Reparo aberto de aneurisma de aorta toracoabdominal: atualização da abordagem multimodal

Abstract

Open surgical repair of thoracoabdominal aortic aneurysms (TAAA) has evolved significantly over the last decades thanks to technical improvements, especially in the area of organ protection. However, despite adjunctive strategies, morbidity and mortality rates are still not negligible.In order to plan the best possible treatment modality for every patient, accurate imaging must be obtained and processed. The preferred imaging method is multidetector computed tomography (CT) scan. As well as defining diameters and extension of the pathology, analysis of vessels includes characteristics of calcification and thrombus, possible anatomic variations, and patency of vessels. At present, aortic diameter is the best criterion for predicting the risk of aortic rupture 1 and patients with TAAA can be considered for elective surgery if the aortic diameter exceeds 6.0 cm, or less in case of patients with chronic dissection or a connective tissue disorder.As the number of elderly people in the population has increased, so has the number of patients with TAAA associated with comorbidities. An adequate pre-operative assessment of cardiac, pulmonary, and renal function and an accurate knowledge of cerebral and spinal cord vascular anatomy are useful when evaluating operative risk and planning the best operative strategy.Pre-operative trans-thoracic echocardiography is a satisfactory noninvasive screening method that evaluates both valvular and biventricular function. Computed tomographic coronary angiography has emerged as a less-invasive method for assessing coronary artery disease and is routinely performed in patients with asymptomatic TAAA. In case of severe coronary artery disease, a coronary angiography is then performed and significant lesions are treated with percutaneous transluminal angioplasty prior to aneurysm repair, possibly avoiding the use of drug-eluting stents that would require prolonged double antiplatelet therapy. Surgical myocardial revascularization is limited to selected patients with severe high-risk coronary lesions that are not suitable for percutaneous transluminal angioplasty.Renal function is an established predictor of postoperative outcome. Based on eGFR assessment, chronic kidney disease has been shown to be a strong predictor of death after thoracic aneurysm repair for both open and endovascular procedures, even in patients without clinical evidence of preoperative renal disease. 2Evaluation of pulmonary function with arterial blood gases and spirometry is performed for all patients undergoing open TAAA repair.A CT brain scan and neuropsychological evaluation are performed in the elective setting. Anatomical anomalies or cerebral diseases that may contraindicate the use of Cerebrospinal fluid (CSF) drainage should be identified.Surgical strategy is preoperatively explained to any elective patient and informed consent is obtained.With regard to surgical strategy, the patient is positioned in a right lateral decubitus over a beanbag with the shoulders at 60° and the hips flexed back to 30° to acce...