title: It is not just assisted circulation, hypothermic arrest, or clamp and sew.
abstract: We have surgically treated 771 patients for thoracic and thoracoabdominal aortic aneurysms since 1983. Our primary effort has been to develop experimentally validated strategies to reduce paraplegia, renal failure, and mortality in these high-risk patients. This approach has led to a spinal cord protection protocol that has reduced paraplegia risk by 80% (observed/expected ratio = 0.19) with the use of cerebral spinal fluid drainage, moderate hypothermia (31°C-33°C), endorphin receptor antagonist (naloxone), and thiopental burst suppression while optimizing mean arterial pressure (> 90 mm Hg) and cardiac index. The elective mortality rate is 2.80% (17% for acute patients), and with rapid renal cooling for renal protection, only 0.88% required permanent dialysis. These results were achieved without the use of assisted circulation. We have reattached intercostal arteries since 2005 using preoperative magnetic resonance angiographic localization, but it remains unclear whether intercostal reimplantation reduces paraplegia risk, as we had initially proposed. We strongly believe that a consistent anesthetic and postoperative care protocol uniformly built and applied around these principles greatly enhances our surgical outcomes. We also show that improved outcomes with assisted circulation and hypothermic arrest in treatment of thoracoabdominal aortic disease follow similar principles of spinal cord and end-organ protection.
authors.affiliation: Department of Surgery, University of Wisconsin, Madison, Wis., USA. acher.c@gmail.com
authors.forename: Charles
authors.initials: C
authors.lastname: Acher
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018686:Anesthetics, Intravenous / Q000008:administration & dosage; D017545:Aortic Aneurysm, Thoracic / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001243:Assisted Circulation; D002557:Cerebrospinal Fluid Shunts; D002648:Child; D003250:Constriction; D005260:Female; D006324:Heart Arrest, Induced; D006439:Hemodynamics; D006801:Humans; D007036:Hypothermia, Induced; D008297:Male; D008875:Middle Aged; D009270:Naloxone / Q000008:administration & dosage; D009292:Narcotic Antagonists / Q000008:administration & dosage; D010264:Paraplegia / Q000209:etiology / Q000517:prevention & control; D011182:Postoperative Care; D051437:Renal Insufficiency / Q000209:etiology / Q000517:prevention & control; D012092:Replantation; D018570:Risk Assessment; D012307:Risk Factors; D020760:Spinal Cord Ischemia / Q000209:etiology / Q000517:prevention & control; D013536:Suture Techniques; D013874:Thiopental / Q000008:administration & dosage; D013895:Thoracic Arteries / Q000601:surgery; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D014922:Wisconsin; D055815:Young Adult
chemical_list: D018686:Anesthetics, Intravenous; D009292:Narcotic Antagonists; D009270:Naloxone; D013874:Thiopental