Anesthesia and Perioperative Care for Aortic Surgery (eBook)

Kathirvel Subramaniam, MD Clinical Assistant Professor Department of Anesthesiology University of Pittsburgh Medical Center - Presbyterian Hospital Pittsburgh, PA USA Kyung W. Park, MD, MBA Professor of Clinical Anesthesia and of Surgery Associate Vice President/Physician Director of Perioperative Services The Ohio State University Medical Center Columbus, OH USA Balachundhar Subramaniam, MBBS, MD Assistant Professor of Anesthesia Harvard Medical School Director, Division of Cardiovascular Anesthesiology Research Beth Israel Deaconess Medical Center Boston, MA USA

Preface 8
Contents 10
Contributors 12
1: Applied Anatomy of the Aorta 16
Anatomy 16
Ascending Aorta 16
Arch of Aorta 18
Descending Aorta 23
Abdominal Aorta 24
Anatomy of the Blood Supply to the Spinal Cord 26
Longitudinal Arteries 27
Segmental Arteries 27
Pelvic Circulation 28
Key Notes 28
References 29
2: Acute Aortic Syndrome 31
Definition and Epidemiology 31
Aortic Dissection 31
Intramural Hematoma 35
Penetrating Aortic Ulcer 36
Acute Expanding Aneurysms 36
Etiopathogenesis 36
Hypertension and Mechanical Forces 37
Genetic Predisposition 37
Matrix Metalloproteins 37
Clinical Presentation 37
Diagnostic Evaluation 38
Electrocardiogram 39
Chest Radiography 39
Computerized Tomography (CT) 40
Magnetic Resonance Imaging (MRI) 41
Echocardiography 42
Aortography 42
Management 42
Type A Aortic Dissection 44
Type B Aortic Dissection 45
Uncomplicated Type B Dissection 45
Complicated Type B Dissections 45
Intramural Hematoma 46
Type A Disease 46
Type B Disease 46
Penetrating Aortic Ulcers 46
Natural History and Prognosis 46
Prevention and Follow-Up 47
Conclusion 47
Key Notes 48
References 48
3: Preoperative Cardiac Evaluation Before Aortic Surgery 51
Noninvasive Cardiac Testing 52
Risk Modification by Perioperative Medical Therapy 53
“Prophylactic” Coronary Revascularization? 55
Patients with Valvular Stenosis 57
Key Notes 58
References 58
4: Role of Echocardiography in Aortic Surgery 61
Introduction 61
TTE 61
TEE 66
TEE in Conscious Subjects 68
Preparation 68
Procedure 68
Precautions and Complications 68
Echocardiographic Anatomy 69
Aortic Dimensions 69
TEE Views of the Thoracic Aorta 70
Artifacts in Aortic TEE 76
Utility of TEE in the Diagnosis of Classic Aortic Dissection 78
Intimomedial Flap 78
Intimal Tear 78
Reentry Tears 79
True and False Lumens 81
Aortic Valve Involvement in Aortic Dissection (Fig. 4.27) 81
Coronary Artery Involvement 82
Branch Vessel Involvement 82
Aortic Arch 82
Visceral Ischemia 85
Ruptured and Leaking Dissections 87
Late Complications 88
Mitral Regurgitation 89
Intramural Hematoma 90
Penetrating Aortic Ulcers 91
Echocardiographic Evaluation of Aneurysms 93
Sinus of Valsalva Aneurysms 93
Role of Intraoperative TEE in Aortic Aneurysm Surgery 93
Infectious Endocarditis Involvement in Aortic Root 96
Traumatic Aortic Injuries 96
Coarcation of Aorta 97
Iatrogenic Aortic Injury 98
Echocardiography for Endovascular Aortic Surgery 98
TEE 98
IVUS 99
TEE and Pre-stent Deployment Phase 100
Stent Deployment Phase 100
Post-deployment Phase 101
Detection of Endoleaks 102
Definition of Endoleaks and Endotension 102
Utility of TEE in Endoleak Detection 103
Comparison of TEE with Other Modalities for Endoleak Detection 105
TEE Guided Algorithm for Stent Placement in Aortic Dissection 105
