title: Surgical and anesthetic considerations for the endovascular treatment of ruptured descending thoracic aortic aneurysms.
abstract: OBJECTIVE
  Ruptured descending thoracic aortic aneurysm (rDTAA) is a life-threatening disease. In the last decade, thoracic endovascular aortic repair (TEVAR) has evolved as a viable option and is now considered the preferred treatment for rDTAAs. New opportunities as well as new challenges are faced by both the surgeon and the anesthesiologist. This review describes the impact of current developments and new modalities for the surgical and anesthetic management of rDTAAs.
  
  
  RESULTS
  A collaborative approach between the anesthesiologist and surgeon during critical moments such as induction, moment of aortic occlusion and placement of the aortic stent-graft is mandatory. Important issues to consider on preoperative imaging evaluation are correct sizing of the aortic stent-graft and localization of the artery of Adamkiewicz. Emergency TEVAR should preferentially be started under local anesthesia and could be switched to general anesthesia after stent placement. Patients should be kept in permissive hypotension preoperatively and during the intervention before stent-graft deployment and relative hypertension after deployment. The use of a proactive spinal cord protection protocol could decrease the risk of spinal cord ischemia and/or paraplegia and consists of permissive hypertension after stent deployment, cerebrospinal fluid drainage to maintain adequate spinal cord perfusion, relative hypothermia and possibly use of mannitol.
  
  
  CONCLUSIONS
  In order to improve outcomes of TEVAR for rDTAA, a close communication between the anesthesiologist and the surgeon and a thorough understanding of the events during the procedure is mandatory. The use of a proactive spinal cord protection protocol may decrease the rates of devastating spinal cord ischemia.
authors.affiliation: aSection of Vascular Surgery, Department of Surgery bSection of Interventional Radiology, Department of Radiology cDepartment of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, USA.
authors.forename: Wouter
authors.initials: W
authors.lastname: Hogendoorn
authors.forename: Felix J V
authors.initials: FJ
authors.lastname: Schlösser
authors.forename: Bart E
authors.initials: BE
authors.lastname: Muhs
authors.forename: Wanda M
authors.initials: WM
authors.lastname: Popescu
mesh_terms: D000758:Anesthesia; D000777:Anesthetics; D017542:Aneurysm, Ruptured / Q000601:surgery; D001013:Aorta, Thoracic / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000601:surgery*; D003693:Delirium / Q000517:prevention & control; D057510:Endovascular Procedures / Q000379:methods*; D006801:Humans; D016343:Monitoring, Intraoperative; D011182:Postoperative Care; D011183:Postoperative Complications / Q000523:psychology / Q000628:therapy; D011300:Preoperative Care; D015607:Stents
chemical_list: D000777:Anesthetics