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Page 12 of 16 Katz et al. Vessel Plus 2023;7:1 https://dx.doi.org/10.20517/2574-1209.2022.52

AKI (e.g., volume resuscitation, adequate MAP) overlap with methods used to prevent spinal cord ischemia.

Multidisciplinary rounding with a pharmacist is invaluable for avoiding iatrogenic medication-related
exacerbation of AKI. Early nephrology consultation should be considered for any patient who develops
AKI. Close adherence to the guidelines suggested by the Kidney Disease Improving Global Outcomes
(KDIGO) initiative is critical. The use of contrast imaging should be carefully weighed against the risk for
[48]
contrast nephropathy that could exacerbate preoperative CKD or postoperative AKI, and adequate
hydration should be maintained. Peripheral insertion of catheters is avoided whenever possible to preserve
future dialysis access options in the upper extremities.

Gastrointestinal
Early gastrointestinal complications after TAAA or DTA repair are not common (6%) but are associated
with a considerable increase in operative mortality (34%) and major morbidity . As with abdominal
[49]
surgery in general, the most common gastrointestinal complication after TAAA or DTA repair is ileus.
With ileus, opioids and anticholinergics should be avoided as much as possible, and the patient’s electrolytes
should be kept in a normal range. Stress-ulcer prophylaxis should be routine after TAAA or DTA repair.

Unexplained acidosis, excessive fluid requirements, or abdominal pain and distension may indicate
mesenteric ischemia. Although CT angiography may be necessary, mesenteric ischemia often occurs in the
setting of AKI, and the possibility of contrast nephropathy must be considered. If clinical suspicion is
strong, prompt laparotomy should be considered. Along those lines, abdominal compartment syndrome
also is a consideration, especially in patients with a ruptured aneurysm at the time of presentation, and
appropriate bladder pressure monitoring in the appropriate clinical context is essential for timely
[50]
management . In addition, significant elevation in hepatic transaminases should prompt Doppler
ultrasonography to exclude mesenteric vascular thrombosis.

Enteral nutrition should be initiated as soon as possible and when safe, usually on or after the third
postoperative day after removal of the nasogastric tube. For patients who remain intubated or who are
deemed unsafe for oral intake, enteral feeds via nasoduodenal tube should be given.

Patients who undergo splenectomy during their procedure should be vaccinated against Streptococcus
pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis infection . If not administered
[51]
preoperatively, these vaccinations should be given within 2 weeks postoperatively. Patients who have
undergone splenectomy are also at risk for injury to the tail of the pancreas. Suspicious abdominal drain
output or feeding intolerance warrants evaluation of serum pancreatic enzymes. Postoperative pancreatitis
should be treated in a standard manner, with bowel rest.

Hematological
Management of postoperative bleeding should focus on correcting coagulopathy, systemic warming, and
prompt return to the operating room when indicated. Our postoperative targets include a platelet count
> 100,000/μL of blood, an INR < 1.6, and a serum fibrinogen level > 200 mg/dL. Correction with platelet
transfusion, fresh frozen plasma, and cryoprecipitate should be initiated as needed . We aim for a
[52]
hemoglobin level > 10 g/dL to prevent spinal cord ischemia. Increasingly, the use of thromboelastography
and prothrombin concentrated complex has allowed for targeted transfusions.