Skip to main content

Advertisement

SpringerLink
Log in

Techniken der shuntunterstützten Operation bei thorakoabdominellen Aortenaneurysmen

Techniques of shunt-assisted operations for thoraco-abdominal aortic aneurysms

  • Der technische Tipp
  • Published:
Gefässchirurgie Aims and scope Submit manuscript

Zusammenfassung

Operative Ausschaltungen von thorakoabdominellen Aortenaneurysmen sind signifikant mit technischen Risiken behaftet, die meistens durch verlängerte Aortenklemmperioden und durch die Schwierigkeit gekennzeichnet sind, alle relevanten renoviszeralen und spinal versorgenden Gefäße zu erkennen und rechtzeitig wieder mit dem Blutstrom zu verbinden. Eine Reihe von adjuvanten Techniken wurde mit dem Ziel entwickelt, die Morbidität zu senken. Hierzu gehören der maschinell unterstützte atriofemorale bzw. der pulmonal-arteriofemorale, extrakorporale Bypass, die subarachnoidale Liquordrainage, die epidurale Kühlung und der unilaterale, axillofemorale Bypass.

In dieser Arbeit werden physiologische, amaschinelle und an mehr als 100 Patienten angewandte Techniken beschrieben, die entwickelt wurden, um die distale Perfusion während der Ausschaltungsoperation zu gewährleisten, beginnend vom proximalsten Aspekt des Aneurysmas, endend an der linken A. iliaca. Diese Techniken haben das Potenzial, hämodynamische Instabilitäten zu minimieren, während die Ischämiezeit der Becken- und Bauchorgane sowie der Extremitäten deutlich verkürzt werden. Diese Methoden zeigen weitere Optionen zur operativen Therapie von thorakoabdominellen Aortenaneurysmen auf, v. a. dann, wenn ein Linksherzbypass oder eine Zentrifugalpumpen nicht zur Verfügung stehen bzw. nicht zum Einsatz kommen sollen.

Abstract

Surgery of thoraco-abdominal aortic aneurysms (TAAA) is significantly associated with technical risks which are characterized by prolonged periods of aortic cross-clamping, the difficulty to recognize all relevant reno-visceral and spinal arteries and to reconnect the blood supply in time. Numerous adjuncts have been developed to reduce morbidity, such as mechanical-assisted atriofemoral or pulmonary arterofemoral extracorporeal bypass, spinal cord liquor drainage, epidural cooling and unilateral, axillofemoral bypass.

In this article physiological, non-mechanical techniques are described, which were developed and used for over 100 patients. The aim was always to install a distal perfusion during aortic cross-clamping, starting from the most proximal aspect of the aneurysm and ending at the left iliac artery. These techniques have the potential to minimize hemodynamic instability while ischemia to pelvic and abdominal organs is reduced. These methods show further options for a surgical therapy of TAAAs mainly when a left heart bypass or a centrifugal pump is not available or should not be used.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4

Literatur

  1. Belcher PR, Muriithi EW, Milne EM et al (2000) Heparin, platelet aggregation, neutrophils, and cardiopulmonary bypass. Thromb Res 98:249–256

    Article  CAS  PubMed  Google Scholar 

  2. Cambria RP, Davison JK, Zannetti S et al (1997) Clinical experience with epidural cooling for spinal cord protection during thoracic and thoracoabdominal aneurysm repair. J Vasc Surg 25:234–241

    Article  CAS  PubMed  Google Scholar 

  3. Cambria RP, Davison JK, Giglia JS, Gertler JP (1998) Mesenteric shunting decreases visceral ischemia during thoracoabdominal aneurysm repair. J Vasc Surg 27:745–749

    Article  CAS  PubMed  Google Scholar 

  4. Cambria RP, Davison JK, Carter C et al (2000) Epidural cooling for spinal cord protection during thoracoabdominal aneurysm repair: a five-year experience. J Vasc Surg 31:1093–1102

    CAS  PubMed  Google Scholar 

  5. Comerota AJ, White JV (1995) Reducing morbidity of thoracoabdominal aneurysm repair by preliminary axillofemoral bypass. Am J Surg 170:218–222

