Repair of Thoracic Aneurysms, with Special Emphasis on the Preoperative Work-Up

Abstract

The anesthetic approach to the patient with a thoracic aortic aneurysm depends on the urgency of repair. Symptomatic patients with leaking aneurysms require urgent intervention, and there is generally little time to perform more than the most basic preoperative assessment. For elective repair, however, one must consider nearly every organ system. Many of the specific issues are inherent to the underlying pathophysiology that has resulted in aneurysm formation, and some stem from the requirements of the surgical procedure itself. A thorough knowledge of the extent and location of the aneurysm, the functional status of the heart, and the coronary artery anatomy are critical. Most patients aged older than 40 years undergo coronary angiography preoperatively, as do younger patients with specific risk factors for myocardial ischemia. Respiratory failure is one of the most common sequelae of these procedures, and a thorough preoperative pulmonary work-up is mandatory. Neurologic deficits are not uncommon postoperatively, and pre-existing deficits in the central nervous system must be sought. Coagulopathy is common in the immediate postoperative period, and preoperative assurance of hemo-static competence is important. Computed tomography scans and magnetic resonance imaging are the mainstay of diagnosis, although the adjunctive use of echocardiography provides important information. Routine preoperative laboratory studies include complete blood count, chemistries, coagulation profile, and indices of renal function; an electrocardiogram, and chest radiograph. Close communication with the surgeon regarding the operative procedure, cannulation strategy (where applicable), and planned evoked potential monitoring is necessary to ensure appropriate perioperative management. Prophylactic antibiotics and antifibrinolytics are routine.