Thoracoabdominal aortic aneurysms: surgical indications, intra and postoperative management

Thoracoabdominal aortic aneurysms still represent in the twenty first century one of the few remaining true surgical challenges that the cardiovascular surgeon has to face. The magnitude of the endeavour when treating these patients comes from the dismal prognosis they have if left unoperated and the dreadful potential complications associated to their surgery. The need to invade both the thoracic and abdominal cavities, the use of single lung ventilation, the massive blood loss, the heart overload and the interference with the perfusion to the spinal chord, kidneys, abdominal organs and lower limbs, together with the advanced atherosclerosis that the great majority of these patients features, explains the main sources of mortality and morbidity when dealing with this pathology and the quasi-military logistics that their surgical treatment requires. A team approach is, thus, warranted in this multi-system, multi-complication scenario in which the surgical group must work in close cooperation with anesthesiologists, perfusionists, ICU staff and clinicians, if adequate surgical results are to be obtained. The need to concentrate the pathology in a few reference surgical centers may not be overemphasized, as the quality of the results in this field is in direct relationship with the hospital and the surgeon's case load. We hereunder give summarized and updated information on the clinical and anatomical characteristics of these aneurysms, their natural history, indications for surgery, pre-, intra-and post-operative management strategies, paying particular attention to the main sources of poor surgical outcomes.