    Article  CAS  PubMed  Google Scholar 

  6. Crawford ES, Crawford JL, Safi HJ et al (1986) Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients. J Vasc Surg 3:389–404

    Article  CAS  PubMed  Google Scholar 

  7. Davison JK, Cambria RP, Vierra DJ et al (1994) Epidural cooling for regional spinal cord hypothermia during thoracoabdominal aneurysm repair. J Vasc Surg 20:304–310

    CAS  PubMed  Google Scholar 

  8. Derrow AE, Seeger JM, Dame DA et al (2001) The outcome in the United States after thoracoabdominal aortic aneurysm repair, renal artery bypass, and mesenteric revascularization. J Vasc Surg 34:54–61

    Article  CAS  PubMed  Google Scholar 

  9. van Dongen EP, Schepens MA, Morshuis WJ et al (2001) Thoracic and thoracoabdominal aortic aneurysm repair: use of evoked potential monitoring in 118 patients. J Vasc Surg 34:1035–1040

    Article  Google Scholar 

  10. Engle J, Safi HJ, Miller CC 3rd et al (1999) The impact of diaphragm management on prolonged ventilator support after thoracoabdominal aortic repair. J Vasc Surg 29(1):150–156

    Article  CAS  PubMed  Google Scholar 

  11. Ennker J, Stegmann T, Gimbel C, Borst HG (1985) Surgery of abdominal aortic aneurysm – results in 502 patients. Langenbecks Arch Chir 366:313–316

    Article  CAS  PubMed  Google Scholar 

  12. Fiore WM, Ouriel K, Green R, Geary JE (1987) High-risk aortic aneurysm repair with partial cardiopulmonary bypass. J Vasc Surg 6:563–565

    Article  CAS  PubMed  Google Scholar 

  13. Frank SM, Parker SD, Rock P et al (1994) Moderate hypothermia, with partial bypass and segmental sequential repair for thoracoabdominal aortic aneurysm. J Vasc Surg 19:687–697

    CAS  PubMed  Google Scholar 

  14. Freye E, Grabitz K, Sandmann W (1996) Spinal cord ischemia – use of spinal-evoked potentials for intraoperative monitoring in thoraco-abdominal aortic aneurysms (TAA) repair. Acta Anaesthesiol Scand (Suppl) 109:50–53

    Google Scholar 

  15. Galt SW, Bech FR, McDaniel MD et al (1991) The effect of ibuprofen on cardiac performance during abdominal aortic cross-clamping. J Vasc Surg 13:876–883

    Article  CAS  PubMed  Google Scholar 

  16. Grabitz K, Freye E, Stühmeier K, Sandmann W (1993) Spinal evoked potential in patients undergoing thoracoabdominal aortic reconstruction: a prognostic indicator of postoperative motor deficit. J Clin Monit 9(3):186–190

    Article  CAS  PubMed  Google Scholar 

  17. Grabitz K, Sandmann W, Stühmeier K et al (1996) The risk of ischemic spinal cord injury in patients undergoing graft replacement for thoracoabdominal aortic aneurysms. J Vasc Surg 23:230–240

    Article  CAS  PubMed  Google Scholar 

  18. Hafez HM, Berwanger CS, McColl A et al (2000) Myocardial injury in major aortic surgery. J Vasc Surg 31:742–750

    Article  CAS  PubMed  Google Scholar 

  19. Jacobs MJ, Meylaerts SA, de Haan P et al (1999) Strategies to prevent neurologic deficit based on motor-evoked potentials in type I and II thoracoabdominal aortic aneurysm repair. J VascSurg 29:48–57

    Article  CAS  Google Scholar 

  20. Kaschner AG, Sandmann W, Larkamp H (1984) Percutaneus flexible bipolar epidural neuroelectrode for spinal cord stimulation. Technical note. J Neurosurg 60(6):1317–1319

    Article  CAS  PubMed  Google Scholar 

  21. Kawahito K, Mohara J, Misawa Y, Fuse K (1997) Platelet damage caused by the centrifugal pump: in vitro evaluation by measuring the release of alpha-granule packing proteins. Artif Organs 21:1105–1109

