Invited Commentary

Abstract

Dr Coselli discloses a financial relationship with Terumo Aortic, Medtronic, and W.L. Gore & Associates.For more than 30 years, Nicholas Kouchoukos has worked to reduce the life-altering complications of thoracoabdominal aortic aneurysm (TAAA) repair.1Laschinger J.C. Izumoto H. Kouchoukos N.T. Evolving concepts in prevention of spinal cord injury during operations on the descending thoracic and thoracoabdominal aorta.Ann Thorac Surg. 1987; 44: 667-674Abstract Full Text PDF PubMed Scopus (89) Google Scholar Specifically, he has focused on the use of hypothermia to protect the spinal cord and kidneys during the ischemic conditions necessitated by extensive aortic repair.2Kouchoukos N.T. Kulik A. Haynes M. Castner C.F. Early outcomes after thoracoabdominal aortic aneurysm repair with hypothermic circulatory arrest.Ann Thorac Surg. 2019; 108: 1338-1344Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Kouchoukos was present at the dawn of contemporary distal aortic replacement. In his early years, he used temporary shunts, as well as left heart bypass, to provide downstream perfusion of the aorta after noting the risk of substantial spinal cord and kidney injury when using a clamp-and-sew approach.3Carlson D.E. Karp R.B. Kouchoukos N.T. Surgical treatment of aneurysms of the descending thoracic aorta: an analysis of 85 patients.Ann Thorac Surg. 1983; 35: 58-69Abstract Full Text PDF PubMed Scopus (79) Google Scholar Unsatisfied, he was led to the routine use of hypothermic circulatory arrest during descending thoracic aortic aneurysm and TAAA repair because of the protection it provides to highly sensitive spinal cord and renal tissue.4Kouchoukos N.T. Wareing T.H. Izumoto H. Klausing W. Abboud N. Elective hypothermic cardiopulmonary bypass and circulatory arrest for spinal cord protection during operations on the thoracoabdominal aorta.J Thorac Cardiovasc Surg. 1990; 99: 659-664Abstract Full Text PDF PubMed Google Scholar Dr Coselli discloses a financial relationship with Terumo Aortic, Medtronic, and W.L. Gore & Associates. In his most recent description of the use of hypothermia during open TAAA repair, Kouchoukos and colleagues2Kouchoukos N.T. Kulik A. Haynes M. Castner C.F. Early outcomes after thoracoabdominal aortic aneurysm repair with hypothermic circulatory arrest.Ann Thorac Surg. 2019; 108: 1338-1344Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar report their experience with 285 such repairs, including 104 Crawford extent II TAAA repairs. Most of these repairs were in patients with degenerative aneurysms (73%), which typically carry a higher operative risk than repair of chronic aortic dissection. In addition to the use of hypothermic circulatory arrest, cerebrospinal fluid drainage and select reimplantation of intercostal and lumbar arteries were used to reduce the likelihood of postoperative spinal cord deficit further. Kouchoukos and colleagues2Kouchoukos N.T. Kulik A. Haynes M. Castner C.F. Early outcomes after thoracoabdominal aortic aneurysm repair with hypothermic circulatory arrest.Ann Thorac Surg. 2019; 108: 1338-1344Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar sagely point out that in their series, cerebrospinal fluid drainage had no favorable impact on spinal cord injury when it was used in combination with hypothermic circulatory arrest, even in the most extensive TAAA repairs—Crawford extent II TAAA repairs. In contrast, the reimplantation of intercostal and lumbar arteries proved beneficial during extent II TAAA repair. Kouchoukos and colleagues2Kouchoukos N.T. Kulik A. Haynes M. Castner C.F. Early outcomes after thoracoabdominal aortic aneurysm repair with hypothermic circulatory arrest.Ann Thorac Surg. 2019; 108: 1338-1344Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar make the point that cerebrospinal fluid drainage is clearly not an innocuous procedure and poses an occasional but significant risk, which may be exacerbated by full heparinization. Further, its use may be entirely unnecessary in patients undergoing extensive TAAA repair while using the protection of cardiopulmonary bypass with hypothermic circulatory arrest. In conclusion, the results of Kouchoukos and colleagues2Kouchoukos N.T. Kulik A. Haynes M. Castner C.F. Early outcomes after thoracoabdominal aortic aneurysm repair with hypothermic circulatory arrest.Ann Thorac Surg. 2019; 108: 1338-1344Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar speak for themselves and are among the best possibly achieved: a 6% rate of renal failure requiring dialysis, a 5% rate of permanent paraplegia or paraparesis, and a 7% rate of 30-day death. No doubt, many surgeons sweat during TAAA repair, but Kouchoukos and colleagues keep their cool as they keep it cold. Dr Coselli receives a departmental educational grant from Terumo Aortic and serves as a co-investigator for CytoSorbents. Dr Coselli's work is partly supported by the Cullen Foundation. Early Outcomes After Thoracoabdominal Aortic Aneurysm Repair With Hypothermic Circulatory ArrestThe Annals of Thoracic SurgeryVol. 108Issue 5PreviewA variety of intraoperative strategies are currently used for organ protection during open operations on the thoracoabdominal aorta. We report our experience with cardiopulmonary bypass and hypothermic circulatory arrest as the primary modality for organ protection, focusing on the early outcomes. Full-Text PDF