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KEY POINTS

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“The tragedies of life are largely arterial”–Sir William Osler

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KEY POINTS

  1. Permissive hypotension while ensuring adequate organ perfusion is recommended in ruptured abdominal aortic aneurysm (AAA).

  2. Acute spinal cord ischemia post-thoraco-AAA repair mandates emergent lumbar CSF catheter placement and monitored drainage in an intensive care unit.

  3. High index of suspicion for postoperative ischemic colitis—abdominal pain, rising lactate, fever, and leukocytosis.

  4. Management of acute aortic dissections with impulse control by intravenous beta blockers followed by nitroprusside.

  5. Early recognition of malperfusion syndromes in type B aortic dissection.

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INTRODUCTION

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Care of the vascular surgery patient postoperatively presents a challenging clinical scenario to the intensivist. These patients are at a high risk for perioperative complications whether undergoing open or endovascular surgery. Advanced age, comorbidities such as coronary artery disease, congestive heart failure, chronic kidney disease, advanced diabetes, peripheral vascular disease in addition to the insult of major vascular surgery places these patients at a high-risk category and potentially requiring intensive care unit (ICU). Major vascular surgery exposes the patient to extensive tissue damage, elicits a robust inflammatory response and can predispose to profound hemodynamic changes.

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This chapter will review the commonly encountered vascular procedures most likely to require subsequent ICU care.

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ABDOMINAL AORTIC ANEURYSM

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An abdominal aortic aneurysm (AAA) is defined as a pathologic focal dilation of the aorta that is more than 30 mm or 1.5 times the adjacent diameter of the normal aorta. Male aortas tend to be larger than female, and there is a generalized growth of the aortic diameter with each decade of life. Ninety percent of the AAA are infrarenal in location and fusiform in morphology.1

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Most AAAs are asymptomatic and are found incidentally during workup for chronic back pain or kidney stones. The indications for surgery are any patient who is symptomatic with back pain and/or abdominal pain with a tender pulsatile mass or any asymptomatic aneurysm that is greater than or equal to 5 to 5.5 cm or increases by greater than 0.5 cm/year.

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There are 2 approaches to AAA repair—the open surgical approach and endovascular aneurysm repair (EVAR).2 The majority of AAAs today are managed using EVAR. Therefore, the number of patients requiring ICU care after aneurysm repair has decreased. Currently, those with AAA not treatable with EVAR often have pararenal or juxta-renal morphology increasing the risk of open repair. These aneurysms increase the challenge of repair and often require supraceliac aortic clamping. The physiologic disturbance in this cohort is much greater.

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The advantage of open repair (Figure 56–1) is that the AAA is permanently eliminated because it is entirely replaced by a prosthetic graft and risk of recurrence or delayed rupture is less. Consequently, long-term imaging surveillance is not needed in most patients. However, several prospective clinical trials across devices and databases have ...

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