Reduced renal failure following thoracoabdominal aortic aneurysm repair by selective perfusion1

Abstract

Objectives: Renal failure and visceral ischemia are feared complications following thoracoabdominal aortic aneurysm (TAAA) repair, significantly contributing to mortality. This prospective study describes volume-and pressure-controlled perfusion of the renal and visceral arteries during TAAA surgery. Methods: In 73 consecutive patients (mean age 59 years), TAAA repair (27 type I, 28 type II, 8 type III and 10 type IV) was performed, using retrograde and selective organ perfusion. Sixteen patients had impaired renal function with blood creatinine higher than 100 mmol/l. During the thoracic part of the procedure, the mean distal aortic pressure was kept above 60 mm Hg by means of left-heart bypass. After opening the abdominal aorta, the renal and visceral arteries were individually perfused by means of perfusion catheters (9 French) in the first 33 patients (group I). Volume flow through each catheter was assessed with ultrasound flow meters and maintained at least at 60 ml/min. In addition to volume flow measurements, catheters with pressure sensors were used in the last 40 patients (group II), allowing pressure-controlled selective perfusion. The extent of the aneurysm was comparable in both groups. Results: Mean cross-clamp time for the thoracic part was 46 min, including proximal anastomosis and reattachment of intercostal arteries. Mean cross-clamp time for the abdominal part was 74 min, including re-implantation of intestinal and renal arteries and selective dacron grafts to the celiac-axis arteries (n = 5), superior mesenteric arteries (n = 8) and renal arteries (n = 25), through which the catheters guaranteed continuous perfusion during the time the anastomosis was performed. Urine output was uninterrupted in all patients, irrespective of cross-clamp time. In group I, one patient (3%) developed renal failure and three patients (9%) required temporary peritoneal dialysis. In group II, no patients developed renal failure and two patients (5%) required temporary peritoneal dialysis. Thirteen patients with preexisting renal impairment did not deteriorate. No patients developed visceral ischemia or multiple-organ failure. Total in-hospital mortality was 6/73 (8%) and was related to cardiopulmonary complications. Conclusions: Renal and visceral ischemia can be reduced significantly by continuous perfusion during cross-clamping in TAAA repair. Not only sufficient volume flow but also adequate arterial pressure appears to be essential in maintaining renal function.

Assessment of hepatosplanchnic pathophysiology during thoracoabdominal aortic aneurysm repair using visceral perfusion and shunt☆

“…Currently Coselli's group perfuses the celiac and superior mesenteric arteries at 200-300 ml/min under mild hypothermia [16], which seems similar to ours. Jacobs and co-workers advocated the pressure-controlled perfusion for better outcome in visceral function [17]. They perfuse visceral branches at a flow of 60-210 ml/min per branch and the renal arteries at 200-280 ml/min, which also seems not far different from our protocol.…”

“…They perfuse visceral branches at a flow of 60-210 ml/min per branch and the renal arteries at 200-280 ml/min, which also seems not far different from our protocol. On the other hand, it was pointed out that too much flow through a small diameter catheter might lead to jeopardized rheological properties of the blood [12,17]. We reported that our original heparincoated 10 mm tube circuit with four 6 mm side-arm branches could provide a free flow of 230 ml/min at 60 mmHg and 335 ml/min at 100 mmHg through a 12 F balloon [8].…”

Pathophysiology of Aortic Cross-clamping

“…Optimizing circulating blood volume may decrease the risk of renal complications by inhibiting the formation of renal vasoconstrictive compounds [1]. Other methods that may be used to protect renal function during aortic cross-clamping include distal aortic perfusion and selective pressure-controlled and flow-volume-controlled renal perfusion [17]. Other, more controversial techniques include administering intravenous mannitol, furosemide, dopamine, fenoldopam, and ACE inhibitors.…”

Thoracoabdominal aortic aneurysm: Diagnosis and management

“…Adjunctive end-organ protective measures, if used during the repair of a TAAA, markedly decrease the likelihood of renal, mesenteric, and spinal ischemia, with resultant decrease in the risk of visceral injury, paraplegia, and paraparesis. These adjunctive measures include distal aortic perfusion via left heart bypass, profound hypothermic cardiopulmonary bypass, selective perfusion of renal and visceral arteries, reimplantation of vessels between intercostals and lumbar arteries, cerebrospinal fluid drainage, and instillation of intrathecal papaverine for high-risk patients [15][16][17][18]. Among all TAAAs, Crawford type II aneurysms have of the highest surgical morbidity and mortality rates.…”