Thoracic aortic aneurysm surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammad Salih, MD. Aarti Narayan, M.B.B.S [2]; Raviteja Guddeti, M.B.B.S. [3]

Overview

Indications for surgical repair of a thoracic aortic aneurysm include rupture; symptoms such as pain consistent with impending rupture; aortic regurgitation; growth ≥ 0.5 - 1 cm/year; bicuspid aortic valve; asymptomatic patients with degenerative thoracic aneurysm, chronic aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, mycotic aneurysm, or pseudoaneurysm, who are otherwise suitable candidates once a TAA reaches a pre-specified size (>5 cm in the ascending aorta, >6 cm in the descending segment) referral for surgical or endovascular repair sholuld be initiated. Most patients undergo repair once they reach >5.5 cm diameter in the ascending aorta and > 6.5 cm in the descending thoracic aorta, respectively. Patients with marfan syndrome or other genetically mediated disorders (vascular ehlers-danlos syndrome, turner syndrome, bicuspid aortic valve, or familial thoracic aortic aneurysm and dissection) should undergo elective operation at smaller diameters (4.0 to 5.0 cm depending on the condition. To avoid acute dissection or rupture, adult patients with loeys-dietz syndrome should undergo surgery for an aortic diameter of >4.4 to 4.6 cm. If a marfan syndrome patient is contemplating pregnancy, they should undergo aortic root replacement if the diameter is greater than 4 cm, and patients undergoing aortic valve repair or replacement and who have an ascending aorta or aortic root of greater than 4.5 cm should be considered for concomitant repair of the aortic root or replacement of the ascending aorta. A woven dacron tube graft is most commonly used in the repair of thoracic aortic aneurysms.

Surgery

Evaluating The Patient's Risk Of Dissection And Rupture

The annual risk of rupture is closely related to aneurysm size (3% for TAAs <4 cm and 7% for >6 cm). Shown below is the annual risk of thoracic aortic rupture, dissection or death for different diameters of thoracic aortic aneurysms. The curvilinear nature of the risk of cardiovascular events forms the basis for performing surgery when the aorta is 5.0 to 6 cm in diameter depending upon whether the patient has marfan syndrome or loeys-dietz syndrome or not.

Once a thoracic aortic aneurysm is identified, the patient should be followed with clinical and noninvasive testing every three months and then every six months for yearly thereafter.

Indications for Surgery

  • Rupture
  • Symptomatic states
  • Growth ≥ 0.5 - 1 cm/year
  • Bicuspid aortic valve
    • Immediate surgical repair is recommended, as this condition is associated with faster rate of aortic dilatation[1]
  • Absolute size
Marfan's Non-Marfan's
Ascending aorta 5.0 cm 5.5 cm
Descending aorta 6.0 cm 6.5 cm
  • Patients with marfan syndrome or other genetically mediated disorders (vascular ehlers-danlos syndrome, turner syndrome, bicuspid aortic valve, or familial thoracic aortic aneurysm and dissection) should undergo elective operation at smaller diameters (4.0 to 5.0 cm depending on the condition; to avoid acute dissection or rupture.
  • Adult patients with loeys-dietz syndrome should undergo surgery for an aortic diameter of >4.4 to 4.6 cm.
  • If marfan syndrome patient is contemplating pregnancy, they should undergo aortic root replacement if the diameter is greater than 4 cm.
  • Asymptomatic patients with degenerative thoracic aneurysm, chronic aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, mycotic aneurysm, or pseudoaneurysm, who are otherwise suitable candidates and for whom the ascending aorta or aortic sinus diameter is 5.5 cm or greater should be evaluated for surgical repair.
  • Patients undergoing aortic valve repair or replacement and who have an ascending aorta or aortic root of greater than 4.5 cm should be considered for concomitant repair of the aortic root or replacement of the ascending aorta.

Surgery for Thoracic Aortic Aneurysm

The choice of operation depends on:

  • Underlying pathology
  • Extent of the disease (both proximally and distally)
  • Patient's life expectancy
  • Desired anti-coagulation status

Ascending Aortic Aneurysms

Ascending aorta with normal aortic valves, annulus and sinus of valsalva Simple dacron tube graft
Diseased aortic valve and normal sinus and annulus Replace aortic valve separately from repair of aneurysm (with supracoronary synthetic graft)
Normal valves with aneurysmal sinus and aortic insufficiency 1) Remodelling method: resecting the sinus tissue and repair with dacron graft to form new sinus

2) Re-implantation method: reimplanting the scalloped valve with dacron graft

Diseased aortic valve and diseased aortic root Aortic root replacement. Younger individuals: composite valve graft consisting of mechanical valve inserted into a Dacron graft coronary artery reimplantation. Older individuals, women of child bearing age, those with contraindications to use of warfarin: aortic homografts, pulmonary autografts
Marfan syndrome Valve sparing aortic root replacement or complete aortic root replacement

Aortic Arch

Proximal arch involvement with ascending aorta Hemiarch replacement with Dacron graft
As a part of delayed repair of descending aortic aneurysm Dacron graft is telescoped into the descending aorta, facilitating later replacement of the descending aorta
Hybrid Procedures for Aortic Arch
  • They are a combination of both open and endovascular procedures.
  • Advantages:
    • Less invasive
    • No aortic cross-clamping required
    • Decreased overall morbidity and mortality

