Prevention and management of spinal cord ischemia following aortic surgery: A survey of contemporary practice.

OBJECTIVE: Spinal cord ischemia (SCI) is a devastating complication of thoracoabdominal aortic aneurysm repair. We aim to characterize current practices pertaining to SCI prevention and treatment across Canada. METHODS: Two questionnaires were developed by the Canadian Thoracic Aortic Collaborative and the Canadian Cardiovascular Critical Care Society targeting aortic surgeons and intensivists. A list of experts in the management of patients at risk of SCI was developed, with representation from each of the Canadian centers that perform complex aortic surgery. RESULTS: The response rate was 91% for both intensivists (21/23), and from cardiac and vascular surgeons (39/43). Most surgeons agreed that staging is important during endovascular repair of extent II thoracoabdominal aortic aneurysm (60%) but not for open repair (34%). All of the surgeons felt prophylactic lumbar drains were effective in reducing SCI, whereas only 66.7% of intensivists felt that lumbar drains were effective (P < .001). There was consensus among surgeons over when to employ lumbar drains. A majority of surgeons preferred to keep the hemoglobin over 100 g/L if the patient demonstrated loss of lower-extremity function, whereas most intensivists felt a target of 80 g/L was adequate (P < .001). Management of perioperative antihypertensives, use of intraoperative adjuncts, and management of venous thromboembolism prophylaxis in the presence of a lumbar drain, were highly variable. CONCLUSIONS: We observed some consensus but considerable variability in the approach to SCI prevention and management across Canada. Future studies focused on the areas of variability may lead to more consistent and improved care for this high-risk population.

A Province-Wide Analysis of the Epidemiology of Thoracic Aortic Disease: Incidence Is Increasing in a Sex-Specific Way.

BACKGROUND: The contemporary incidence and prevalence of thoracic aortic aneurysm and dissection (TAAD) remains understudied. Epidemiological research on TAAD has been limited by incomplete case identification within administrative data sources. The objectives of this study were to develop a case identification method and determine the incidence and prevalence of TAAD, based on data from Manitoba, Canada. METHODS: Hospital records and medical claims housed at the Manitoba Centre for Health Policy, and data from the Manitoba Thoracic Aortic Diseases Clinic were used to develop a case definition and identify patients with TAAD in Manitoba, Canada. The age-standardized incidence and prevalence of thoracic aortic disease was determined and stratified by sex from 1998 to 2016. RESULTS: We identified 4264 patients with TAAD, of whom 63% were male. The age standardized incidence was 2 times higher in men, peaking at 42 cases per 100,000 in 2013. Although the overall incidence was lower in female patients, the number of incident cases increased 68% compared with 25% in male patients. In hospitalized patients, the incidence and prevalence of aneurysms increased over time, whereas the incidence of dissection and rupture has remained stable. CONCLUSIONS: The use of a novel case identification method provided a more complete description of the epidemiology of TAAD. The incidence and prevalence of TAAD is rising, more so in female patients over time. These data support increased resource allocation to thoracic aortic diseases clinics to ensure appropriate monitoring, treatment, and follow-up for the growing number patients with thoracic aortic disease.

Extracorporeal Membrane Oxygenation, Pulmonary Embolectomy, and Right Ventricular Assist Device for Massive Pulmonary Embolism.

Consensus regarding the management of massive pulmonary embolism (PE) and persistent shock after thrombolysis is lacking. A 30-year-old man collapsed with massive PE 3 days after an exploratory laparotomy for penetrating trauma, and he remained hypoxic and hypotensive despite thrombolytic therapy. Extracorporeal membrane oxygenation (ECMO) was instituted as a bridge to surgical embolectomy, and placement of a right ventricular assist device (RVAD) was used to facilitate separation from cardiopulmonary bypass. After 48 hours, the RVAD was removed, and the patient survived to discharge. ECMO and temporary RVAD to support surgical embolectomy are lifesaving therapeutic considerations.

Vocal Cord Paralysis After Thoracic Aortic Surgery: Incidence and Impact on Clinical Outcomes.

BACKGROUND: Vocal cord paralysis (VCP) is a serious complication associated with thoracic aortic surgery; however, there is a paucity of literature regarding the incidence and impact of VCP on postoperative outcomes. We sought to determine the incidence of VCP and its impact on clinical outcomes in patients who underwent thoracic aortic repair at our center. METHODS: A retrospective chart review was conducted on all patients who underwent thoracic aortic surgery between January 2009 and September 2012. RESULTS: A total of 259 patients underwent a thoracic aortic procedure during the study period. Vocal cord paralysis was diagnosed in 12 (5%) patients, a median of 6 [3 to 21] days after extubation. The incidence was 1%, 0%, 20%, and 25% in those undergoing an open ascending, hemiarch, total arch, or descending aortic procedure, respectively. Patients with VCP had an increased incidence of pneumonia (58% vs 17%, p = 0.003), readmission to the intensive care unit for respiratory failure (17% vs 2%, p = 0.047), and longer hospital length of stay (18 [11 to 43] days versus 9 [6 to 15] days, p = 0.002). A propensity-matched analysis confirmed a higher incidence of pneumonia (58% vs 17%, p = 0.020) and longer hospital length of stay (18 [11 to 43] vs 10 [7 to 14] days, p = 0.015) in patients suffering VCP. CONCLUSIONS: Vocal cord paralysis is a common complication in patients undergoing open surgery of the aortic arch and descending aorta, and is associated with significant morbidity. Further research may be warranted to determine if early fiberoptic examination and consideration of a vocal cord medialization procedure may mitigate the morbidity associated with VCP.