Key Notes 107
References 107
5: Operative Techniques in Surgery of the Proximal Thoracic Aorta and Aortic Arch 112
Introduction 112
History 112
Spectrum of Aortic Diseaseand Clinical Presentation 113
Prevalence and Incidence 113
Etiology and Pathogenesis 114
Natural History 115
Indications for Operation 115
Preoperative Imaging 117
Operative Approach 117
Choice of Procedure 117
Incisions 118
Cannulation 118
General Conduct of Operation 119
Neurocerebral Protection 119
Surgical Techniques 120
Ascending Aorta Aneurysm Repair 120
Surgical Options for Aortic Root Aneurysms 121
Prefabricated Aortic Root Replacement 122
Pulmonary Autograft 123
Valve-Sparing Root Reconstructions 124
Remodeling Technique 124
Reimplantation Technique 125
Aortic Arch Aneurysms 126
References 131
6: Anesthesia for Surgery of the Ascending Aorta and Aortic Arch 135
Introduction 135
Aneurysmal Diseases of Thoracic Aorta 135
Aortic Pseudoaneurysms 137
Inflammatory Aortic Disease 137
Infectious Aortitis 138
Noninfectious Aortitis 138
Preoperative Preparation 138
Anesthetic Management 139
Discussion with the Patient 139
Planning 139
Monitoring 140
Hemodynamic Monitoring 140
Echocardiography 140
Cerebral Monitoring 141
Temperature Monitoring 141
Induction and Maintenance 143
Airway Management 144
Hemodynamic Management 144
Coagulopathy 145
Transfusion 148
Antifibrinolytics 149
Implications for Cardio-Pulmonary Bypass 150
Cannulation Options 150
Cardiac Protection 152
Cerebral protection 152
Key Notes 153
References 153
7: Deep Hypothermic Circulatory Arrest 157
Historical Notes 157
Hypothermic Cerebral Protection 158
Grades of Hypothermia 158
Mechanisms of Hypothermic Cerebral Protection 158
Profound Hypothermia and Hibernation 159
Moderate Hypothermia and Aortic Surgery 160
DHCA and Postoperative Neurologic Dysfunction 161
DHCA and Extracerebral Organs Dysfunction 161
Temperature Management and Monitoring 161
Cooling 162
Rewarming and Reperfusion 162
Afterdrop 162
Deliberate Postoperative Hypothermia 162
Cardiopulmonary Bypass Management 163
Pulsatile Flow 163
pH Management Strategies 163
Oxygen Transport 164
Hemodilution 165
Pharmacological Adjuncts to DHCA 166
Thiopental 167
Other Anesthetics 168
Steroids 168
Other Potential Pharmacologic Adjuncts to Hypothermia 169
Glucose Control and Insulin 170
Improvements in Surgical Techniques 170
Alternative and Supplemental Methods to Improve Outcome After DHCA 170
Low-Flow CPB 171
Intermittent Perfusion 171
Antegrade and Retrograde Cerebral Perfusion 171
Key Notes 172
Practical Tips and Tricks for DHCA 172
Cooling Phase 172
DHCA Phase 175
Rewarming Phase 175
Post-CPB Phase 175
References 175
8: Cerebral Monitoring During Aortic Surgery 182
Introduction 182
Intraoperative Neurophysiological Monitoring 182
Instrumentation 182
Stimulation and Acquisition Parameters for SSEP, EEG, MEP 183
Electrical Safety 183
Somatosensory Evoked Potentials (SSEP) 185
Recording SSEP 185
Factors Affecting SSEP 185
Anesthesia Drugs 185
Cerebral Blood Flow (CBF), Mean Arterial Blood Pressure (MAP), and SSEP 187
Hypothermia and SSEP 188
Role of Intraoperative SSEP in Aortic Surgery 189
Electroencephalography 189
EEG and Anesthetic Drugs 190
EEG and Cerebral Blood Flow 190
Hypothermia and EEG 191
EEG and Aortic Surgery 192
Transcranial Doppler (TCD) 192
Malperfusion 192
Rewarming from DHCA 192
