Optimal perioperative care for thoracoabdominal and descending thoracic aortic aneurysm repair: a review

Achieving successful outcomes after thoracoabdominal aortic aneurysm (TAAA) or descending thoracic aortic aneurysm (DTA) repair requires meticulous attention throughout the entire perioperative period. This includes not only appropriate intraoperative technical considerations, but also preoperative optimization for patients with comorbidities, careful anesthetic management during the procedure, and diligent postoperative care[1]. Because preventing complications is the primary goal of perioperative management, deviations from the expected perioperative course must be recognized promptly and addressed aggressively to reduce the likelihood of deleterious consequences. In this narrative review, we discuss typical characteristics of patients who require TAAA or DTA repair, the perioperative risks associated with surgery for these conditions, and the management of associated organ systems so as to reduce morbidity. In addition, we consider unique aspects of managing endovascular repair of TAAAs and DTAs. Our literature review included the following search terms: thoracoabdominal aortic surgery, descending thoracic aortic aneurysm, and thoracic endovascular aortic repair. Our discussion is based on our collective experience of more than 4000 open repairs over the last 3 decades.It is common for patients to have coexisting medical conditions that should be evaluated before TAAA repair. Special attention should be given to optimizing those comorbidities preoperatively, followed by organ system-specific evaluation and discussion of management considerations. Broadly speaking, two general categories of patients require TAAA repair: (1) younger patients who are likely to have Marfan syndrome or other connective tissue disorders and who frequently have had previous aortic surgery, present with a higher proportion of Crawford extent I or II aneurysms, and have fewer medical comorbidities; and (2) older patients presenting with degenerative atherosclerotic aortic aneurysms and typically having a higher proportion of Crawford extent IV aneurysms, less-frequent previous aortic surgery, and more medical comorbidities