Anesthesia for Aortic Aneurysm Repair

This is the last week of my Cardiac Surgery rotation at the County Hospital. The anesthesia techniques that I have learned this past month have been very interesting. Today I was able to put it all together for a sort of cap-stone experience in a big case.

Aortic dissection repair is not a surgical case that is approached lightly. This condition may result from chronic hypertension and possibly congenital weakness of the intima of the aorta leading to aneurysm formation and dissection. Unchecked an aortic dissection often proves to be fatal. Remember John Ritter from Three’s Company – he fell victim to a ruptured aortic dissection. Death is usually extremely quick and mercifully without drawn out pain.

This vascular case required not only sternotomy but a thoracotomy as well. These are big surgeries. Initially, the plan was for circulatory arrest and profound hypothermia with lumbar drain for cerebral protection. The surgical team decided on the double incision providing a greater exposure and was able to perform the surgery without the circulatory arrest. This was a good thing for everyone. Rewarming after a complete circulatory arrest with profound hypothermia takes several hours. As it was the surgery was long.

Preparation and setup for anesthesia was nevertheless extensive with two arterial line placements both a right radial and right femoral, double lumen introducer central line placement in the internal right jugular and floating a pulmonary artery catheter. Additionally because of the thoracotomy and the extensive dissection into the left chest that was required we used a double lumen endotracheal tube which allowed us to deflate the left lung improving the surgical exposure on the left side. At the end of the case the double lumen tube was replaced with a single lumen endotracheal tube. This was a great experience and wonderful case for me to participate in. You can see the entire Slide Show of the case at flickr. I must warn you that some of the pictures are very graphic and not for the squeamish.

These cases require cardio-pulmonary by-pass. For this case it was a partial bypass that was used when the surgeons isolated the aortic arch. Never the less this resulted in full heparinization and use of the “heart lung machine”. You can see Julia here with her bight smile behind the mask. The presence of the perfusion team in the cardiac room is always a pleasure.

Enjoy the pictures at flickr. If you can recall your anatomy you will notice the aortic arch repair and marvel at the gortex graft creation by the sugical team.