Retrograde Cerebral Perfusion (RCP) and Antegrade Cerebral Perfusion (ACP) 193
Detection of Emboli 193
Limitations 194
Jugular Bulb Venous Oxygen Saturation (SJVO2) 194
Near-Infrared Regional Spectroscopy 194
Basic Principle of NIRS: Lambert Law 195
Correction for Extracerebral Tissue 195
Spatial Resolution 195
Temporal Resolution 195
Partitioning of Cerebral Arterial and Venous Blood 196
NIRS and Retrograde Cerebral Perfusion 197
NIRS and Anterograde Cerebral Perfusion (ACP) 197
NIRS and Cerebral Malperfusion 197
NIRS Versus SJVO2 Monitoring 198
Key Points 199
References 200
9: Understanding Open Repair of the Descending Thoracic and Thoracoabdominal Aorta 205
Introduction 205
Early Development of Surgical Approach 206
Symptomatology and Diagnosis 206
Indications for Repair 208
Anesthesia 208
Strategy for Repair 209
Surgical Technique 210
Positioning 210
Exposure 210
Cerebrospinal Fluid Drainage 211
Left Heart Bypass 211
Selective Visceral Perfusion 211
Cold Crystalloid Renal Perfusion 211
Use of Hypothermic Circulatory Arrest in Distal Aortic Repair 214
Elephant Trunk Approach for Extensive Aortic Repair 215
Management of the Descending Thoracic Aorta 215
Management of Thoracoabdominal Aorta 216
Closure 217
Postoperative Management 217
Outcomes 218
Key Notes 219
References 219
10: Anesthesia for Descending Aortic Surgery 221
Introduction 221
Pathology of Distal Aortic Disease 221
Preoperative Evaluation 221
Anesthetic Management 224
Epidural and Spinal Catheter Placement 224
Induction 225
Airway Management 226
Monitoring 227
Positioning 229
Aortic Cross Clamping 230
Distal Arterial Perfusion Techniques 232
Passive Shunts (Gott Shunt) 232
Partial Cardiopulmonary Bypass 232
Left Heart Partial Bypass 233
Antihypertensive Therapy 234
Aortic Unclamping 235
Blood Loss and Transfusion 236
Spinal Cord Protection 236
Anatomic and Surgical Strategies 236
Cross Clamp Time 236
Sequential Cross Clamping 237
Preoperative Imaging of Spinal Cord Blood Supply 238
Intercostal Vessel Management 238
Physiologic Strategies 238
Spinal Cord Perfusion Pressure 238
Hypothermia 238
Systemic Hypothermia 238
Regional Hypothermia 239
Pharmacologic Agents 239
Glucose Control 239
Renal Protection 239
Meseteric Ischemia 240
Completion of Surgery 241
Postoperative Management 241
Respiratory Management 241
Neurologic Complications 241
Cardiovascular Management 242
Pain Management 243
Reoperations 243
Key Notes 243
References 244
11: Spinal Cord Protection Strategies 248
Introduction 248
Clinical Presentation of Spinal Cord Ischemia 248
Contemporary Risk of Spinal Cord Ischemia 250
Predictors and Pathogenesis of Spinal Cord Ischemia 251
Spinal Cord Protection Strategies: Balancing Oxygen Supplywith Oxygen Demand 254
Minimize Interruption of Spinal Blood Supply due to Aortic Clamping 254
Maximize Spinal Cord Perfusion Pressure 255
Management of the Segmental Arterial Supply 255
Cerebrospinal Fluid Drainage 256
Augmentation of Systemic Arterial Pressure 258
Hypothermia 258
Pharmacologic Neuroprotection 259
Intensive Neurological Monitoring for Early Detection of Spinal Cord Ischemia 259
Conclusion 260
Key Notes 260
References 261
12: Understanding Endovascular Aortic Surgery: Endovascular Repair of Aortic Aneurysmal Disease 266
Background 266
Published Results 266
Patient Selection 267
Indications and Anatomic Eligibility 267
