Optimizing Outcomes of Open Thoracoabdominal Aortic Aneurysm Repair

Abstract

Open thoracoabdominal aortic aneurysm (TAAA) repair is a high-risk surgery associated with significant morbidity and mortality. It can be difficult to accumulate experience managing open TAAA repairs due to the low volume of cases and the increasing popularity of endovascular approaches. It is important to review management strategies for these challenging cases as clinical situations remain for which an open repair is preferred. Recent advances now allow for distal aortic perfusion during an off-pump open thoracoabdominal aortic aneurysm repair. This approach is not without risks and a clear, team based, plan is essential for successful management. Key considerations include managing co-morbidities, spinal cord protection, prevention of ischemia (coronary, cerebral, visceral, and peripheral), renal protection, massive transfusion, rapid hemodynamic changes, acidosis, coagulopathy, one lung ventilation, and postoperative pain control. In this case report, we detail an off-pump perioperative approach involving retrograde aortic perfusion, transesophageal echocardiography, and multiple spinal cord protective strategies which resulted in a favorable patient outcome.