Page 116 - Read Online

Monaco et al. Vessel Plus 2023;7:23 https://dx.doi.org/10.20517/2574-1209.2023.113 Page 9 of 14

Figure 3. Main therapeutic targets and decision-making algorithm in the occurrence of left ventricular (LV) dysfunction. LV: Left
ventricular; CVP: central venous pressure; RWMA: regional wall motion abnormalities.

decrease in SCPP secondary to decreased MAP and active bleeding. Hypotension following declamping can
be corrected through various means, including increasing blood volume, infusing vasoactive drugs,
reducing the clamp time, or employing a gradual release of the clamp. Rapid treatment of metabolic
alterations may prove useful.

Partial left heart bypass
To date, partial left heart bypass (PLHB) is considered the best technique to reduce ischemia time in tissues
vascularized by arteries originating downstream of the aortic clamp, to support left ventricular function and
[33]
to control hypertension during TAAA correction surgery .

Dynamic use of PLHB makes it possible to modulate the perfusion pressure in the district proximal and
distal to the clamp by keeping it between 85 mmHg and 100 mmHg for the whole duration of the surgical
procedure and ensuring adequate SCPP. If the MAP falls below 60 mmHg, the perfusion pressure in the
collateral medullary network is proportionally reduced. The use of PLHB has been associated with a
reduced risk of paraplegia . Safi et al. report that the use of PLHB in patients undergoing TAAA repair also
[34]
improves the outcome in Crawford type I and II by reducing the risk of paraplegia when used in
combination with CSF drainage . Furthermore, although heparin is routinely administered to prevent
[35]
intraoperative thrombosis, when PLHB is used, a higher degree of anticoagulation compared with the
“clamp-and-go” technique is required. This may eventually worsen both the underlying TAAA-related
coagulopathy and bleeding.

Cerebrospinal fluid drainage
Cerebrospinal fluid (CSF) drainage is the most effective procedure in preventing SCI after aortic repair .
[36]
The pathophysiological rationale behind the use of CSF drainage is the need to lower cerebrospinal fluid
pressure (CSFP) by increasing SCPP. In light of this, the use of CSF drainage has entered clinical practice.
CSF drainage positioning was found to significantly reduce the risk of paraplegia in a randomized
controlled trial of 145 patients undergoing extent I and II TAA surgery . These data are further supported
[37]
by clinical practice. The use of CSF drainage as a rescue in patients who have developed neurological deficits
following surgical interventions is able to reverse paraplegia and paresis by decreasing the CSFP. Hence, its
use has become an essential tool in the multimodal approach for the prevention of SCI, in combination with
the above-mentioned hemodynamic optimization strategies. Preventing catheter obstruction and deflecting
any complications may be achieved by continuous monitoring of CSFP, even if this procedure carries its