8/21/2021 What are potential complications of surgery for thoracic aortic aneurysm (TAA)?

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Today on Medscape

What are potential complications

of surgery for thoracic aortic
aneurysm (TAA)?
Updated: Apr 02, 2021
Author: Elaine Tseng, MD; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...

References

ANSWER
Early morbidity and mortality are related to bleeding, neurologic injury (eg, stroke), cardiac failure, and
pulmonary failure (eg, acute respiratory distress syndrome [ARDS]). Risk factors include emergency
operation, older age, dissection, congestive heart failure (CHF), prolonged CPB time, arch
replacement, previous cardiac surgery, need for concomitant coronary revascularization, and
reoperation for bleeding. Late mortality is usually related to cardiac disease or distal aortic disease.

Bleeding is a potential complication for all aneurysm repairs. It is minimized by the use of
antifibrinolytics, felt strips, and factors, including fresh frozen plasma and platelets. For patients who
undergo hypothermic circulatory arrest, the use of aprotinin is controversial, but most groups routinely
use aminocaproic acid. Coagulopathy and bleeding in severe cases may warrant the use of
recombinant factor VII.

Aprotinin, an antifibrinolytic agent used to reduce operative blood loss in patients undergoing open
heart surgery, is now only available via a limited-access protocol. Fergusson et al reported an
increased risk for death compared with tranexamic acid or aminocaproic acid in high-risk cardiac
surgery.
[46]

Stroke is a major cause of morbidity and mortality and typically results from embolization of
atherosclerotic debris or clot. TEE and epiaortic ultrasonography may be beneficial in localizing
appropriate areas to clamp. Patients undergoing arch repairs are at the highest risk of permanent and
transient neurologic injury. Retrograde cerebral perfusion is beneficial for flushing out embolic debris,
but it may be detrimental, with increased intracranial pressure and cerebral edema. Antegrade
cerebral perfusion is beneficial for reducing neurologic injury during hypothermic circulatory arrest.

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8/21/2021 What are potential complications of surgery for thoracic aortic aneurysm (TAA)?

Stroke incidence for open surgical repair versus endovascular repair of descending TAAs is
equivalent.

Myocardial infarction may occur with technical problems with coronary ostia implantation during root
replacement for ascending aortic aneurysms and may require reoperation. Pulmonary dysfunction and
renal dysfunction are other potentially morbid complications.

Paraparesis and paraplegia, either acute or delayed, are the most devastating complications of
descending TAA and TAAA repairs. Despite CSF drainage, reimplantation of intercostal arteries,
evoked potential monitoring, mild hypothermia, and atrial femoral bypass, spinal cord injury still
occurs. Endovascular stent grafting has not eliminated spinal cord paraplegia; the incidence varies
widely, with an overall incidence of 2.7%.
[30, 47, 48, 49]

Complications specific to endovascular stenting include endoleaks, stent fractures, stent graft
migration or thrombosis, iliac artery rupture, retrograde dissection, microembolization,
aortoesophageal fistula, and complications at the site of delivery (eg, groin infection, lymphocele,
seroma).

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