Hemodynamics and prostacyclin release in the early phases of aortic surgery: Comparison of transabdominal and retroperitoneal approaches

Abstract

Although the retroperitoneal aortic approach (RP) is advocated to reduce myocardial ischemia and cardiac-related death, inadequate physiologic data exist to support this contention. As the aorta is exposed via the transabdominal approach (TA) we noted some patients have manifested reduced systemic vascular resistance (SVR) associated with tachycardia, reduced blood pressure, and facial flushing. To determine whether RP offered physiologic advantages over TA we compared cardiac dynamics and blood levels of 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha), the stable metabolite of prostacyclin, during exposure of the aorta in 52 patients (33 with TA and 19 with RP), comparable in age, cardiac history, medications, and body surface area. Serial measurements of mean arterial pressure, heart rate, wedge pressure, pulmonary artery pressure, cardiac index, and 6-keto-PGF1 alpha were obtained. Results revealed decreased mean arterial pressure and systemic vascular resistance, increased cardiac index and heart rate, and facial flush occurring 10 minutes after the bowel was explored in TA. This was not observed in RP. These hemodynamic alterations correlated in time and magnitude with a fourteen fold increase in 6-keto-PGF1 alpha. These changes in cardiac indexes can produce increased myocardial oxygen consumption with the risk for myocardial ischemia, particularly in patients with coronary artery disease. The absence of this response to bowel exploration in RP may account for some of the observed advantages in "high-risk" aortic reconstruction.

Cardiac response and complications during endovascular repair of abdominal aortic aneurysms: A concurrent comparison with open surgery

“…This stress is the combined result of anesthetic induction, aortic clamping and declamping, blood loss that is inherent to open aortic surgery, and the associated hemodynamic and metabolic consequences. 10,11 In contrast, endovascular repair is believed not to produce such profound hemodynamic alterations. Therefore, EAR may be expected to impose less stress on the myocardium and to cause fewer cardiac complications.…”

“…6,7,9 Adverse cardiac events have been attributed to excessive stress on the myocardium caused by the combined effect of anesthetic induction, aortic clamping and declamping, operative blood loss, and associated hemodynamic and metabolic changes. 10,11 It is likely that hemodynamic alterations associated with endovascular aneurysm repair (EAR) are less severe. If this assumption is true, myocardial stress will be reduced, and the risk of cardiac complications will be minimized.…”

Interleukin-6 production is reduced by the extraperitoneal approach in elective abdominal aortic aneurysm repair

“…This is because the mucosa at the tip of villi is particularly prone to ischaemia due to the counter-current . In patients undergoing AAA repair, intestinal perfusion may be reduced by many factors including traction on the mesentery and eventration of the small bowel into a plastic bag which are often utilised when a transperitoneal approach to the aorta is used [5,11,17,18]. These manoeuvres can produce systemic effects due to release of prostaglandins which are potent vasoactive agents [18].…”

“…These manoeuvres can produce systemic effects due to release of prostaglandins which are potent vasoactive agents [18]. The effects are typified by hypotension, tachycardia and cutaneous flushing and the constellation has been termed 'blush' syndrome [11]. The contribution of mesenteric traction to the development of these systemic effects has been documented by Seeling et al [17], who observed that the most pronounced changes occurred after evisceration of the small intestine and not after clamping or unclamping of the aorta.…”

Die Abhängigkeit des Operationstraumas bei Aorteneingriffen von dem gewählten Zugang Eine prospektive Studie

“…Die Eventrierung des Darms führt zur Freisetzung von Serotonin und Arachidonsäure-Metaboliten, was eine systemische vor allem vasodepressive Reaktion zur Folge hat [7,10,11,18]. Daû eine weniger ausgedehnte Incision des Peritoneums Vorteile hat, konnte im Bereich der minimal-invasiven Visceralchirurgie klinisch und experimentell gezeigt werden.…”