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The surgical repair of thoraco-abdominal aortic aneurysms (TAAAs): state of the art

The surgical repair of TAAAs has always been and still is the ultimate challenge of cardiothoracic and major vascular surgery. From the anatomical standpoint an aortic aneurysm can be identified as “thoraco-abdominal” if both the visceral segment and the thoracic aorta are involved in various degrees. According to Crawford’s classification, TAAAs can be divided into four different extents based on their extension along the aorta (Fig. 1). Despite the finest Medical Institutions around the world working hard to reduce morbidity and mortality associated with TAAA repair over the past 50 years, intraoperative and postoperative complications such as paraplegia, paraparesis, acute renal failure (ARF) and acute respiratory distress syndrome (ARDS) may still occur with significant incidence (0-40% for paraplegia and 5-20% for ARF). These complications are severe since the lesions are usually irreversible and might also significantly influence patient’s survival. During the last half century several methods of intraoperative protection of the visceral organs and spinal cord have been proposed and eventually used as common practice. Other methods regarding complications to either general cardio-thoracic surgery or major vascular surgery have also been proposed in order to reduce the incidence of adverse events such as respiratory and cardiac failure, postoperative bleeding and thromboembolic events. Nevertheless, the most severe complication of TAAA repair still remains postoperative paraplegia and this explains why most research around the world over the last five decades has been targeting this issue. During the early 1950s Michael DeBackey et al. tried to use cold water infusion through the intercostal arteries in the attempt to reduce spinal cord ischemia (spinoplegia). Subsequently Hollier et al. developed the CSF-drainage technique, eventually modified by Svensson et al. with the use of papaverin infusion into the CSF-catheter and by Acher et al. with Naloxone infusion. Dr. Stanley Crawford in Houston first proposed the “clamp and go” technique which was based only on the surgeon’s ability to “sew fast”, regardless of any hypothermic organ protection. More recently Cambria et al. have proposed “epidural cooling” which is a spinoplegia performed by cooling down the epidural space. Among all these methods, only the CSF-drainage has been proven effective in reducing...


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