Physiopathology of Intraoperative Visceral Ischemia and Anesthesiological Management of Supravisceral Aortic Clamping

  • Fabrizio MonacoEmail author
  • Barucco Gaia
  • Mattioli Cristina
  • De Luca Monica


Vascular surgery, in which a supraceliac aortic clamp is required, is at highest risk of visceral ischemia and postoperative complications. The interruption of the blood flow to the organs, secondary to the artic cross-clamp, triggers cellular and molecular alterations with local and systemic effects. In particular, the tissues distal to the clamp become ischemic with a shift from aerobic to anaerobic metabolism. Since the reperfusion, following aortic clamp removal, may further increase the organ damage of the ischemic tissues, an ischemia/reperfusion (I/R) injury is usually observed during aortic surgery. The I/R injury is responsible for an extensive systemic inflammatory response which may trigger postoperative multi-organ failure. Polymorphonuclear neutrophils, oxygen radicals, nitric oxide, complement system, and cytokines are mainly involved in this double pathophysiological phenomenon.

In light of this, any technique, strategy, or drug able to mitigate the I/R injury may significantly affect the outcome. Although several perioperative medications have been proposed, the results remain elusive. On the contrary, left heart bypass, CFS drainage, and avoidance of nephrotoxic drugs, together with a maintenance of a mean arterial pressure above 80 mmHg, have shown to be the only measures effective in reducing perioperative morbidity and mortality.

Supplementary material

Video 14.1

Midesophageal four-chamber view. Severe right ventricle dysfunction (WMV 1325 kb)

Video 14.2

Midpapillary transgastric view. Severe right ventricle dysfunction with left ventricle D-shape (WMV 1568 kb)

Video 14.3

Midpapillary transgastric view. Severe left ventricle dilation and systolic dysfunction (AVI 1916 kb)

Video 14.4

Mid-transgastric short-axis view. Empty left ventricle with papillary muscles “kissing” (AVI 14042 kb)


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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Fabrizio Monaco
    • 1
    Email author
  • Barucco Gaia
    • 1
  • Mattioli Cristina
    • 1
  • De Luca Monica
    • 1
  1. 1.Department of Cardiothoracic and Vascular Anesthesia and Intensive CareIRCCS San Raffaele Scientific InstituteMilanItaly

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