Descending Aorta and Thoracoabdominal Aneurysm

  • Endovascular stent grafts
    • GORE TAG - FDA approved nitinol based stent graft
    • Zenith TX2 endovascular graft
    • Talent thoracic stent graft
  • Open surgery
  • Factors deciding the type of surgery:
  • Age
  • Co-morbidities
  • Symptoms
  • Life expectancy
  • Aortic diameter
  • Extent of the lesion

Complications Of Thoracic Aorta Aneurysm Surgery

Bleeding

  • Bleeding is a potential complication of all aneurysm repairs, particularly a large one such as aortic aneurysm repair

Neurologic Injuries

  • Stroke- major cause of mortality
  • Due to an obstructed blood vessel by embolized atherosclerotic debris
  • Patients undergoing aortic arch repairs are at the highest risk of neurologic complications
  • Paraparesis and paraplegia

Cardiac

Pulmonary

Acute respiratory distress syndrome

Endovascular Stenting Complications

  • Endoleaks
  • Stent fractures
  • Stent graft migration or thromobosis
  • Iliac artery rupture
  • Retrograde dissection
  • Microembolization
  • Aortoesophageal fistula

2017 ESC/EACTS Guidelines

Indications for Surgery in Aortic Root Disease or Tubular Ascending Aortic Aneurysm (Irrespective of the Severity of Aortic Regurgitation)


Indications for Surgery Class of

Recommendation

Level of

Evidence

Aortic valve repair, using the reimplantation or remodelling with aortic annuloplasty technique, is recommended in young patients with aortic root dilation and tricuspid aortic valves, when performed by experienced surgeons. I C
Surgery is indicated in patients with Marfan syndrome who have aortic root disease with a maximal ascending aortic diameter ≥ 50 mm. I C
Surgery should be considered in patients who have aortic root disease with maximal ascending aortic diameter: IIa C
  • ≥ 45 mm in the presence of Marfan syndrome and additional risk factorsa or patients with a TGFBR1 or TGFBR2 mutation (including Loeys–Dietz syndrome).b
 IIa C
  • ≥ 50 mm in the presence of a bicuspid valve with additional risk factorsa or coarctation.
 IIa C
  • ≥ 55 mm for all other patients.
 IIa C
When surgery is primarily indicated for the aortic valve, replacement of the aortic root or tubular ascending aorta should be considered when ≥ 45 mm, particularly in the presence of a bicuspid valve.c IIa C
aFamily history of aortic dissection (or personal history of spontaneous vascular dissection), severe aortic regurgitation or mitral regurgitation, desire for pregnancy, systemic hypertension and/or aortic size increase >3 mm/year (on repeated measurements using the same ECG-gated imaging technique measured at the same level of the aorta with side-by-side comparison and confirmed by another technique).
bA lower threshold of 40 mm may be considered in women with low body surface area (BSA), in patients with a TGFBR2 mutation or in patients with severe extra-aortic features.[2]
cConsidering age, BSA, aetiology of the valvular disease, presence of a bicuspid aortic valve and intraoperative shape and thickness of the ascending aorta.

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease - Surgical and Endovascular Treatment by Location of Disease (DO NOT EDIT)[3]

Asymptomatic Patients With Ascending Aortic Aneurysm (DO NOT EDIT)[3]

Class I
"1. Asymptomatic patients with degenerative thoracic aneurysm, chronic aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, mycotic aneurysm, or pseudoaneurysm, who are otherwise suitable candidates and for whom the ascending aorta or aortic sinus diameter is 5.5 cm or greater should be evaluated for surgical repair.[4] (Level of Evidence: C)"
"2. Patients with Marfan syndrome or other genetically mediated disorders (vascular Ehlers-Danlos syndrome, Turner syndrome, bicuspid aortic valve, or familial thoracic aortic aneurysm and dissection) should undergo elective operation at smaller diameters (4.0 to 5.0 cm depending on the condition; to avoid acute dissection or rupture.[5][6][7][8][9][10][11][12] (Level of Evidence: C)"
"3. Patients with a growth rate of more than 0.5 cm/y in an aorta that is less than 5.5 cm in diameter should be considered for operation. (Level of Evidence: C)"
"4. Patients undergoing aortic valve repair or replacement and who have an ascending aorta or aortic root of greater than 4.5 cm should be considered for concomitant repair of the aortic root or replacement of the ascending aorta. (Level of Evidence: C)"
Class IIa
"1. Elective aortic replacement is reasonable for patients with Marfan syndrome, other genetic diseases, or bicuspid aortic valves, when the ratio of maximal ascending or aortic root area (πr²) in cm² divided by the patient's height in meters exceeds 10.[13][14] (Level of Evidence: C)"
"2. It is reasonable for patients with Loeys-Dietz syndrome or a confirmed TGFBR1 or TGFBR2 mutation to undergo aortic repair when the aortic diameter reaches 4.2 cm or greater by transesophageal echocardiogram (internal diameter) or 4.4 to 4.6 cm or greater by computed tomographic imaging and/or magnetic resonance imaging (external diameter).[15] (Level of Evidence: C)"

