Surgical repair of extensive thoracic aorta disease represents an interesting challenge, both surgical and anesthetic. We describe the surgical repair of an acute aortic dissection beginning in the aortic arch in relation with aortic coartation and a post coartation aneurism, and the aspects related to planning, management and perioperative care.
The clamshell incision is associated with respiratory complications, bleeding and post-operative severe pain. Interruption of spinal cord blood supply is one of the causes of spinal cord injury after thoracic aortic aneurism repair. Aortic arch surgery requiring circulatory arrest bears significant risk of brain injury.
Descending aorta cannulation and perfusion, preservation of its posterior wall, lumbar paravertebral NIRS and femoral arterial invasive pressure monitoring were used as spinal cord protective strategies. Cerebral antegrade perfusion, initially unilateral and then bilateral, with BIS and cerebral NIRS monitoring were the key components of the cerebral protection strategy.
A bilateral erector spinae plane block (BESPB) was performed to allow good pain control in the postoperative period, early extubation and rehabilitation. Intravenous antifibrinolytic, goal directed transfusion therapy and maintaining a coagulation friendly environment were the mainstays of the non-surgical hemostasis strategy.
The patient was successfully extubated in the operating room presenting no neurological deficits. The surgical drains were removed on the fifth day; on the following day it was necessary to surgically remove part of the left thoracic drain, under combined anesthesia with the ipsilateral ESPB catheter. The remaining postoperative period was uneventful and the patient was discharged home in the 10th postoperative day.
No subarachnoid catheter was placed (to drain cerebrospinal fluid to protect the spinal cord from ischemia), after discussing it in advance with the surgical team, given the risks associated with it and the protective strategy to be adopted: direct perfusion of the descending aorta, preservation of its posterior wall, lumbar paravertebral NIRS ant femoral arterial invasive pressure monitoring., in the intraoperative period, on table extubation and direct neurological monitoring, together with adequate systemic arterial pressures, in the immediate postoperative period. Good pain control with BESPB and on table extubation allowed for early rehabilitation
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