Progress and Future Challenges in Thoracoabdominal Aortic Aneurysm Management

Abstract

Postoperative paraplegia and paraparesis have been the scourge of thoracoabdominal aortic repair since the inception of the procedure. In our experience with more than 1,250 cases in 15 years, we have developed adjunctive strategies that have pushed neurologic deficit rates down from over 30% percent in the most extensive cases to less than 2% overall in the modern era. The dramatic reductions in risk reported by ourselves and others have led to recent complacency regarding the importance of this complication, and widening use of endovascular technologies raises the potential specter of a return to suboptimal results. Utmost care is required in the vetting of these new technologies to prevent regression of the hard-won excellent results obtainable by open repair. Postoperative renal failure, in stark contrast to neurologic deficit, has remained resistant to every treatment that has been described in the literature. The fact that we haven't learned to treat it means that we don't understand the mechanisms behind it, and this problem is worthy of a major focused discovery and management effort. We have recently begun a multi-pronged research program to discover basic mechanisms of renal injury so that appropriate and effective treatments can be discovered.