aSection of Vascular Surgery, Department of Surgery bSection of Interventional Radiology, Department of Radiology cDepartment of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, USA.
Curr Opin Anaesthesiol. 2014 Feb;27(1):12-20. doi: 10.1097/ACO.0000000000000028.
Ruptured descending thoracic aortic aneurysm (rDTAA) is a life-threatening disease. In the last decade, thoracic endovascular aortic repair (TEVAR) has evolved as a viable option and is now considered the preferred treatment for rDTAAs. New opportunities as well as new challenges are faced by both the surgeon and the anesthesiologist. This review describes the impact of current developments and new modalities for the surgical and anesthetic management of rDTAAs.
A collaborative approach between the anesthesiologist and surgeon during critical moments such as induction, moment of aortic occlusion and placement of the aortic stent-graft is mandatory. Important issues to consider on preoperative imaging evaluation are correct sizing of the aortic stent-graft and localization of the artery of Adamkiewicz. Emergency TEVAR should preferentially be started under local anesthesia and could be switched to general anesthesia after stent placement. Patients should be kept in permissive hypotension preoperatively and during the intervention before stent-graft deployment and relative hypertension after deployment. The use of a proactive spinal cord protection protocol could decrease the risk of spinal cord ischemia and/or paraplegia and consists of permissive hypertension after stent deployment, cerebrospinal fluid drainage to maintain adequate spinal cord perfusion, relative hypothermia and possibly use of mannitol.
In order to improve outcomes of TEVAR for rDTAA, a close communication between the anesthesiologist and the surgeon and a thorough understanding of the events during the procedure is mandatory. The use of a proactive spinal cord protection protocol may decrease the rates of devastating spinal cord ischemia.
破裂性胸降主动脉瘤（rDTAA）是一种危及生命的疾病。在过去十年中，胸主动脉腔内修复术（TEVAR）已成为一种可行的选择，现在被认为是 rDTAAs 的首选治疗方法。外科医生和麻醉师都面临着新的机遇和新的挑战。这篇综述描述了当前发展和新方法对 rDTAA 的手术和麻醉管理的影响。
在诱导、主动脉闭塞和放置主动脉支架移植物等关键时刻，麻醉师和外科医生之间的协作方法是强制性的。术前影像学评估中需要考虑的重要问题是主动脉支架移植物的正确尺寸和 Adamkiewicz 动脉的定位。紧急 TEVAR 应优先在局部麻醉下进行，支架放置后可切换为全身麻醉。在支架放置前和放置过程中，患者应保持术前和术中允许性低血压，相对高血压。积极的脊髓保护方案的使用可以降低脊髓缺血和/或截瘫的风险，包括支架放置后允许性高血压、脑脊液引流以维持足够的脊髓灌注、相对低温和可能使用甘露醇。
为了提高 rDTAA 的 TEVAR 治疗效果，麻醉师和外科医生之间必须进行密切沟通，并充分了解手术过程中的事件。使用积极的脊髓保护方案可能会降低灾难性脊髓缺血的发生率。