Symptomatic Patients With Thoracic Aortic Aneurysm (DO NOT EDIT)[3]

Class I
"1. Patients with symptoms suggestive of expansion of a thoracic aneurysm should be evaluated for prompt surgical intervention unless life expectancy from comorbid conditions is limited or quality of life is substantially impaired. (Level of Evidence: C)"

Open Surgery for Ascending Aortic Aneurysm (DO NOT EDIT)[3]

Class I
"1. Separate valve and ascending aortic replacement are recommended in patients without significant aortic root dilatation, in elderly patients, or in young patients with minimal dilatation who have aortic valve disease. (Level of Evidence: C)"
"2. Patients with Marfan, Loeys-Dietz, and Ehlers-Danlos syndromes and other patients with dilatation of the aortic root and sinuses of Valsalva should undergo excision of the sinuses in combination with a modified David reimplantation operation if technically feasible or, if not, root replacement with valved graft conduit.[16][17][14][18] (Level of Evidence: B)"

Aortic Arch Aneurysms (DO NOT EDIT)[3]

Class IIa
"1. For thoracic aortic aneurysms also involving the proximal aortic arch, partial arch replacement together with ascending aorta repair using right subclavian/axillary artery inflow and hypothermic circulatory arrest is reasonable.[19][20][21] (Level of Evidence: B)"
"2. Replacement of the entire aortic arch is reasonable for acute dissection when the arch is aneurysmal or there is extensive aortic arch destruction and leakage.[20][21] (Level of Evidence: B)"
"3. Replacement of the entire aortic arch is reasonable for aneurysms of the entire arch, for chronic dissection when the arch is enlarged, and for distal arch aneurysms that also involve the proximal descending thoracic aorta, usually with the elephant trunk procedure.[22][23][24] (Level of Evidence: B)"
"4. For patients with low operative risk in whom an isolated degenerative or atherosclerotic aneurysm of the aortic arch is present, operative treatment is reasonable for asymptomatic patients when the diameter of the arch exceeds 5.5 cm.[25] (Level of Evidence: B)"
"5. For patients with isolated aortic arch aneurysms less than 4.0 cm in diameter, it is reasonable to reimage using computed tomographic imaging or magnetic resonance imaging, at 12-month intervals, to detect enlargement of the aneurysm. (Level of Evidence: C)"
"6. For patients with isolated aortic arch aneurysms 4.0 cm or greater in diameter, it is reasonable to reimage using computed tomographic imaging or magnetic resonance imaging, at 6-month intervals, to detect enlargement of the aneurysm. (Level of Evidence: C)"

Descending Thoracic Aorta and Thoracoabdominal Aortic Aneurysms (DO NOT EDIT)[3]

Class I
"1. For patients with chronic dissection, particularly if associated with a connective tissue disorder, but without significant comorbid disease, and a descending thoracic aortic diameter exceeding 5.5 cm, open repair is recommended.[6][26][27] (Level of Evidence: B)"
"2. For patients with degenerative or traumatic aneurysms of the descending thoracic aorta exceeding 5.5 cm, saccular aneurysms, or postoperative pseudoaneurysms, endovascular stent grafting should be strongly considered when feasible.[6][28] (Level of Evidence: B)"
"3. For patients with thoracoabdominal aneurysms, in whom endovascular stent graft options are limited and surgical morbidity is elevated, elective surgery is recommended if the aortic diameter exceeds 6.0 cm, or less if a connective tissue disorder such as Marfan or Loeys-Dietz syndrome is present.[6] (Level of Evidence: C)"
"4. For patients with thoracoabdominal aneurysms and with end-organ ischemia or significant stenosis from atherosclerotic visceral artery disease, an additional revascularization procedure is recommended.[29] (Level of Evidence: B)"

Preoperative Evaluation (DO NOT EDIT)[3]

Class I
"1. In preparation for surgery, imaging studies adequate to establish the extent of disease and the potential limits of the planned procedure are recommended. (Level of Evidence: C)"
"2. Patients with thoracic aortic disease requiring a surgical or catheter-based intervention who have symptoms or other findings of myocardial ischemia should undergo additional studies to determine the presence of significant coronary artery disease. (Level of Evidence: C)"
"3. Patients with unstable coronary syndromes and significant coronary artery disease should undergo revascularization prior to or at the time of thoracic aortic surgery or endovascular intervention with percutaneous coronary intervention or concomitant coronary artery bypass graft surgery. (Level of Evidence: C)"
Class IIa
"1. Additional testing is reasonable to quantitate the patient’s comorbid states and develop a risk profile. These may include pulmonary function tests, cardiac catheterization, aortography, 24-hour Holter monitoring, noninvasive carotid artery screening, brain imaging, echocardiography, and neurocognitive testing. (Level of Evidence: C)"
"2. For patients who are to undergo surgery for ascending or arch aortic disease, and who have clinically stable, but significant (flow limiting), coronary artery disease, it is reasonable to perform concomitant coronary artery bypass graft surgery. (Level of Evidence: C)"
Class IIb
"1. For patients who are to undergo surgery or endovascular intervention for descending thoracic aortic disease, and who have clinically stable, but significant (flow limiting), coronary artery disease, the benefits of coronary revascularization are not well established.[30][31][32] (Level of Evidence: B)"