Proximal Landing Zone 267
Distal Landing Zone 268
Access Arteries 269
Inferior Mesenteric Artery and Visceral Perfusion 269
Pararenal Aneurysms 269
Occlusive Disease 269
Types of Stent Grafts (Fig. 12.4) 269
Radiation Safety 270
Contrast-Induced Nephropathy 271
Graft Selection and Placement 272
Procedure 272
Intraoperative Complications 275
Access Vessel Injury 275
Renal Artery Exclusion 275
Rupture of Aneurysm 275
Embolization 276
Postoperative Care 276
Immediate Postoperative Complications 276
Late Complications 276
Endoleaks 277
Types of Endoleaks 277
Early Endoleaks 277
Late Onset Endoleaks 278
Kinking of Endograft 279
Infection 279
Late Device Failure 279
Endovascular Repair of Ruptured Abdominal Aortic Aneurysms 280
Endovascular Therapy for Thoracic Aortic Diseases 282
Thoracic Aortic Aneurysms 282
Thoracic Aortic Dissections 282
Traumatic Aortic Injuries 283
Thoracoabdominal Aneurysms 283
Coarctation of Aorta 283
Aortic Arch Aneurysms 283
Technical Considerations 283
Key Notes 284
References 284
13: Anesthesia for Endovascular Aortic Surgery 289
Introduction 289
Preoperative Evaluation 289
Anesthesia Type 291
Published Reports 292
Special Considerations for Preparation, Equipment, and Monitoring 293
Invasive Arterial Pressure Monitoring 293
Central Venous and Pulmonary Wedge Pressure Monitoring 295
Transesophageal Echocardiography 295
Cerebral Monitoring 296
Spinal Cord Monitoring 298
Temperature Control 300
Techniques for Precise Endograft Placement 300
Induced Hypotension 301
Adenosine Cardiac Arrest 302
Rapid Ventricular Pacing 302
Other Methods 303
Postoperative Considerations in Endovascular Aortic Surgery 303
Postimplantation Syndrome 303
Summary 304
Key Notes 304
References 304
14: Anesthesia for Open Abdominal Aortic Aneurysm Repair 309
Definition 309
Etiology 309
Risk Factors 310
Pathogenesis 310
Clinical Presentation and Diagnosis 311
Unruptured AAAs 311
Ruptured AAA (RAAA) 313
Surgical Management 313
Indications for Open Repair 313
Open Versus Endovascular AAA Repair 313
Techniques of Infrarenal AAA Repair 314
Transperitoneal Approach 314
Retroperitoneal Approach 314
Pararenal AAA Repair 315
Laparascopic Approach 315
Systemic Inflammatory Response Syndrome (SIRS) 315
Risk Stratification and Perioperative Mortality 316
Preoperative Evaluation and Preparation 317
Monitoring 319
Aortic Cross-Clamping 320
Aortic Unclamping 321
Anesthesia for Ruptured Abdominal Aortic Aneurysms 322
Fluid and Transfusion Management 323
Pain Management 325
Blunt Aortic Trauma 326
Postoperative Management 327
Postoperative Complications 327
Cardiac Complications 327
Pulmonary Complications 327
Renal Insufficiency 328
Neurologic Complications 328
Gastrointestinal Complications 329
Hemorrhage 329
Disseminated Intravascular Coagulation (DIC) 329
Limb Ischemia 329
Key Notes 330
References 331
15: Renal Protection Strategies 336
Introduction 336
Renal Anatomy and Physiology 336
Gross Anatomy/Ultrastructure (Fig. 15.1a and b) 336
Ultrastructure (Fig. 15.1c and d) 338
Correlation of Structure and Function 338
Clinical Assessment and Definitions of AKI 340
Risk Factors for Surgery-Related AKI 341
Mechanisms of Surgery-Related AKI 343
Renal Preservation Strategies 345
Modifiable Clinical Factors (Nonpharmacologic) 345
Preoperative Management 345
Intraoperative Management 345
Postoperative Management 347
