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20th BACTS Annual Meeting, Brussels 21st November 2015
A single-centre experience in open thoraco-abdominal aortic aneurysm repair Buonocore M, Van den Brande F, Matthys A, Ranschaert W, Verrelst P, Graulus E, Schepens M Hartheelkunde Dienst – AZ Sint Jan, Brugge
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OPEN SURGICAL TREATMENT OF TAAA: WHEN IS IT STILL INDICATED ?
Excellent results Extremely low reintervention rate Extremely durable No graft failures No anatomical limitations Immediate elimination of compression symptoms Reproducible results Lower costs Treatment failure in chronic postdissection aneurysms Effective in case of infection Definitive solution in case of aorto-enteric fistulas Only acceptable solution in connective tissue disorders
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The «TAAA Protocol» Preoperative preparation
- Before admission - Day -5 - Day -2 - Day -1 - Day of surgery Intra-operative management - Induction - Positioning - Transfusion - Left heart bypass - Hemodynamic goals - Coagulation - Renal protection - Spinal Cord protection - Temperature management Post-operative management in ICU - Temperature managment - Sedation and neurologic evaluation - Hemodynamics - Ventilation - Late onset paraplegia - Antibiotics - Nutrition - Mobilisation and respiratory Physiotherapy - Catheters management
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Use of left heart bypass
Control of afterload when clamping Provide continuous splanchnic and spinal cord perfusion L/min flow
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2. Heparin-free strategy
5000 IU Heparine in 3000 ml priming fluid in a 700 ml circuit (coated) Tranexamic acid 1 g IV after induction of anesthesia and repeated after LHB is discontinued Goal ACT ≤200 sec Liberal transfusion of FFP and ACT check every 30 minutes Transfusion management 2 cellsaver devices 14 units of pRBC are crossmatched, 4 available in the OR 16 units of FFP are available in the transfusion dpt 2x8 units of PLT are available in the transfusion dpt 2-4 vials of PPBS in case of massive blood (difficult control of ACT) 90µg/kg of Novoseven in case of profound coagulopathy
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3. Mild passive hypothermia
Passive body temperature allowed to drop up to 32.5°C, below that active rewarming by heat exchanger Rewarming to 34°C at the end of the procedure or 33°C + external rewarming in ICU
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4. Cerebrospinal Fluid (CSF) drainage
Spinal Cord Protection CSF drainage up to 72h post-op Corticoids before LHB Hypothermia LHB Intrathecal Papaverine Spinal Oximetry SCPP= MAPd – CSFP SCPP goal >70 mmHg MAPd > 80 mmHg CSFP = 10 mmHg
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5. Kidney protection (nefroplegia)
Kidney cooling solution: 500ml Ringer’s Acetate + 20 ml Mannitol 20% at 4°C 300 ml/kidney first dose, 100ml/kidney/min Repeat 200 ml/kidney every 20 minutes Indigocarmin LHB
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Yearly Activity From 2009 up to now 52 patients underwent to open surgical treatment for TAAA
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General Preoperative features
Gender (Male) 79% Age (Yrs) 53.81±14.52 (min 18; max 78) BSA (m2) 2.02±0.25 BMI (Kg/m2) 26.38±4.75 Obesity (BMI>30) 17% Hypertension 63% Diabetes 6% CAD 12% Previous CABG 8% COPD 25% Renal Insufficiency (GFR<60ml/h) 44% CVA 4% Spinal Injury 2%
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Aortic-related Preoperative features
Prior Arch Surgery 29% Prior AAA Surgery 10% Prior TAA Surgery 12% Prior TEVAR 14% Etiology Dissection Degenerative Inflammatory Other 69% 27% 2% Symptoms (pain,hoarsness,dysphagia) Ruptured Aneurysm 4%
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Aortic-related Preoperative features
2% 2% 2% 4% 23% 67%
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Crawford Classification
13.5% 65.4% 9.6% 9.6% 1.9%
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Intra-operative Results
Total Surgery Time (min) 396±127 Use of LHB 94% LHB Time (min) 155±45 Use of CSF drain 98% Amount CSF drainage (ml) 37±29 Inflow cannula Left common femoral artery Infra-renal aorta 85% 10% Outflow cannula Left inferior pulmonary vein Descending aorta 75% 19% LSA clamp 42% Nefroplegia 85% Intercostals Reimplanted (n°-median) 67% 2 pRBC (units) PLT FFP 16 11 CellSaver blood reinfused (ml) 2638±1138 Minimum temperature (°C) 33±0.9 Use of CPB + DHCA CPB time Minimum rectal T °C 4% 306±27 16±1
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Outcomes In-hospital Mortality -Intra-operative 3 (5.8%) 1 (1.9%)
ICU Length of stay (days) 12±13 (median 7 days) Blood drainage at I POD (ml) 717±432 Surgical Revision 6% CSF drainage at I POD (ml) 79±77 CSF drain-related complications 2% Need Mechanical Ventilation (hours) 36±73 (median 19 hrs) MOF Prosthetic Infection
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Complications Mechanical Ventilation (h) 36±73 (median 19) NIV support
39% Tracheotomy 6% Pneumonia 15% ARDS 12% Stroke 2% SCI Paraparesis Paraplegia 4% 6% Recurrent Nerve Palsy 8% Critical Illness Polyneuropathy AKI Injury (GFR↓50%) Failure (GFR ↓75%) Loss & EDRD 17% 13% 4% CVVH Creatinine at discharge (mg/dl) 1.08±0.76
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Conclusions Despite the increase of EVAR, open surgical treatmen still play a significant role for TAAA, expecially in patients with connective tissue disorders Open surgery for TAAA requires a highly-specialized team and a strict protocol for patient-selection, preoperative, intraoperative and post operative management to achieve the desirable results Mortality, as well as major complications, in experts’hands are acceptable and mostly related to pre-operative conditions Neurologic protection still deserves further research
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Thank you
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