Choice of Anesthetic and Monitoring Techniques (DO NOT EDIT)[3]

Class I
"1. The choice of anesthetic techniques and agents and patient monitoring techniques should be tailored to individual patient needs to facilitate surgical and perfusion techniques and the monitoring of hemodynamics and organ function. (Level of Evidence: C)"
Class III (Harm)
"1. Regional anesthetic techniques are not recommended in patients at risk of neuraxial hematoma formation due to thienopyridine antiplatelet therapy, low-molecular-weight heparins, or clinically significant anticoagulation.[33] (Level of Evidence: C)"
"2. Routinely changing double-lumen endotracheal (endobronchial) tubes to single-lumen tubes at the end of surgical procedures complicated by significant upper airway edema or hemorrhage is not recommended. (Level of Evidence: C)"
Class IIa
"1. Transesophageal echocardiography is reasonable in all open surgical repairs of the thoracic aorta, unless there are specific contraindications to its use. Transesophageal echocardiography is reasonable in endovascular thoracic aortic procedures for monitoring, procedural guidance, and/or endovascular graft leak detection.[34][35][36] (Level of Evidence: B)"
"2. Motor or somatosensory evoked potential monitoring can be useful when the data will help to guide therapy. It is reasonable to base the decision to use neurophysiologic monitoring on individual patient needs, institutional resources, the urgency of the procedure, and the surgical and perfusion techniques to be employed in the open or endovascular thoracic aortic repair.[37][38] (Level of Evidence: B)"

Transfusion Management and Anticoagulation in Thoracic Aortic Surgery (DO NOT EDIT)[3]

Class IIa
"1. An algorithmic approach to transfusion, antifibrinolytic, and anticoagulation management is reasonable to use in both open and endovascular thoracic aortic repairs during the perioperative period. Institutional variations in coagulation testing capability and availability of transfusion products and other prothrombotic and antithrombotic agents are important considerations in defining such an approach.[39] (Level of Evidence: C)"

Brain Protection During Ascending Aortic and Transverse Aortic Arch Surgery (DO NOT EDIT)[3]

Class I
"1. A brain protection strategy to prevent stroke and preserve cognitive function should be a key element of the surgical, anesthetic, and perfusion techniques used to accomplish repairs of the ascending aorta and transverse aortic arch.[40][41][42][43][44][45][46] (Level of Evidence: B)"
Class III (Harm)
"1. Perioperative brain hyperthermia is not recommended in repairs of the ascending aortic and transverse aortic arch as it is probably injurious to the brain.[47][48][49] (Level of Evidence: B)"
Class IIa
"1. Deep hypothermic circulatory arrest, selective antegrade brain perfusion, and retrograde brain perfusion are techniques that alone or in combination are reasonable to minimize brain injury during surgical repairs of the ascending aorta and transverse aortic arch. Institutional experience is an important factor in selecting these techniques.[50][51][52][53][54][55][56][57][58][59][60][61][62][63][64][65][66][67][68][69][70][71][72][73] (Level of Evidence: B)"

Spinal Cord Protection During Descending Aortic Open Surgical and Endovascular Repairs (DO NOT EDIT)[3]

Class I
"1. Cerebrospinal fluid drainage is recommended as a spinal cord protective strategy in open and endovascular thoracic aortic repair for patients at high risk of spinal cord ischemic injury.[74][75][76] (Level of Evidence: B)"
Class IIa
"1. Spinal cord perfusion pressure optimization using techniques, such as proximal aortic pressure maintenance and distal aortic perfusion, is reasonable as an integral part of the surgical, anesthetic, and perfusion strategy in open and endovascular thoracic aortic repair patients at high risk of spinal cord ischemic injury. Institutional experience is an important factor in selecting these techniques.[77][78][79] (Level of Evidence: B)"
"2. Moderate systemic hypothermia is reasonable for protection of the spinal cord during open repairs of the descending thoracic aorta.[80] (Level of Evidence: B)"
Class IIb
"1. Adjunctive techniques to increase the tolerance of the spinal cord to impaired perfusion may be considered during open and endovascular thoracic aortic repair for patients at high risk of spinal cord injury. These include distal perfusion, epidural irrigation with hypothermic solutions, high-dose systemic glucocorticoids, osmotic diuresis with mannitol, intrathecal papaverine, and cellular metabolic suppression with anesthetic agents.[79][81][82][83] (Level of Evidence: B)"
"2. Neurophysiological monitoring of the spinal cord (somatosensory evoked potentials or motor evoked potentials) may be considered as a strategy to detect spinal cord ischemia and to guide reimplantation of intercostal arteries and/or hemodynamic optimization to prevent or treat spinal cord ischemia.[84][85][86] (Level of Evidence: B)"

Renal Protection During Descending Aortic Open Surgical and Endovascular Repairs (DO NOT EDIT)[3]

