1. 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

3. 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

4. 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

5. Use of left heart bypass
Control of afterload when clamping
Provide continuous splanchnic and spinal cord perfusion
L/min flow

6. 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

7. 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

8. 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

9. 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

10. Yearly Activity
From 2009 up to now 52 patients underwent to open surgical treatment for TAAA

12. 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%

13. 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%

14. Aortic-related Preoperative features2% 2% 2% 4%
23%
67%

15. Crawford Classification
13.5% 65.4% 9.6% 9.6% 1.9%

16. 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

17. 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

18. 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

19. 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

20. Thank you