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Page 2 of 16 Katz et al. Vessel Plus 2023;7:1 https://dx.doi.org/10.20517/2574-1209.2022.52

Keywords: Aortic aneurysm, perioperative care, surgical procedures, operative, reperfusion, reperfusion injury,
cerebrospinal fluid drainage, coronary artery bypass

INTRODUCTION
Achieving successful outcomes after thoracoabdominal aortic aneurysm (TAAA) or descending thoracic
aortic aneurysm (DTA) repair requires meticulous attention throughout the entire perioperative period.
This includes not only appropriate intraoperative technical considerations, but also preoperative
optimization for patients with comorbidities, careful anesthetic management during the procedure, and
diligent postoperative care . Because preventing complications is the primary goal of perioperative
[1]
management, deviations from the expected perioperative course must be recognized promptly and
addressed aggressively to reduce the likelihood of deleterious consequences.

In this narrative review, we discuss typical characteristics of patients who require TAAA or DTA repair, the
perioperative risks associated with surgery for these conditions, and the management of associated organ
systems so as to reduce morbidity. In addition, we consider unique aspects of managing endovascular repair
of TAAAs and DTAs. Our literature review included the following search terms: thoracoabdominal aortic
surgery, descending thoracic aortic aneurysm, and thoracic endovascular aortic repair. Our discussion is
based on our collective experience of more than 4000 open repairs over the last 3 decades.

It is common for patients to have coexisting medical conditions that should be evaluated before TAAA
repair. Special attention should be given to optimizing those comorbidities preoperatively, followed by
organ system-specific evaluation and discussion of management considerations. Broadly speaking, two
general categories of patients require TAAA repair: (1) younger patients who are likely to have Marfan
syndrome or other connective tissue disorders and who frequently have had previous aortic surgery, present
with a higher proportion of Crawford extent I or II aneurysms, and have fewer medical comorbidities; and
(2) older patients presenting with degenerative atherosclerotic aortic aneurysms and typically having a
higher proportion of Crawford extent IV aneurysms, less-frequent previous aortic surgery, and more
[2]
medical comorbidities. See Figure 1 .

PREOPERATIVE EVALUATION AND CONSIDERATIONS
Standardized procedures for the preoperative evaluation of patients scheduled for surgical TAAA or DTA
repair are available from professional organizations such as the American Society of Anesthesiologists and
the European Society of Anesthesiology and Intensive Care. Preoperative assessment should emphasize
evaluation of airway, cardiac, pulmonary, and neurological systems, preoperative laboratory tests, and
[1]
[3]
imaging . A listing by organ system and diagnostic preoperative considerations is provided in Figure 2 .
Although age itself is not a contraindication to open TAAA or DTA repair, the operative mortality risk in
octogenarians is 10-fold higher than in younger patients and warrants careful patient selection . Perhaps
[4]
unsurprisingly, preoperative functional status has been shown to be the strongest independent predictor of
perioperative death, with completely dependent functional status yielding a threefold-higher mortality
[5]
risk . Thus, baseline functional status and mobility should be observed in all patients.
Neurological (cerebral)
Neurological deficits can develop in TAAA and DTA patients not only as sequelae of underlying
cerebrovascular disease, but also as complications of surgical repair. Careful preoperative screening can be
helpful in preventing such complications. For example, in our institutional experience, 10% of patients
presenting for TAAA or DTA repair have evidence of previous stroke. Neurological consultation should be