Extrapleural access with removal of the 11th rib in type IV thoracoabdominal aneurysms: Impact on postoperative management

Aim. Postoperative respiratory failure is one of the most frequent complications of thoracoabdominal aortic aneurysms (-TAAA): its occurrence is mainly linked to the extent of the surgical access (thoraco-phreno-laparotomy). The aim of this study was to evaluate the postoperative management of Type 4 TAAA, paying special attention to respiratory complications, with left extrapleural surgical access and removal of the 11th rib. Methods. Type IV TAAA treated using left extrapleural surgical access and removal of the 11th rib were examined in a retrospective study. The following parameters were analysed: preoperative respiratory (FEV1) and renal function, postoperative intubation time, length of intensive care unit stay, postoperative respiratory complications, postoperative renal insufficiency, perioperative morbidity and mortality (30 days). Results. The study was performed in 10 patients (9 males) with a mean age of 69 years (range 60-75), diagnosed with Type 4 TAAA whose upper proximal limit was the celiac tripod. None of the patients were obese; 90% of the patients were smokers. The preoperative chest X-ray showed a supraelevation of the left hemidiaphragm in 2 cases. In 10 cases, FEV1 ranged from 57% to 144%. Preoperative renal insufficiency was present in 2 cases (creatinine >2.0 mgdl). Surgery was performed electively in all cases. In total, there were 2 cases of postoperative respiratory failure (postoperative intubation time >12 hours). In the remaining cases mean postoperative intubation time was 5.3 hours (range: 4-8 hours). Both cases of respiratory failure were associated with transient renal insufficiency. The mean length of intensive care unit stay was 3.5 days (range: 0-15 days): a single day was sufficient in 50% of cases. Postoperative chest X-rays revealed only 1 new case of supraelevation of the left hemidiaphragm (2 were already present preoperatively), no case of pneumothorax and no case of infection. Two cases of transient postoperative renal insufficiency were observed: only 1 case required temporary hemodialysis. Redo surgery was necessary in 2 cases: in 1 case to empty the retroperitoneal hematoma and cross-over surgery in 1 case due to thrombosis of an iliac branch. There was no case of perioperative mortality. Conclusion. Based on these preliminary results, when practicable, this surgical access appears to promote a more rapid recovery of postoperative respiratory function.