Tissue Ischemia During Aortic Repair: The Point of View of the Perfusionist

  • De Simone FrancescoEmail author
  • Tshiombo Gianbattista
  • Colombo Elisa


Thoracoabdominal aortic surgery involves the cross-clamping of the descending thoracic aorta, which causes an abrupt reduction of the blood supply to both viscera and lower limbs. The reduction of blood flow induces the decrease of oxygen and substrates, which are essential for the Krebs cycle and the “respiratory chain.” It also lowers the clearance of cellular catabolites, increases the probability of bleeding disorders, and prompts the release of inflammation mediators and free radicals [1–4].


  1. 1.
    Kahn RA, Stone ME. Anesthetic consideration for descending thoracic aortic aneurysm repair. Semin Cardiothorac Vasc Anesth. 2007;11(3):205–23.PubMedCrossRefGoogle Scholar
  2. 2.
    Hessel EA. Techniques for descending thoracic aorta surgery. Semin Cardiothorac Vasc Anesth. 2001;5:293–320.CrossRefGoogle Scholar
  3. 3.
    Schepens M, Dossche K. Introduction of adjuncts and their influence on changing results in 402 consecutive thoracoabdominal aortic aneurysm repairs. Eur J Cardiothorac Surg. 2004;25(5):701–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Pantin EJ, Cheung AT. Thoracic aortic disease. In: Kaplan JA, Reich DL, Lake CL, et al., editors. Kaplan’s cardiac anesthesia. 5th ed. Philadelphia: Saunders Elsevier; 2006. p. 723–64.Google Scholar
  5. 5.
    Coselli JS, Lemaire SA. Descending and thoracoabdominal aortic aneurysms. In: Cohn LH, editor. Cardiac surgery in the adult. 3rd ed. New York: McGraw-Hill Medical; 2008. p. 1277–98.Google Scholar
  6. 6.
    Coselli JS. The use of left heart in the repair of thoracoabdominal aortic aneurysms: current techniques and results. Semin Thorac Cardiovasc Surg. 2003;15(4):326–32.PubMedCrossRefGoogle Scholar
  7. 7.
    Crawford ES, Walker HS. Graft replacement of aneurysm in descending thoracic aorta: results without bypass or shunting. Surgery. 1981;89(1):73–85.PubMedGoogle Scholar
  8. 8.
    Murray GF, Young WG Jr. Thoracic aneurysmectomy utilizing direct left ventriculofemoral shunt (TDMAC–heparin) bypass. Ann Thorac Surg. 1976;21(1):26–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Fayad A, Sawchuk C. Transesophageal echocardiography in the management of left atrio-femoral during thoracoabdominal aortic aneurysm repair: a case report. Can J Anaesth. 2002;49(10):1081–3.PubMedCrossRefGoogle Scholar
  10. 10.
    Suzuki S, Davis CA. Cardiac function predicts mortality following thoracoabdominal and descending thoracic aortic aneurysm repair. Eur. J Cardiothorac Surg. 2003;24(1):119–24.CrossRefGoogle Scholar
  11. 11.
    Fayad A, Yang H. Acute diastolic dysfunction in thoracoabdominal aortic aneurysm surgery. Can J Anaesth. 2006;53(2):168–73.PubMedCrossRefGoogle Scholar
  12. 12.
    Palombo D, Valenti D. Early experience with the minimal extracorporeal circulation system (MECC) during thoracoabdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg. 2004;27(3):324–6.PubMedGoogle Scholar
  13. 13.
    Moore EE, Burch JM. Repair of the torn descending thoracic aorta using the centrifugal pump for partial left heart. Ann Surg. 2004;240(1):38–43.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Edwards JT, Brown DM. A versatile extracorporeal circuit for use during repair of descending and thoracoabdominal aortic aneurysms in high-risk patients with cardiac and/or pulmonary dysfunction: a novel approach to a significant perfusion management dilemma. J Extra Corpor Technol. 2004;36(3):245–9.PubMedGoogle Scholar
  15. 15.
    Ziganshin B, Elefteriades JA. Deep hypothermic circulatory arrest. Ann Cardiothorac Surg. 2013;2(3):303–15.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Kouchoukos NT. TAAA repair using hypothermic cardiopulmonary bypass and circulatory arrest. Ann Cardiothorac Surg. 2012;1(3):409–11.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Leach WR, Sundt TM. Oxygenator support for partial left-heart. Ann Thorac Surg. 2001;72(5):1770–1.PubMedCrossRefGoogle Scholar
  18. 18.
    Downing SW, Cardarelli MG. Heparinless partial cardiopulmonary for the repair of aortic trauma. J Thorac Cardiovasc Surg. 2000;120(6):1104–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Tagarakis GI, Tsilimingas NB. Heparin-coated extracorporeal circulation systems in heart surgery. Recent Pat Cardiovasc Drug Discov. 2009;4(3):177–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Paparella D, Yau TM. Cardiopulmonary induced inflammation: pathophysiology and treatment. An update. Eur J Cardiothorac Surg. 2002;21(2):232–44.PubMedCrossRefGoogle Scholar
  21. 21.
    Greeley WJ, Ungerleider RM, Kern FH, Brusino FG, Smith LR, Reves JG. Effects of cardiopulmonary bypass on cerebral blood flow in neonates, infants, and children. Circulation. 1989;80:I209.PubMedGoogle Scholar
