The Annals of thoracic surgery
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During simple cross-clamp repair of the descending thoracic or thoracoabdominal aorta, the likelihood of neurologic complications increases greatly after only 30 minutes of spinal cord ischemia. At greatest risk are patients with type II thoracoabdominal aortic aneurysms. ⋯ With the surgical adjuncts of cerebrospinal fluid drainage and distal aortic perfusion, the probability of neurologic deficit is lowered appreciably.
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To determine the factors that influence hospital death and neurologic complications after surgery on the thoracic aorta using circulatory arrest and antegrade selective cerebral perfusion. ⋯ Hospital mortality is affected significantly by the choice of technique used for antegrade cerebral perfusion. The incidence of both temporary and permanent postoperative central neurologic damage is influenced by preoperative hemodynamic instability. Duration of cerebral perfusion had no influence on the postoperative neurologic outcome.
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With increasing clinical experience, it has become clear that two distinct forms of neurological injury occur after operations on the thoracic aorta that require temporary exclusion of the cerebral circulation. Traditionally, evaluation of neurological outcome was limited to reporting the incidence of postoperative stroke related to ischemic infarcts due to particulate embolization. More recently, the symptom complex defined as "temporary neurological dysfunction" (TND) was recognized as a functional manifestation of subtle and presumably transient brain injury, but whether this early postoperative syndrome is associated with long-term deficits of cognitive and intellectual functions has not been established. ⋯ The incidence and severity of clinically apparent temporary neurological dysfunction correlates significantly with poor performance on neuropsychological tests 1 week postoperatively. Such poor performance predicts continued deficits in memory and motor function at 6 weeks. Thus, TND may not be a benign self-limited condition as previously supposed, but rather a clinical marker for insidious but significant neurological injury associated with measurable long-term deficits in cerebral function. A concerted effort to reduce the incidence of this complication is therefore necessary.
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The establishment of hemostasis without the excessive transfusion of homologous blood and blood products is critical to successful aortic surgery. ⋯ The strategy described is safe: our overall survival rate for 204 patients has been 98%, with a 1% incidence of stroke.