Part IX: Vascular Surgery: Renal and Spinal Cord Protection

2204 Part IX: Vascular Surgery centers.
ery centers. Nonoperative therapy may be se- be broadly divided into those that preserve
lected initially in very elderly patients, those spinal cord blood flow such as cerebrospi-nal
with modest-size aneurysms (see above), and fluid drainage (CSFD), distal aortic per-
assessment of perioperative risk and long- those for whom associated comorbid fusion, and intercostal reconstruction, and,
term preservation of renal function. With the conditions make the short-term risk of sur- second, neuroprotective adjuncts that in
exception of Type I TAAA, which fre-quently gery prohibitive and/or life expectancy lim- clinical practice largely involve variations on
will terminate just proximal to the renal ited to a degree that surgical treatment is not the theme of hypothermia. There exists a firm
artery level, types II, III, and IV thora- rational. Patients selected for nonopera-tive literature base supportive of CSFD for spinal
coabdominal aneurysm designation im-plies therapy should be treated aggressively with cord protection; the same cannot be said of
aneurysmal degeneration of the entire beta-blockade, hypertension control, and the multiple other adjuncts cur-rently in use.
visceral aortic segment. Some patients with cessation of cigarette smoking. Major clinical We previously described and applied a
renal insufficiency will have the potential for series emphasize a significant inci-dence of technique of regional cord hypo-thermia and
retrieval or salvage of renal function with prior aortic resections (1/3 of pa-tients in our demonstrated that it produced
renal artery reconstruction. We believe series); the most common pat-tern is the a significant reduction in SCI. Nonetheless,
extreme levels of preoperative azotemia patient who has undergone a prior infrarenal SCI could not be reduced beyond a finite
(serum creatinine greater than 2.5 cm/dL) AAA repair (60% of total prior resections). approximate 8% level. These data coupled
constitute a relative contraindication to While synchronous proxi-mal aneurysm is with the development of the collateral net-
elective operation unless preoperative stud- noted in 6% to 13% of de-generative TAAA work concept referable to spinal cord blood
ies indicate some potential for salvage or patients, contiguous arch aneurysm is rare, flow, led to a transition in our operative ap-
retrieval of renal function with renal artery typically occurring only in patients with a proach wherein epidural cooling yielded to
reconstruction. prior DeBakey Type I aortic dissection, distal aortic perfusion with motor-evoked
which requires complex, staged repairs. Dr. potential (MEVOP) monitoring (coupled
CARDIAC AND PULMONARY Crawford’s emphasis on an expe-ditious with CSFD) as the principal cord protective
operation, minimizing cross-clamp time, strategy. Elegant magnetic resonance imag-
RISK STRATIFICATION heparin use, and blood turnover are ing studies of spinal cord circulation com-
Irrespective of the firm literature base against principles we continue to apply with certain bined with intraoperative MEVOP data re-
routine preoperative cardiac test-ing, all modifications. ported by Jacobs et al. indicated that (a)
patients should be evaluated with physiologic individual intercostal vessels were typically
testing to assess perioperative myocardial not “critical” for cord preservation and (b)
ischemic potential. In addition, patients with PROTECTIVE ADJUNCTS most collaterals that support the cord orig-
a history or symptoms sug-gestive of heart AND MOTOR-EVOKED inated distal to the distal clamp (i.e., the
failure should have an as-sessment of left POTENTIAL MONITORING pelvis), and preservation of continuous per-
ventricular function. While patients with fusion thereof accordingly was logical. Fi-
significant impairments of pulmonary reserve Renal and Spinal cord Protection nally, this approach allows for selective
can usually be detected on a historical basis (based on intraoperative MEVOP) rather than
alone, we routinely obtain preoperative Outcomes in TAAA repair are closely corre- routine intercostal reconstruction. MEVOP
pulmonary function studies. Preoperative lated with renal and spinal cord complica- monitoring does mandate a depar-ture from
consultation with a pulmonologist for tions; accordingly, operative adjuncts to anesthetic techniques typically used in North
optimization of bron-chodilator therapy and minimize these complications have been America, and the technical requirements of
pulmonary toilet is an important component principal drivers of the technical conduct of such monitoring can only be satisfied by a
in the manage-ment of patients with the operation. Consistent with a firm litera- dedicated team specialized in
significant COPD. However, institution of ture base supporting regional hypothermic neurophysiology. Online intraoperative
preoperative steroid therapy with the intent of protection of the kidneys, our approach in- consultation is often required to interpret
improving respi-ratory function is volves direct installation of renal preserva- potential deterioration of potentials.
contraindicated since we have observed this tion fluid (Lactated Ringers with 25 g of
maneuver to precipitate aneurysm rupture. mannitol/L and 1 g/L methyl prednisolone at
Advanced age is an im-portant component 4°C) into the renal artery ostia after the aorta TECHNICAL FACETS
only in as much as it is accompanied by is opened. Initially, 250 mL of this solu-tion
is instilled into each renal artery ostium and a
OF RECONSTRUCTION
overall fragility and im-paired functional
continuous drip of the same begun through
status.
size 6 French perfusion balloon-tipped
Operative Exposure
catheters. Experience has shown that such an Irrespective of individual preferences about
infusion will result in a rapid decline of renal the various technical components of the op-
SURGICAL TREATMENT parenchymal temperature to 15°C after the eration, the absolute requirement for a suc-
General Principles of Operation bolus infusion. During the continu-ous cessful technical operation is the provision of
infusion, renal core temperatures re-main in broad continuous exposure of the entire left
Graft replacement by a direct surgical ap- the 25°C level as monitored by direct posterolateral aspect of the aorta. Particu-
proach is the current standard treatment for temperature probes in the renal cortex. larly in extensive Type II aneurysm, maneu-
TAAA. Total endovascular repair has been The general topic of adjuncts for spinal vers that tend to improve proximal exposure
plagued by device and regulatory constraints cord protection is beyond the scope of this can compromise distal exposure and vice
and is not generally available; hybrid opera- chapter and the reader is referred to collec- versa. The location and extent of the thoracic
tion has perhaps increased the pool of sur- tive reviews on the topic. Such adjuncts can portion of the incision is dictated by the
geons treating TAAA, but the reported re-
sults, including our own, compare poorly
with conventional operation in competent

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2204 Part IX: Vascular Surgery centers.

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