  22. 22.
    Govier AV, Reves JG, McKay RD, Karp RB, Zorn GL, Morawetz RB, et al. Factors and their influence on regional cerebral blood flow during nonpulsatile cardiopulmonary bypass. Ann Thorac Surg. 1984;38:592.PubMedCrossRefGoogle Scholar
  23. 23.
    Murkin JM, Farrar JK, Tweed WA, McKenzie KN, Cuirauden G. Cerebral autoregulation and flow/metabolic coupling during cardiopulmonary bypass: the influence of PaCO2. Anesth Analg. 1987;66:825.PubMedCrossRefGoogle Scholar
  24. 24.
    Prough DS, Stump DA, Roy RC, Gravlee GP, Williams T, Mills SA, et al. Response of cerebral blood flow to changes in carbon dioxide tension during hypothermic cardiopulmonary bypass. Anesthesiology. 1986;64:576.PubMedCrossRefGoogle Scholar
  25. 25.
    Ataka K, Okada M. Clinical study of optimal flow for temporary with centrifugal pump in surgical treatment of aneurysm of the descending thoracic aorta. Nippon Kyobu Geka Gakkai Zasshi. 1994;42(6):879–85.PubMedGoogle Scholar
  26. 26.
    Szwerc MF, Benckart DH. Recent clinical experience with left heart using a centrifugal pump for repair of traumatic aortic transection. Ann Surg. 1999;230(4):484–90.PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    Cimen B, et al. Pulmonary function tests, aerobic capacity, respiratory muscle strength and endurance of patients with rheumatoid arthritis. Clin Rheumatol. 2001;20:168–73.PubMedCrossRefGoogle Scholar
  28. 28.
    Jacobs MJ, Mommertz G. Surgical repair of thoracoabdominal aortic aneurysms. J Cardiovasc Surg. 2007;48(1):49–58.Google Scholar
  29. 29.
    Cimen OB, et al. Pulmonary function tests, respiratory muscle strength, and endurance of patients with osteoporosis. South Med J. 2003;96:423–6.PubMedCrossRefGoogle Scholar
  30. 30.
    Jacobs MJ, et al. Prevention of renal failure in patients undergoing thoracoabdominal aortic aneurysm repair. J Vasc Surg. 2004;40:1067–73. discussion 1073.PubMedCrossRefGoogle Scholar
  31. 31.
    Kouchoukos NT, et al. Hypothermic bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg. 1995;60:67–76. discussion 76–77.PubMedCrossRefGoogle Scholar
  32. 32.
    Fehrenbacher JW, et al. Optimal end-organ protection for thoracic and thoracoabdominal aortic aneurysm repair using deep hypothermic circulatory arrest. Ann Thorac Surg. 2007;83:1041–6.PubMedCrossRefGoogle Scholar
  33. 33.
    Koksoy C, et al. Renal perfusion during thoracoabdominal aortic operations: cold crystalloid is superior to normothermic blood. Ann Thorac Surg. 2002;73:730–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Huguet C, Nordlinger B, Bloch P, Conard J. Tolerance of the human liver to prolonged normothermic ischemia. Arch Surg. 1978;113:1448.PubMedCrossRefGoogle Scholar
  35. 35.
    Rittenhouse EA, Mohri H, Reichenbach DD, Merendino KA. Morphological alterations in vital organs after prolonged cardiac arrest at low body temperature. Ann Thorac Surg. 1972;13:564.PubMedCrossRefGoogle Scholar
  36. 36.
    Hassoun HT, Kozar RA, Kone BC, Safi HJ, Moore FA. Intraischemic hypothermia differentially modulates oxidative stress proteins during mesenteric ischemia/reperfusion. Surgery. 2002;132:369–76.PubMedCrossRefGoogle Scholar
  37. 37.
    Swaminathan M, Phillips-Bute BG. The association of lowest hematocrit during cardiopulmonary bypass with acute renal injury after coronary artery bypass surgery. Ann Thorac Surg. 2003;76(3):784–91.PubMedCrossRefGoogle Scholar
  38. 38.
    De Somer F, Van Belleghem Y. Phosphorylcoline coating offers natural platelet preservation during cardiopulmonary bypass. Perfusion. 2002;17(1):39–44.CrossRefGoogle Scholar
  39. 39.
    Harris EA, Seelye ER, Barratt-Boyes BG. Respiratory and metabolic acid-base changes during cardiopulmonary bypass in man. Br Anesth. 1970;42:912.CrossRefGoogle Scholar
  40. 40.
    Hanssen SJ, Derikx JP. Visceral injury and systemic inflammation in patients undergoing extracorporeal circulation during aortic surgery. Ann Surg. 2008;248(1):117–25.PubMedCrossRefGoogle Scholar
  41. 41.
    Kouchoukos NT, Masetti P, Rokkas CK, Murphy SF, Blackstone EH. Safety and efficacy of hypothermic ardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg. 2001;72:699.PubMedCrossRefGoogle Scholar
  42. 42.
    Brusino FG, Reves JG, Smith LR, Prough DS, Stump DA, McIntyre RW. The effect of age on cerebral blood flow during hypothermic cardiopulmonary bypass. J Thorac Cardiovasc Surg. 1989;97:541.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • De Simone Francesco
    • 1
    Email author
  • Tshiombo Gianbattista
    • 2
  • Colombo Elisa
    • 3
  1. 1.Department of Extracorporeal CirculationIRCCS San Raffaele Scientific InstituteMilanItaly
  2. 2.Fondazione CariploMilanItaly
  3. 3.Vascular Surgery UnitIRCCS San Raffaele Scientific InstituteMilanItaly

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