Class III (Harm)
"1. Furosemide, mannitol, or dopamine should not be given solely for the purpose of renal protection in descending aortic repairs.[87][88] (Level of Evidence: B)"
Class IIb
"1. Preoperative hydration and intraoperative mannitol administration may be reasonable strategies for preservation of renal function in open repairs of the descending aorta. (Level of Evidence: C)"
"2. During thoracoabdominal or descending aortic repairs with exposure of the renal arteries, renal protection by either cold crystalloid or blood perfusion may be considered.[89][90][91] (Level of Evidence: B)"

References

  1. ↑ Tadros TM, Klein MD, Shapira OM (2009). "Ascending aortic dilatation associated with bicuspid aortic valve: pathophysiology, molecular biology, and clinical implications". Circulation. 119 (6): 880–90. doi:10.1161/CIRCULATIONAHA.108.795401. PMID 19221231. Unknown parameter |month= ignored (help)
  2. ↑ Jondeau G, Ropers J, Regalado E, Braverman A, Evangelista A, Teixedo G, De Backer J, Muiño-Mosquera L, Naudion S, Zordan C, Morisaki T, Morisaki H, Von Kodolitsch Y, Dupuis-Girod S, Morris SA, Jeremy R, Odent S, Adès LC, Bakshi M, Holman K, LeMaire S, Milleron O, Langeois M, Spentchian M, Aubart M, Boileau C, Pyeritz R, Milewicz DM (December 2016). "International Registry of Patients Carrying TGFBR1 or TGFBR2 Mutations: Results of the MAC (Montalcino Aortic Consortium)". Circ Cardiovasc Genet. 9 (6): 548–558. doi:10.1161/CIRCGENETICS.116.001485. PMC 5177493. PMID 27879313.
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 Hiratzka LF, Bakris GL, Beckman JA; et al. (2010). "2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine". Circulation. 121 (13): e266–369. doi:10.1161/CIR.0b013e3181d4739e. PMID 20233780. Unknown parameter |month= ignored (help)
  4. ↑ Svensson LG, Kouchoukos NT, Miller DC, Bavaria JE, Coselli JS, Curi MA; et al. (2008). "Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts". Ann Thorac Surg. 85 (1 Suppl): S1–41. doi:10.1016/j.athoracsur.2007.10.099. PMID [ 18083364 [ Check |pmid= value (help).
  5. ↑ Gott VL, Greene PS, Alejo DE; et al. (1999). "Replacement of the aortic root in patients with Marfan's syndrome". N. Engl. J. Med. 340 (17): 1307–13. doi:10.1056/NEJM199904293401702. PMID 10219065. Unknown parameter |month= ignored (help)
  6. ↑ 6.0 6.1 6.2 6.3 Svensson LG, Kouchoukos NT, Miller DC; et al. (2008). "Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts". Ann. Thorac. Surg. 85 (1 Suppl): S1–41. doi:10.1016/j.athoracsur.2007.10.099. PMID 18083364. Unknown parameter |month= ignored (help)
  7. ↑ Kouchoukos NT, Dougenis D (1997). "Surgery of the thoracic aorta". N. Engl. J. Med. 336 (26): 1876–88. doi:10.1056/NEJM199706263362606. PMID 9197217. Unknown parameter |month= ignored (help)
  8. ↑ Elefteriades JA (2002). "Natural history of thoracic aortic aneurysms: indications for surgery, and surgical versus nonsurgical risks". Ann. Thorac. Surg. 74 (5): S1877–80, discussion S1892–8. PMID 12440685. Unknown parameter |month= ignored (help)
  9. ↑ Boissonnas CC, Davy C, Bornes M; et al. (2009). "Careful cardiovascular screening and follow-up of women with Turner syndrome before and during pregnancy is necessary to prevent maternal mortality". Fertil. Steril. 91 (3): 929.e5–7. doi:10.1016/j.fertnstert.2008.09.037. PMID 18990374. Unknown parameter |month= ignored (help)
  10. ↑ Svensson LG, Kim KH, Lytle BW, Cosgrove DM (2003). "Relationship of aortic cross-sectional area to height ratio and the risk of aortic dissection in patients with bicuspid aortic valves". J. Thorac. Cardiovasc. Surg. 126 (3): 892–3. PMID 14502185. Unknown parameter |month= ignored (help)
  11. ↑ Tzemos N, Therrien J, Yip J; et al. (2008). "Outcomes in adults with bicuspid aortic valves". JAMA. 300 (11): 1317–25. doi:10.1001/jama.300.11.1317. PMID 18799444. Unknown parameter |month= ignored (help)
  12. ↑ Vallely MP, Semsarian C, Bannon PG (2008). "Management of the ascending aorta in patients with bicuspid aortic valve disease". Heart Lung Circ. 17 (5): 357–63. doi:10.1016/j.hlc.2008.01.007. PMID 18514024. Unknown parameter |month= ignored (help)
  13. ↑ Svensson LG, Khitin L (2002). "Aortic cross-sectional area/height ratio timing of aortic surgery in asymptomatic patients with Marfan syndrome". J. Thorac. Cardiovasc. Surg. 123 (2): 360–1. PMID 11828302. Unknown parameter |month= ignored (help)
