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J Thorac Cardiovasc Surg 1999;118:481-482
© 1999 Mosby, Inc.

SURGERY FOR ACQUIRED CARDIOVASCULAR DISEASE

Commentary

Gerald M. Lawrie, MD, Houston, Texas


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 Introduction
 
In this series of 19 patients who underwent an emergency operation for thoracoabdominal aneurysm, 42.1% died, one third became paraplegic, and almost one half had acute renal failure. Clearly, surgery in this critically ill group of patients carries high risks. The role of various adjuncts to prevent these complications is difficult to evaluate in the experience reported because of the small numbers of patients, the heterogeneity of the extent of aneurysms, and the varying clinical presentations of the patients. As occurred in this experience, some patients, even with a true rupture that is contained, will be in hemodynamically stable condition for a while and can be treated with surgical adjuncts in a manner similar to patients having elective operations. However, in the case of hypotension or free rupture, consideration should be given to performance of the simplest, most rapid operation possible. Rapid control of the proximal aorta followed by expeditious restoration of visceral and lower limb blood flow from a short clamp time should be the priority in these patients. "Nonsurgical" problems such as hypothermia, metabolic acidosis, and coagulopathy can easily assume overwhelming importance in these patients, despite the technical success of the operation. Referral of theses patients before rupture of these aneurysms requires ongoing education of the medical community as to the benefits and relative safety of elective operations compared with operations after rupture has occurred. The patient with a ruptured thoracoabdominal aneurysm represents an extreme surgical challenge, and the authors are to be commended for their efforts to improve the care of these critically ill patients.





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