Kidney protection in thoracoabdominal aortic aneurysm surgery

Loschi, Diletta; Melloni, Andrea; Kahlberg, Andrea; Chiesa, Roberto; Melissano, Germano

doi:10.23736/s0021-9509.20.11745-2

Cited by 4 publications

(4 citation statements)

References 91 publications

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“…Renal failure is one of the most feared complications during and after TAAA OSR, and it is known to be associated with perioperative mortality. For this reason, renal protection strategies have a key role during TAAA OSR, and above all, include perfusion of the kidneys using cold crystalloid solutions [39]. Cold Lactated Ringers is the universally approved solution for kidney perfusion during renal ischemia; however, HTK solution, usually employed for cardioplegia during cardiac surgery, may also be considered a valid alternative for renal perfusion due to its well-known efficacy in preserving kidneys during organ transplantations [21].…”

Section: Discussionmentioning

confidence: 99%

Outcomes following Management of Complex Thoracoabdominal Aneurysm by an Open Approach

Chiesa

Rinaldi

Kahlberg

et al. 2023

JCM

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Background: In the last decade, advances in surgical techniques, and the introduction of adjuncts for organ protection, have modified the approach for thoracoabdominal aortic aneurysm (TAAA) surgical repair. The aim of this study is to determine whether the contemporary approach influenced the outcomes. Methods: From 1989 to 2022, patients who had received elective open surgical repair (OSR) for TAAA at our institution were retrospectively analyzed. This series has been divided in two groups: Group 1 (1989–2009), and Group 2 (2010–2022). Patients included in Group 1 were those treated with a selective use of adjuncts, and Group 2 included patients treated with the systematic use of adjuncts. Results: A total of 1107 patients were treated (Group 1: 455; Group 2: 652). The surgical management was significantly different between the two groups. The in-hospital mortality was significantly different between the two groups (Group 1: 13.4%, Group 2: 8.1%; p 0.004), as was the rate of permanent spinal cord ischemia (Group 1: 11.9%, Group 2: 7.8%; p 0.023). Renal and respiratory failure were reduced in Group 2, but not significantly. Conclusions: The use of the adjuncts enabled the achievement of improvement in mortality and SCI prevention in TAAA OSR. Although a refined surgical technique, mortality and morbidity are still noteworthy in this complex aortic field.

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Section: Discussionmentioning

confidence: 99%

Outcomes following Management of Complex Thoracoabdominal Aneurysm by an Open Approach

Chiesa

Rinaldi

Kahlberg

et al. 2023

JCM

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“…In this scenario, AKI prevention by reducing contrast volume administration with the use of advanced imaging techniques and meticulous preoperative planning may be important. 39…”

Section: Discussionmentioning

confidence: 99%

“…In this scenario, AKI prevention by reducing contrast volume administration with the use of advanced imaging techniques and meticulous preoperative planning may be important. 39 Study limitations include the retrospective design, which can generate disparities in data gathering and interpretation across different centers with possible reporting biases. Moreover, the different policies on CSFD across the 4 institutions reduce the study power to determine its impact on SCI incidence and outcomes.…”

Section: Discussionmentioning

confidence: 99%

Spinal Cord Ischemia After Thoracoabdominal Aortic Aneurysms Endovascular Repair: From the Italian Multicenter Fenestrated/Branched Endovascular Aneurysm Repair Registry

