Endovascular repair of a descending thoracic aortic aneurysm: a tip for systemic pressure reduction

Partial Right Atrial Inflow Occlusion for Transient Systemic Hypotension During Deployment of Thoracic Stentgrafts

Purpose

Temporary balloon occlusion of the inferior vena cava to lower cardiac output is a relatively infrequently used technique to induce controlled systemic hypotension. In this technical note, we describe the feasibility, reliability, and safety of partial occlusion of right atrial inflow and the effect on systemic blood pressure during the deployment of a thoracic stentgraft.

Materials and Methods

Twenty consecutive patients undergoing thoracic endovascular aortic repair, with proximal landing in zone 0–3 of the thoracic aorta, were prospectively included. Right atrial inflow occlusion was performed with a compliant occlusion balloon.

Results

Median time to reach a mean arterial pressure of 50 mmHg was 43 s. Median recovery time of blood pressure was 42 s.

Conclusion

Partial right atrial inflow occlusion with an occlusion balloon is feasible with reliable results and without procedure-related complications.

Endovascular approaches and perioperative considerations in acute aortic dissection

Aortic dissections remain complicated management issues both in the acute setting and in the chronic setting. Acute problems revolve around malperfusion syndromes or rupture, whereas chronic issues progress from the development of aneurysms in the residual dissected aorta. Endovascular approaches to dealing with these difficult situations are being used more frequently to treat acute issues in type B dissections and prevent secondary complications in type A dissections that may require significant intervention in the future. This article discusses the endovascular approaches employed in the care of acute dissections with particular attention toward the anesthetic considerations involved in these challenging cases.

Placement of aortic endoprostheses

Endovascular stent-grafting has found its place in the elective treatment of 60% of abdominal or thoracic aortic lesions. The morbidity and mortality rates are clearly lower than those of classical repair but the results are suboptimal with 9% residual endoleaks at 6 months. Anesthetic management with extensive monitoring even under local anesthesia remains mandatory and tends to reduce the postoperative care requirements. Future development will allow emergent endovascular treatment of ruptured aorta and further improvement will decrease the rate of late endoleaks.

Partial inflow occlusion facilitates accurate deployment of thoracic aortic endografts

PURPOSE

To present a maneuver consisting of temporary blockage of the venous return to the heart for accurate deployment of thoracic aortic endoprostheses.

TECHNIQUE

During endovascular repairs in the thoracic aorta, an occluding balloon was introduced through the femoral vein into the right atrium under transesophageal echocardiographic control. The venous return through the inferior vena cava was temporarily blocked to reduce aortic flow during device deployment. The technique was applied in 21 patients with various lesions of the thoracic aorta. Partial inflow occlusion resulted in a mean systolic pressure of 49+/-6 mmHg and lasted for 52+/-14 seconds. Cardiac function was comparable to the preocclusion state, and no arrhythmias or ischemic events were encountered. In 7 procedures, inotropic or vasoconstrictor support was necessary after deployment. No complications related to the venous system were observed. The endoprostheses were precisely deployed at the target site in all patients.

CONCLUSIONS

The force of aortic flow often impairs precise deployment of thoracic endoprostheses, resulting in distal displacement. Partial inflow occlusion provides precise control over the extent and duration of the hypotensive period, allowing accurate deployment of thoracic endoprostheses.

Open surgical repair for a perigraft leak after endovascular stent-graft emplacement of descending thoracic aneurysm

Although transluminal stent-graft implantation is less invasive for treating an aneurysm in the thoracic descending aorta, this technique is not always successful. Here, we report two cases of a perigraft leak identified after stent-graft deployment, and complete occlusion of the leak could not be attained by additional stent-graft deployment. Open surgical repair using a stented graft was performed through a median sternotomy without opening the left pleura. This procedure should be considered as one of the less-invasive techniques for treating a perigraft leak after endovascular stent-graft emplacement.