J Cardiovasc Surg
-
Unresolved for over half a century now since the beginning of aortic surgery spinal cord injury (SCI) remains the most devastating complication after extensive open and endovascular thoracoabdominal aortic aneurysm (TAA/A) repair. Over the past decade extensive research on spinal cord perfusion lead to a better understanding of previously unknown physiologic mechanisms involved in the suspension of the cord's arterial supply and the consecutive development of SCI underscoring the need for new concepts in treatment strategy and monitoring methods during and after TAA/A repair. Based on this knowledge, new treatment strategies in particular the staged-repair were developed. ⋯ Another approach to overcome the most critical initial period after segmental artery occlusion due to stent graft deployment in the descending or thoracoabdominal aorta is temporary aneurysm sac perfusion, which also has recently been clinically trialed. Furthermore, the new non-invasive real-time monitoring method to record spinal cord viability by means of near-infrared spectroscopy of the paraspinal collateral network by means of near-infrared spectroscopy has also been suggested and successfully introduced in a pilot series to a clinical setting. This review addresses problems, unsolved questions and future perspectives regarding these three new concepts.
-
Blunt thoracic aortic injury (BTAI) remains a common cause of death following blunt mechanisms of trauma. Among patients who survive to reach hospital care, significant advances in diagnosis and treatment afford previously unattainable survival. ⋯ These include the refinement of selection criteria, timing for treatment and the need for long-term follow-up data. In addition, the advent of the Aortic Trauma Foundation (ATF) represents an important development in collaborative research in this field.
-
Spinal cord ischemia remains the most impressive and colliding complication following open surgical and endovascular aortic procedures. Paraparesis and paraplegia are devastating, having a major invalidating impact on the patient's life. Also for the surgeon and the entire team this dramatic adverse event causes a significant concussion. ⋯ Now, in 21st century, problem of spinal cord ischemia still exists. By understanding the reasons of its development we shall be able to find more useful methods for prevention as well as for the treatment. The aim of this article was to search what is behind this dreadful complication, explaining different mechanisms which take part in its development during endovascular and open surgical treatment.
-
Review
A new ethical and medico-legal issue: vascular surgery and the postoperative cognitive dysfunction.
Patients undergoing major surgery are at risk for postoperative cognitive dysfunction (POCD). The consciousness of the POCD arises new ethical and medico-legal issues that should be identified, managed and, if possible, prevented. ⋯ Effective communication with the elderly patient is a prerequisite for clear and complete information, involving family members and caregivers when necessary. In every case, the identification of patients with pre-existing risk factors of POCD, shortening the period of time preceding the surgery and a proper technique of the procedure as well as physical and intellectual exercises, nutrition and medication play an important role in decreasing the incidence of neurocognitive deficits in the elderly.
-
Acute type B aortic dissection is a life threatening disease process, which remains a clinical dilemma despite advances in technology, surgical technique and postoperative management. The variability of presenting symptoms, lack of a consensus on indications for treatment and differing opinions about the optimal timing for repair have added to the management confusion. Medical management has been the standard of care for acute uncomplicated type B dissection. ⋯ Recent data suggest that early TEVAR lowers aortic-related events and improves long-term aortic specific survival by covering the entry tear, promoting false lumen thrombosis and inducing aortic wall remodeling. The paucity of supporting data has created controversy surrounding the optimal treatment strategy for acute type B dissection. Nonetheless, recent healthcare trends show a paradigm shift towards the utilization of early TEVAR in acute type B dissection.