et al. 2022

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Purpose: The aim of this study is to report an Italian multicenter experience analyzing the incidence and the risk factors associated with spinal cord ischemia (SCI) in a large cohort of thoracoabdominal aortic aneurysms (TAAAs) treated by fenestrated-branched endovascular aneurysm repair (F-/B-EVAR). Materials and Methods: All consecutive patients undergoing F-/B-EVAR in 4 Italian university centers between 2008 and 2019 were prospectively recorded and retrospectively analyzed. Spinal cord ischemia, 30 day/in-hospital adverse events, and mortality were assessed as early outcomes. Risk factors for SCI were determined by multivariable analysis. Results: A total of 351 patients received F-/B-EVAR for a TAAA. Twenty-eight (8.0%) patients died within 30 postoperative days or during the hospitalization. Regarding SCI, 47 patients (13.4%) developed neurological symptoms related to spinal cord impaired perfusion. Among them, 17 (4.8%) had a major permanent impairment. The multivariable analysis identified that SCI was associated with Crawford extent I to III (odds ratio [OR]: 20.90, p=0.004, 95% confidence interval [CI]=2.69–162.57), and with endovascular procedures performed for ruptured TAAA (OR: 5.74, p=0.010, 95% CI=1.53–21.57). Spinal cord ischemia was also significantly associated with a grade 3 bleeding during the visceral stage (OR: 4.34, p=0.005, 95% CI=1.55–12.16) and a grade 2 renal insufficiency at 30 days (OR: 7.45, p=0.002, 95% CI=2.12–26.18). Conclusion: The present study indicates that SCI is still an open issue after extent I to III TAAA endovascular repair, while its incidence in extent IV TAAA and pararenal/juxtarenal aneurysms is rare. Thoracoabdominal aortic aneurysms extension, urgent TAAA repair for rupture, severe bleeding, and 30 day renal insufficiency have been identified as significant risk factors for SCI. In the presence of such factors, adjunctive strategies may be considered to reduce SCI rates, while in low-risk patients invasive or potentially-risky maneuvers might not be justified.

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“…Current experience suggests that cold crystalloid solutions are the best substrates in preventing ischemia-reperfusion injury. Renal perfusion using Custodiol ® (Dr. Franz-Kohler Chemie GmbH; Bensheim, Germany) 4 °C, even if currently considered off-label, represents an encouraging organ protection tool [ 51 ]. It is imperative to maintain an adequate intravascular volume and renal perfusion pressure throughout the operation.…”

Section: Renal Complicationsmentioning

confidence: 99%

Postoperative Intensive Care Management of Aortic Repair

Paulis

Arlotta

Calabrese

et al. 2022

JPM

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Vascular surgery patients have multiple comorbidities and are at high risk for perioperative complications. Aortic repair surgery has greatly evolved in recent years, with an increasing predominance of endovascular techniques (EVAR). The incidence of cardiac complications is significantly reduced with endovascular repair, but high-risk patients require postoperative ST-segment monitoring. Open aortic repair may portend a prohibitive risk of respiratory complications that could be a contraindication for surgery. This risk is greatly reduced in the case of an endovascular approach, and general anesthesia should be avoided whenever possible in the case of endovascular repair. Preoperative renal function and postoperative kidney injury are powerful determinants of short- and long-term outcome, so that preoperative risk stratification and secondary prevention are critical tasks. Intraoperative renal protection with selective renal and distal aortic perfusion is essential during open repair. EVAR has lower rates of postoperative renal failure compared to open repair, with approximately half the risk for acute kidney injury (AKI) and one-third of the risk of hemodialysis requirement. Spinal cord ischemia used to be the most distinctive and feared complication of aortic repair. The risk has significantly decreased since the beginning of aortic surgery, with advances in surgical technique and spinal protection protocols, and is lower with endovascular repair. Endovascular repair avoids extensive aortic dissection and aortic cross-clamping and is generally associated with reduced blood loss and less coagulopathy. The intensive care physician must be aware that aortic repair surgery has an impact on every organ system, and the importance of early recognition of organ failure cannot be overemphasized.

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Kidney protection in thoracoabdominal aortic aneurysm surgery

Cited by 4 publications

References 91 publications

Outcomes following Management of Complex Thoracoabdominal Aneurysm by an Open Approach

Outcomes following Management of Complex Thoracoabdominal Aneurysm by an Open Approach

Spinal Cord Ischemia After Thoracoabdominal Aortic Aneurysms Endovascular Repair: From the Italian Multicenter Fenestrated/Branched Endovascular Aneurysm Repair Registry

Postoperative Intensive Care Management of Aortic Repair

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