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Katz et al. Vessel Plus 2023;7:1 https://dx.doi.org/10.20517/2574-1209.2022.52 Page 11 of 16

After extubation, close attention should be paid to voice quality. Injury to the recurrent laryngeal nerve
occurs in up to a quarter of patients undergoing extent I or II aneurysm repair [41,42] . The recurrent nerve
loops around the aortic arch close to the proximal clamping site and can be injured by dissection, the clamp,
or traction on nearby structures. If the patient has altered voice or cough after extubation, an
otolaryngology consultation should be requested, and direct laryngoscopy should be performed. For
[43]
patients with impaired vocal-cord movement, transcervical injection laryngoplasty can be effective . This
can be done in the ICU without general anesthesia. Bedside swallow evaluation should be done if impaired
vocal-cord movement is diagnosed to determine whether diet advancement is appropriate or if the patient is
at higher risk for aspiration.

Tracheostomy has been reported in up to 12% of TAAA repairs - unsurprising, given the extensive
pulmonary comorbidities in this patient population. Tracheostomy timing and technique (open versus
percutaneous dilational) should follow local practice. Early tracheostomy (< 14 days after surgery) is
[44]
recommended to facilitate mobility, reduce the risk for pneumonia, and promote ventilator weaning .
Venovenous extracorporeal membrane oxygenation has been used successfully in cases of severe
[45]
hypoxemia .

Cardiovascular
In the immediate postoperative setting, we routinely use a pulmonary artery catheter to maintain a cardiac
index of > 2.2 L/min/m . We administer epinephrine or dobutamine for inotropic support. Cardiac output
2
and various perfusion indices (serum lactate, urine output, mixed venous oxygen saturation, base deficit,
and overall hemodynamics) are monitored to gauge resuscitation.

Up to one-quarter of patients undergoing TAAA repair develop atrial fibrillation. The incidence is highest
[46]
in patients of advanced age and those requiring visceral perfusion intraoperatively . Atrial fibrillation can
lead to hypotension and risks spinal cord ischemia. We recommend an aggressive rhythm-control strategy
with intravenous amiodarone and early electrical cardioversion if needed.

Severe hypertension (systolic blood pressure > 160-170 mmHg) should be avoided. However, the risk for
delayed paraplegia can persist for a month after surgery . For that reason, strict hypertension management
[47]
should not begin until after 1 month postoperatively, in consultation with the patient’s primary care
physician and cardiologist.

Peripheral vascular
Postoperatively, the peripheral pulses are monitored closely. Any change in the pulse exam from
preoperative and immediate postoperative status requires prompt evaluation with Doppler ultrasonography
and timely intervention if needed. As with any operation involving prolonged lower-extremity ischemia and
reperfusion, compartment syndrome and rhabdomyolysis could develop; if so, prompt intervention with
four-compartment fasciotomies is necessary for limb salvage. Lower-extremity ischemia can also be caused
by a nonpatent aortoiliac anastomosis, in which case endovascular intervention or graft revision may be
necessary.

Renal
Both TAAA repair and DTA repair are fraught with various insults to the kidneys. In a narrative review of
nearly 9000 TAAA repairs, the incidence of AKI ranged from 5% to 29%, and the percentage of patients
requiring dialysis was between 4% and 17% . Moderate AKI portends increased mortality , and even mild
[21]
[21]
AKI is associated with a greatly increased need for tracheostomy. In patients with renal failure requiring
dialysis who also require tracheostomy, mortality is as high as 70% . Many of the strategies for preventing
[21]