Anesthetic Management of Open Thoraco-Abdominal Aortic Procedures

Abstract

Open surgical repairs of descending thoracic aortic aneurysms (DTAA) and thoraco-abdominal aortic aneurysms (TAAA) pose many challenges for the anesthesiologist. Preoperative planning must take into account the extent of the aneurysm, associated comorbidities, the patient’s blood coagulation status, possible deformation of the airway by the aneurysm, and any conditions that might interfere with vascular access or cerebrospinal fluid pressure (CSFP) monitoring. During the procedure, the anesthesiologist must monitor the electrocardiogram, CSFP, and central venous, intra-aortic, and pulmonary arterial pressure; transesophageal echocardiography and motor evoked potential (MEP) monitoring often are used, as well. If MEP monitoring is used, the anesthetic plan must be altered significantly to avoid suppressing the MEP signal. Often the left lung must be collapsed during the procedure to allow adequate exposure of the aneurysm. A rapid infuser is used to administer fluids and salvaged blood to maintain filling pressures and minimize red cell loss. Ischemia and blood pressure changes induced by aortic cross-clamping must be addressed by the use of left heart bypass, vasodilators, or both. Coagulation response to TAAA and DTAA is highly variable and must be carefully monitored and corrected when necessary.