Transcript ANATHEManagement of Aortic Arch Surgery

ANAESTHETIC MANAGEMENT
OF AORTIC ARCH SURGERY
Aortic arch surgery



Still one of the risky and
complicated operations.
In spite of advanced
surgical techniques.
In spite of advance in
anaesthetic techniques.
The traditional two anastomosis reconstruction
(Figure 1)
Usually, the dilated arch is accompanied by an ascending (Figure 2) or descending
(Figure 3) aortic aneurysm, or a combination of all three areas (Figure 4).
INDICATION
Urgent indications
 Rupture of an atherosclerotic aneurysm.
 Rupture of false lumen of a type A aortic
dissection.
 Type A dissection with extensive intimal tears in
the arch.
 Mycotic aneurysms
INDICATION
Elective indications
 Arch aneurysms greater than 6cm .
 Saccular aneurysms with rapid enlargement
(1/cm/y) or presence of symptoms.
Preoperative evaluation:






Elderly >60 y.
Diabetic.
Atherosclerotic diseases.
Hypertension, ischemic heart diseases.
Have peripheral vascular disease.
Proper assessment of pulmonary function is
done.
Preoperative investigation




Routine laboratory investigation as blood
picture, Kidney, liver functions tests and
coagulation profile.
Chest X ray.
ECG.
Echocardiography: to assess LT. ventricular
function and exclude valvular diseases.
Diagnosis and evaluation of the AA
aneurysm



CT scan of the entire aorta.
MRI which is the preferred modality for
imaging.
Coronary angiograph. With visualization of the
brachiocephalic vessels especially in patients
with aneurysm of the ascending aorta in whom
Bentall; procedure may be required.
Its very important



Management of CAD should be done preoperative
either medically using antiischemic measures or even
coronary artery bypass surgery or angiogplasty is
considered.
Proper neurological examination should be done
preoperatively and a carotid and vertebral duplex
ultrasound is requested if there is a history of transient
ischemic attacks or strokes.
A history of a focal cerebral insult is not a
contraindication to surgery. CT scan in theses patients
is carried out.
Intraoperative management:


Anaesthesia for AA repair is no different from
that for conventional open heart surgery.
Selective ventilation of the right lung to help
substantial dissection and mobilization of the
descending thoracic aortic.
MONITORING





Basic haemodynamic monitoring is routinely
used.
Pulmonary artery catheterization.
Transoesophageal.
Cerebral oximetry confirm the adequacy of
cerebral perfusion and oxygenation.
Transcranial Dopper is so more sensitive in
detecting embolic events and confirming
cerebral blood flow.
Cannulation sites
Right axillary artery
Usually soft and rarely involved in
the generalized atherosclerotic
process.
Lower risk of turbulent flow.
Useful for selective antegrade
cerebral perfusion during arch
reconstruction.
prefer to use a size 22 or 24 Fr. angled cannula
Femoral vessels are still
commonly used for cannulation.
Perfusion


The routine perfusion protocol for intracardiac
operations is also utilized for repair of arch
aneurysm.
The axillary artery perfusion is begun and slowly
watching for retrograde dissection and adequacy
of flow.
Cooling and rewarming
COOLING
The perfusate temperature is lowered to 10C.
 REWARMING.
During rewarming, we never raise blood
temperature above 36C.
Oesophageal reaches 35C.
bladder temperature of 30C or 32C.

Myocardial protection
Cardioplegia of the coronary ostia are readily
accessible.
Retrograde perfusion, or 60mEq of potassium is
infused into the pump over 1 to 2 minutes just
prior to circulatory arrest.
 Total body hypothermia supplemented with
antegrade and retrograde blood cardioplegia and
topical cooling on the heart for myocardial
protection.

Spinal cord protection and
prevention of paraplegia
paraplegia is not common with AA surgery

More common with surgery involving the thoracic and
thoracoabdominal aorta.
measures to prevent paraplegia
total body hypothermia, cerebrospinal fluid drainage,
regional hypothermia and magnesium or
corticosteroids.
Somatosensory Evoked Potential (SSEP), Motor Evoked
Potentials (MEPs).
Monitoring is continued until the patient exits the
operation room.
Cerebral protection techniques
Hypothermic circulatory arrest (HCA)
HCA protects the brain by profound inhibition of
cerebral metabolism with lowering brain temperature.
HCA prolonged more than 25 minutes: postoperative
EEG changes are observed with neurological
dysfunction as confusion, agitation or transient
parkinsonism, memory deficits.
 High dose methylprednisolone given at 2 and 8 hours
before CPB.
Its important
Now selective hypothermic cerebral perfusion is
carried out by perfusion of the innominate and
left carotid arteries with blood between 6 and
12C (flow 250 to 350 ml/min) it shows good
outcomes.
 Retrograde cerebral perfusion is also used now
and it can reduce neurological insult.
it can worsen neurological outcome by inducing
cerebral edema, so it is not routinely used.

Some special techniques

Bentall procedure:
Ascending aortic aneurysm extending into the
underside of the aortic arch.
Bentall reconstruction, in done of the aortic root
with open resection of the hemi arch.
Perfusion is done via the right axillary artery.
Postoperative care


The patient is transferred to the intensive care unit
mechanically ventilated.
These patients require special attention for:






Coagulopathy.
Cardiac and cerebral complication.
End organ complications.
Patients should be carefully monitored.
All preoperative medication restored again especially
Beta-blockers.
regular imaging at 6-12 months intervals. Medical
therapy includes control of hypertension, B blocker are
continued.
Thank you..........
Dr. Eman Abou-Sief