    Article  CAS  PubMed  Google Scholar 

  22. Keyhani K, Miller CC 3rd, Estrera AL et al (2009) Analysis of motor and somatosensory evoked potentials during thoracic and thoracoabdominal aortic aneurysm repair. J Vasc Surg 49(1):36–41

    Article  PubMed  Google Scholar 

  23. Laschinger JC, Owen J, Rosenbloom M et al (1988) Direct noninvasive monitoring of spinal cord motor function during thoracic aortic occlusion: use of motor evoked potentials. J Vasc Surg 7:161–171

    Article  CAS  PubMed  Google Scholar 

  24. McCullough JL, Hollier LH, Nugent M (1988) Paraplegia after thoracic aortic occlusion: influence of cerebrospinal fluid drainage. Experimental and early clinical results. J Vasc Surg 7:153–160

    Article  CAS  PubMed  Google Scholar 

  25. Ouriel K (2003) The use of an aortoiliac side-arm conduit to maintain distal perfusion during thoracoabdominal aortic aneurysm repair. J Vasc Surg 37:214–218

    Article  PubMed  Google Scholar 

  26. Picone AL, Green RM, Ricotta JR et al (1986) Spinal cord ischemia following operations on the abdominal aorta. J Vasc Surg 3:94–103

    Article  CAS  PubMed  Google Scholar 

  27. Safi HJ, Hess KR, Randel M et al (1996) Cerebrospinal fluid drainage and distal aortic perfusion: reducing neurologic complications in repair of thoracoabdominal aortic aneurysm types I and II. J Vasc Surg 23:223–228

    Article  CAS  PubMed  Google Scholar 

  28. Safi HJ, Miller CC III, Carr C et al (1998) Importance of intercostal artery reattachment during thoracoabdominal aortic aneurysm repair [comments]. J Vasc Surg 27:58–66

    Article  CAS  PubMed  Google Scholar 

  29. Safi HJ, Miller CC III, Subramaniam MH et al (1998) Thoracic and thoracoabdominal aortic aneurysm repair using cardiopulmonary bypass, profound hypothermia, and circulatory arrest via left side of the chest incision. J Vasc Surg 28:591–598

    Article  CAS  PubMed  Google Scholar 

  30. Sandmann W, Kremer K, Staszkiewicz V et al (1979) Neue Aspekte zur Prophylaxe und Therapie von Gefäßinfektionen. Angio 1(1):38–43

    Google Scholar 

  31. Shiiya N, Yasuda K, Matsui Y et al (1995) Spinal cord protection during thoracoabdominal aortic aneurysm repair: results of selective reconstruction of the critical segmental arteries guided by evoked spinal cord potential monitoring. J Vasc Surg 21:970–975

    Article  CAS  PubMed  Google Scholar 

  32. Svensson LG, Patel V, Robinson MF et al (1991) Influence of preservation or perfusion of intraoperatively identified spinal cord blood supply on spinal motor evoked potentials and paraplegia after aortic surgery. J Vasc Surg 13:355–365

    Article  CAS  PubMed  Google Scholar 

  33. Svensson LG, Crawford ES, Hess KR et al (1993) Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg 17:357–368

    Article  CAS  PubMed  Google Scholar 

  34. Wahba A, Rothe G, Lodes H et al (2001) The influence of the duration of cardiopulmonary bypass on coagulation, fibrinolysis and platelet function. Thorac Cardiovasc Surg 49:153–156

    Article  CAS  PubMed  Google Scholar 

Download references

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Author information

Authors and Affiliations

  1. Klinik für Gefäßchirurgie und Nierentransplantation, Heinrich-Heine-Universität Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland

    T.A. Sagban, K. Grabitz, K. Balzer, B.T. Weis-Müller, D. Grotemeyer & W. Sandmann

Authors
  1. T.A. Sagban
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. K. Grabitz
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. K. Balzer
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. B.T. Weis-Müller
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. D. Grotemeyer
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. W. Sandmann
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to T.A. Sagban.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Sagban, T., Grabitz, K., Balzer, K. et al. Techniken der shuntunterstützten Operation bei thorakoabdominellen Aortenaneurysmen. Gefässchirurgie 15, 48–53 (2010). https://doi.org/10.1007/s00772-009-0740-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00772-009-0740-y

Schlüsselwörter

Keywords

Search

Navigation