  14. ↑ 14.0 14.1 Iribarren C, Sidney S, Sternfeld B, Browner WS (2000). "Calcification of the aortic arch: risk factors and association with coronary heart disease, stroke, and peripheral vascular disease". JAMA. 283 (21): 2810–5. PMID 10838649. Unknown parameter |month= ignored (help)
  15. ↑ Loeys BL, Schwarze U, Holm T; et al. (2006). "Aneurysm syndromes caused by mutations in the TGF-beta receptor". N. Engl. J. Med. 355 (8): 788–98. doi:10.1056/NEJMoa055695. PMID 16928994. Unknown parameter |month= ignored (help)
  16. ↑ Vaughan CJ, Casey M, He J; et al. (2001). "Identification of a chromosome 11q23.2-q24 locus for familial aortic aneurysm disease, a genetically heterogeneous disorder". Circulation. 103 (20): 2469–75. PMID 11369687. Unknown parameter |month= ignored (help)
  17. ↑ Abedin M, Tintut Y, Demer LL (2004). "Vascular calcification: mechanisms and clinical ramifications". Arterioscler. Thromb. Vasc. Biol. 24 (7): 1161–70. doi:10.1161/01.ATV.0000133194.94939.42. PMID 15155384. Unknown parameter |month= ignored (help)
  18. ↑ Chiu KM, Lin TY, Chen JS, Li SJ, Chan CY, Chu SH (2006). "Images in cardiovascular medicine. Left ventricle apical conduit to bilateral subclavian artery in a patient with porcelain aorta and aortic stenosis". Circulation. 113 (9): e388–9. doi:10.1161/CIRCULATIONAHA.105.548065. PMID 16520418. Unknown parameter |month= ignored (help)
  19. ↑ Svensson LG, Blackstone EH, Rajeswaran J; et al. (2004). "Does the arterial cannulation site for circulatory arrest influence stroke risk?". Ann. Thorac. Surg. 78 (4): 1274–84, discussion 1274–84. doi:10.1016/j.athoracsur.2004.04.063. PMID 15464485. Unknown parameter |month= ignored (help)
  20. ↑ 20.0 20.1 Crawford ES, Kirklin JW, Naftel DC, Svensson LG, Coselli JS, Safi HJ (1992). "Surgery for acute dissection of ascending aorta. Should the arch be included?". J. Thorac. Cardiovasc. Surg. 104 (1): 46–59. PMID 1614214. Unknown parameter |month= ignored (help)
  21. ↑ 21.0 21.1 Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ (1990). "Dissection of the aorta and dissecting aortic aneurysms. Improving early and long-term surgical results". Circulation. 82 (5 Suppl): IV24–38. PMID 2225411. Unknown parameter |month= ignored (help)
  22. ↑ Greenberg RK, Haddad F, Svensson L; et al. (2005). "Hybrid approaches to thoracic aortic aneurysms: the role of endovascular elephant trunk completion". Circulation. 112 (17): 2619–26. doi:10.1161/CIRCULATIONAHA.105.552398. PMID 16246961. Unknown parameter |month= ignored (help)
  23. ↑ Svensson LG (2005). "The elephant trunk procedure: uses in complex aortic diseases". Curr. Opin. Cardiol. 20 (6): 491–5. PMID 16234619. Unknown parameter |month= ignored (help)
  24. ↑ Svensson LG, Kim KH, Blackstone EH; et al. (2004). "Elephant trunk procedure: newer indications and uses". Ann. Thorac. Surg. 78 (1): 109–16, discussion 109–16. doi:10.1016/j.athoracsur.2004.02.098. PMID 15223413. Unknown parameter |month= ignored (help)
  25. ↑ Coady MA, Rizzo JA, Hammond GL; et al. (1997). "What is the appropriate size criterion for resection of thoracic aortic aneurysms?". J. Thorac. Cardiovasc. Surg. 113 (3): 476–91, discussion 489–91. PMID 9081092. Unknown parameter |month= ignored (help)
  26. ↑ Estrera AL, Rubenstein FS, Miller CC, Huynh TT, Letsou GV, Safi HJ (2001). "Descending thoracic aortic aneurysm: surgical approach and treatment using the adjuncts cerebrospinal fluid drainage and distal aortic perfusion". Ann. Thorac. Surg. 72 (2): 481–6. PMID 11515886. Unknown parameter |month= ignored (help)
  27. ↑ Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ (1993). "Variables predictive of outcome in 832 patients undergoing repairs of the descending thoracic aorta". Chest. 104 (4): 1248–53. PMID 8404201. Unknown parameter |month= ignored (help)
  28. ↑ Matsumura JS, Cambria RP, Dake MD, Moore RD, Svensson LG, Snyder S (2008). "International controlled clinical trial of thoracic endovascular aneurysm repair with the Zenith TX2 endovascular graft: 1-year results". J. Vasc. Surg. 47 (2): 247–257, discussion 257. doi:10.1016/j.jvs.2007.10.032. PMID 18241743. Unknown parameter |month= ignored (help)
