

elevation of blood pressure (increase MAP)
consider CSF drainage
frequent neuro checks

Mechanical injury to the aorta is often do to what kind of trauma

deceleration injury

What is the most common site of injury to the aorta during mechanical injury

site of fixation of the aorta to the thorax known as the ligamentum arteriosum

Where is the ligamentum arteriosum located

just distal to the origin of the left subclavian artery

An endograft repair of the TAAA will be done under what kind of anesthesia

general anesthesia

Ascending aorta and arch aneurysms and dissections have similar considerations to what type of surgery and what might it involve

similar to open heart surgery
might involve aortic valve replacement and will often have aortic regurge

3 requirements for ascending aorta and arch aneurysms and dissections

will require CPB, full anticoagulation, and no cross-clamping

Of Type A and type B, which is most likely to be treated medically and which surgically?

type A - surgically
type B - medically

Most common predisposing factor for dissection

HTN

What are 3 other risk factors for dissection

marfan syndrome
ehlers danlos syndrome
deceleration injuries

Early treatment of ascending aorta and arch aneurysms and dissections

decrease blood pressure (maintain end-organ perfusion)
nicardepine, beta blockers, NTG, nipride
pain control
maintain uop

What is a patient at risk for with aortic arch surgery

high risk of stroke and ischemic brain injury due to interruption of cerebral perfusion

A 10 degree decrease in body temperature decreases cerebral metabolic rate by what

a factor of 2.6

How long can ischemic tolerance last at 15 and 10 deg. C

10 deg. C = 40 minutes
15 deg. C = 30 minutes

At what temperature would you observe an isoelectric EEG line

15deg. C

During DHCA, when does rewarming need to occur

before coming off of CPB

What is systemic hypothermia associated with?

coagulopathy
arrhythmias

What are 3 drugs that are often used in conjunction with DHCA?

barbiturates
sodium thiopental
propofol

What dosage of sodium thiopental and propofol have been used with DHCA

sodium thiopental - 2-40mg/kg
propofol - 3-10mg/kg

What vessels is used during retrograde cerebral perfusion is what is the idea behind this method?

the SVC is used. Cold oxygenated blood is delivered with idea to provide some oxygen and nutrients to the brain

pH stat is used in what population

infants and neonates

alpha stat is used in what population

adults

pH stat used in adults have shown increased incidence of what?

cerebral embolism
(possible C02)

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