REDUCED RENAL-FAILURE FOLLOWING THORACOABDOMINAL AORTIC-ANEURYSM REPAIR BY SELECTIVE PERFUSION

Objectives: Renal failure and visceral ischemia are feared complicatio ns following thoracoabdominal, aortic aneurysm (TAAA) repair, signific antly contributing to mortality. This prospective study describes volu me- and pressure-controlled perfusion of the renal and visceral arteri es during TAAA surgery. Methods: In 73 consecutive patients (mean age 59 years), TAAA repair (27 type I, 28 type II, 8 type III and 10 type IV) was performed, using retrograde and selective organ perfusion. Six teen patients had impaired renal function with blood creatinine higher than 100 mmol/l. During the thoracic part of the procedure, the mean distal aortic pressure was kept above 60 mm Hg by means of left-heart bypass. After opening the abdominal aorta, the renal and visceral arte ries were individually perfused by means of perfusion catheters (9 Fre nch) in the first 33 patients (group I). Volume flow through each cath eter was assessed with ultrasound flow meters and maintained at least at 60 ml/min. In addition to volume flow measurements, catheters with pressure sensors were used in the last 40 patients (group II), allowin g pressure-controlled selective perfusion. The extent of the aneurysm was comparable in both groups. Results: Mean cross-clamp time for the thoracic part was 46 min, including proximal anastomosis and reattachm ent of intercostal arteries. Mean cross-clamp time for the abdominal p art was 74 min, including re-implantation of intestinal and renal arte ries and selective dacron grafts to the celiac-axis arteries (n = 5), superior mesenteric arteries (n = 8) and renal arteries (n = 25), thro ugh which the catheters guaranteed continuous perfusion during the tim e the anastomosis was performed. Urine output was uninterrupted in all patients, irrespective of cross-clamp time. In group I, one patient ( 3%) developed renal failure and three patients (9%) required temporary peritoneal dialysis. In group II, no patients developed renal failure and two patients (5%) required temporary peritoneal dialysis. Thirtee n patients with preexisting renal impairment did not deteriorate. No p atients developed visceral ischemia or multiple-organ failure. Total i n-hospital mortality was 6/73 (8%) and was related to cardiopulmonary complications. Conclusions: Renal and visceral ischemia can be reduced significantly by continuous perfusion during cross-clamping in TAAA r epair. Not only sufficient volume flow but also adequate arterial pres sure appears to be essential in maintaining renal function. (C) 1998 E lsevier Science B.V. All rights reserved.