Introduction
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.
Methods
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.
Results
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.
Discussion
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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Copyright
© 2021 Published by Elsevier Inc.