  29. ↑ Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ (1992). "Thoracoabdominal aortic aneurysms associated with celiac, superior mesenteric, and renal artery occlusive disease: methods and analysis of results in 271 patients". J. Vasc. Surg. 16 (3): 378–89, discussion 389–90. PMID 1522640. Unknown parameter |month= ignored (help)
  30. ↑ Boden WE, O'Rourke RA, Teo KK; et al. (2007). "Optimal medical therapy with or without PCI for stable coronary disease". N. Engl. J. Med. 356 (15): 1503–16. doi:10.1056/NEJMoa070829. PMID 17387127. Unknown parameter |month= ignored (help)
  31. ↑ Cinà CS, Devereaux PJ (2006). "Coronary-artery revascularization before elective major vascular surgery. McFalls EO, ward HB, Moritz TE, Goldman S, Krupski WC, Littooy F, Pierpont G, Santilli S, Rapp J, Hattler B, Shunk K, Jaenicke C, Thottapurathu L, Ellis N, Reda DJ, Henderson WG. N Engl J Med. 2004; 351: 2795-804". Vasc Med. 11 (1): 61–3. PMID 16669417. Unknown parameter |month= ignored (help)
  32. ↑ Poldermans D, Schouten O, Vidakovic R; et al. (2007). "A clinical randomized trial to evaluate the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery: the DECREASE-V Pilot Study". J. Am. Coll. Cardiol. 49 (17): 1763–9. doi:10.1016/j.jacc.2006.11.052. PMID 17466225. Unknown parameter |month= ignored (help)
  33. ↑ Horlocker TT, Wedel DJ, Benzon H; et al. (2003). "Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation)". Reg Anesth Pain Med. 28 (3): 172–97. doi:10.1053/rapm.2003.50046. PMID 12772135.
  34. ↑ "Practice guidelines for perioperative transesophageal echocardiography. A report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography". Anesthesiology. 84 (4): 986–1006. 1996. PMID 8638856. Unknown parameter |month= ignored (help)
  35. ↑ Fattori R, Caldarera I, Rapezzi C; et al. (2000). "Primary endoleakage in endovascular treatment of the thoracic aorta: importance of intraoperative transesophageal echocardiography". J. Thorac. Cardiovasc. Surg. 120 (3): 490–5. doi:10.1067/mtc.2000.108904. PMID 10962409. Unknown parameter |month= ignored (help)
  36. ↑ Abe S, Ono S, Murata K; et al. (2000). "Usefulness of transesophageal echocardiographic monitoring in transluminal endovascular stent-graft repair for thoracic aortic aneurysm". Jpn. Circ. J. 64 (12): 960–4. PMID 11194291. Unknown parameter |month= ignored (help)
  37. ↑ Dong CC, MacDonald DB, Janusz MT (2002). "Intraoperative spinal cord monitoring during descending thoracic and thoracoabdominal aneurysm surgery". Ann. Thorac. Surg. 74 (5): S1873–6, discussion S1892–8. PMID 12440684. Unknown parameter |month= ignored (help)
  38. ↑ Meylaerts SA, Jacobs MJ, van Iterson V, De Haan P, Kalkman CJ (1999). "Comparison of transcranial motor evoked potentials and somatosensory evoked potentials during thoracoabdominal aortic aneurysm repair". Ann. Surg. 230 (6): 742–9. PMC 1420937. PMID 10615928. Unknown parameter |month= ignored (help)
  39. ↑ Ferraris VA, Ferraris SP, Saha SP; et al. (2007). "Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline". Ann. Thorac. Surg. 83 (5 Suppl): S27–86. doi:10.1016/j.athoracsur.2007.02.099. PMID 17462454. Unknown parameter |month= ignored (help)
  40. ↑ Akashi H, Tayama K, Fujino T; et al. (2000). "Cerebral protection selection in aortic arch surgery for patients with preoperative complications of cerebrovascular disease". Jpn. J. Thorac. Cardiovasc. Surg. 48 (12): 782–8. PMID 11197822. Unknown parameter |month= ignored (help)
  41. ↑ Ehrlich MP, Fang WC, Grabenwöger M; et al. (1999). "Impact of retrograde cerebral perfusion on aortic arch aneurysm repair". J. Thorac. Cardiovasc. Surg. 118 (6): 1026–32. PMID 10595974. Unknown parameter |month= ignored (help)
  42. ↑ Di Eusanio M, Wesselink RM, Morshuis WJ, Dossche KM, Schepens MA (2003). "Deep hypothermic circulatory arrest and antegrade selective cerebral perfusion during ascending aorta-hemiarch replacement: a retrospective comparative study". J. Thorac. Cardiovasc. Surg. 125 (4): 849–54. doi:10.1067/mtc.2003.8. PMID 12698148. Unknown parameter |month= ignored (help)
  43. ↑ Hagl C, Ergin MA, Galla JD; et al. (2001). "Neurologic outcome after ascending aorta-aortic arch operations: effect of brain protection technique in high-risk patients". J. Thorac. Cardiovasc. Surg. 121 (6): 1107–21. doi:10.1067/mtc.2001.113179. PMID 11385378. Unknown parameter |month= ignored (help)
  44. ↑ Reich DL, Uysal S, Sliwinski M; et al. (1999). "Neuropsychologic outcome after deep hypothermic circulatory arrest in adults". J. Thorac. Cardiovasc. Surg. 117 (1): 156–63. PMID 9869770. Unknown parameter |month= ignored (help)