Pharmacologic Interventions 347
DA1 Agonist Agents (Dopamine, Fenoldopam, Dopexamine) 347
Diuretic Agents 348
N-Acetylcysteine 349
Alpha 2 Adrenergic Agonist Agents 349
Calcium Channel Blockers 349
Summary 349
Key Notes 350
References 350
16: Comprehensive Management of Patients with Traumatic Aortic Injury 355
Thoracic Aortic Trauma 355
Incidence and Pathophysiology 355
Pathology 356
Prehospital Care 357
Emergency Room Care 357
Clinical Presentation and Preoperative Evaluation 357
Diagnostic Imaging of Aortic Trauma 358
Chest Roentgenography (Fig. 16.2a and b) 358
Computerized Tomography (Fig. 16.3a–c) 358
Aortagraphy 360
Transesophageal Echocardiography (Fig. 16.5) 360
Magnetic Resonance Imaging 361
Modern Therapeutic Strategies for BAI 362
Open Surgery for Aortic Trauma 362
Endovascular (Endoluminal) Stenting 363
Intraoperative Monitoring 366
Standard Monitoring 366
Invasive Monitoring 366
Transesophageal Echocardiography (TEE) 368
Neurologic Monitoring 369
Electroencephalogram (EEG) 369
Evoked Potentials 369
Somatosensory Evoked Potentials (SSEPs) 369
Motor Evoked Potentials (MEPs) 369
Cerebral Oximetry 369
Specific Anesthetic Agents 370
Induction Agents 370
Maintenance of Anesthesia 370
Adjuncts to Anesthesia 371
One-Lung Ventilation for Open Surgical Repair 371
Fluid and Transfusion Management 371
Other Intraoperative Problems 373
Hypoxemia 374
Hypotension 375
Hypothermia 375
Pain Management 376
Intravenous Opioids 377
Patient-Controlled Analgesia (PCA) 378
Nerve Blocks 378
Intrapleural Analgesia 378
Epidural Analgesia 378
Beneficial Effects 378
Limitations 378
Multimodal Approach 379
Postoperative Considerations Following Aortic Trauma 379
Key Notes 379
References 380
17: Anesthesia for Adult Congenital Aortic Surgery* 385
Congenital Supravalvular Aortic Stenosis 385
Diagnosis 386
Treatment 387
Anesthetic Management 388
Coarctation of the Aorta 388
Diagnosis 390
Treatment 390
Anesthetic Management 391
Vascular Rings 392
Diagnosis 393
Treatment 394
Anesthetic Management 394
Patent Ductus Arteriosus 395
Diagnosis 396
Treatment 396
Anesthetic Management 397
Key Notes 397
References 398
18: Atherosclerosis of the Aorta and Prevention of Neurological Dysfunction After Cardiac Surgery 401
Introduction 401
Neurological Dysfunction After Cardiac Surgery 402
Microemboli 403
Hypoperfusion 404
Temperature Management 404
Inflammation 405
Echocardiographic Assessment of Atheromatous Disease 405
A-View Catheter 406
Epiaortic Ultrasound 406
3D TEE 407
Grading of Atheroma 407
Strategies for Preventing Neurological Dysfunction 414
Neurological Dysfunction After Aortic Surgery 416
Key Notes 417
References 418
19: Postoperative Care After Aortic Surgery 423
Introduction 423
Specific Aortic Surgery Considerations 423
Aortic Root and Ascending Aorta 423
Aortic Arch Surgery 423
Descending Thoracic and Thoracoabdominal Aortic Surgery 424
Cerebrospinal Fluid (CSF) Drainage 424
Method of CSF Drainage 424
Patient’s Admission to the Postoperative Intensive Care Unit 424
Hemodynamic Monitoring and Management 425
Blood Pressure Control 425
Coagulation and Bleeding Management 426
Temperature Management 427
Analgesia and Sedation Management 427
Ventilation and Fast Track Management 427
Myocardial Complications 428
Neurological Complications 429
Renal Complications 429
Gastrointestinal Complications 431
References 431
Index 433