  45. ↑ Reich DL, Uysal S, Ergin MA, Bodian CA, Hossain S, Griepp RB (2001). "Retrograde cerebral perfusion during thoracic aortic surgery and late neuropsychological dysfunction". Eur J Cardiothorac Surg. 19 (5): 594–600. PMID 11343938. Unknown parameter |month= ignored (help)
  46. ↑ Usui A, Yasuura K, Watanabe T, Maseki T (1999). "Comparative clinical study between retrograde cerebral perfusion and selective cerebral perfusion in surgery for acute type A aortic dissection". Eur J Cardiothorac Surg. 15 (5): 571–8. PMID 10386399. Unknown parameter |month= ignored (help)
  47. ↑ Grigore AM, Grocott HP, Mathew JP; et al. (2002). "The rewarming rate and increased peak temperature alter neurocognitive outcome after cardiac surgery". Anesth. Analg. 94 (1): 4–10, table of contents. PMID 11772792. Unknown parameter |month= ignored (help)
  48. ↑ Grocott HP, Mackensen GB, Grigore AM; et al. (2002). "Postoperative hyperthermia is associated with cognitive dysfunction after coronary artery bypass graft surgery". Stroke. 33 (2): 537–41. PMID 11823666. Unknown parameter |month= ignored (help)
  49. ↑ Bar-Yosef S, Mathew JP, Newman MF, Landolfo KP, Grocott HP (2004). "Prevention of cerebral hyperthermia during cardiac surgery by limiting on-bypass rewarming in combination with post-bypass body surface warming: a feasibility study". Anesth. Analg. 99 (3): 641–6, table of contents. doi:10.1213/01.ANE.0000130354.90659.63. PMID 15333386. Unknown parameter |month= ignored (help)
  50. ↑ Kunihara T, Grün T, Aicher D; et al. (2005). "Hypothermic circulatory arrest is not a risk factor for neurologic morbidity in aortic surgery: a propensity score analysis". J. Thorac. Cardiovasc. Surg. 130 (3): 712–8. doi:10.1016/j.jtcvs.2005.03.043. PMID 16153918. Unknown parameter |month= ignored (help)
  51. ↑ Schepens MA, Dossche KM, Morshuis WJ, van den Barselaar PJ, Heijmen RH, Vermeulen FE (2002). "The elephant trunk technique: operative results in 100 consecutive patients". Eur J Cardiothorac Surg. 21 (2): 276–81. PMID 11825735. Unknown parameter |month= ignored (help)
  52. ↑ Deeb GM, Williams DM, Quint LE, Monaghan HM, Shea MJ (1999). "Risk analysis for aortic surgery using hypothermic circulatory arrest with retrograde cerebral perfusion". Ann. Thorac. Surg. 67 (6): 1883–6, discussion 1891–4. PMID 10391332. Unknown parameter |month= ignored (help)
  53. ↑ Ehrlich MP, Schillinger M, Grabenwöger M; et al. (2003). "Predictors of adverse outcome and transient neurological dysfunction following surgical treatment of acute type A dissections". Circulation. 108 Suppl 1: II318–23. doi:10.1161/01.cir.0000087428.63818.50. PMID 12970253. Unknown parameter |month= ignored (help)
  54. ↑ Fleck TM, Czerny M, Hutschala D, Koinig H, Wolner E, Grabenwoger M (2003). "The incidence of transient neurologic dysfunction after ascending aortic replacement with circulatory arrest". Ann. Thorac. Surg. 76 (4): 1198–202. PMID 14530011. Unknown parameter |month= ignored (help)
  55. ↑ Moshkovitz Y, David TE, Caleb M, Feindel CM, de Sa MP (1998). "Circulatory arrest under moderate systemic hypothermia and cold retrograde cerebral perfusion". Ann. Thorac. Surg. 66 (4): 1179–84. PMID 9800803. Unknown parameter |month= ignored (help)
  56. ↑ Okita Y, Takamoto S, Ando M, Morota T, Matsukawa R, Kawashima Y (1998). "Mortality and cerebral outcome in patients who underwent aortic arch operations using deep hypothermic circulatory arrest with retrograde cerebral perfusion: no relation of early death, stroke, and delirium to the duration of circulatory arrest". J. Thorac. Cardiovasc. Surg. 115 (1): 129–38. PMID 9451056. Unknown parameter |month= ignored (help)
  57. ↑ Ueda Y, Okita Y, Aomi S, Koyanagi H, Takamoto S (1999). "Retrograde cerebral perfusion for aortic arch surgery: analysis of risk factors". Ann. Thorac. Surg. 67 (6): 1879–82, discussion 1891–4. PMID 10391331. Unknown parameter |month= ignored (help)
  58. ↑ Wong CH, Bonser RS (1999). "Does retrograde cerebral perfusion affect risk factors for stroke and mortality after hypothermic circulatory arrest?". Ann. Thorac. Surg. 67 (6): 1900–3, discussion 1919–21. PMID 10391335. Unknown parameter |month= ignored (help)
  59. ↑ Di Eusanio M, Schepens MA, Morshuis WJ; et al. (2003). "Brain protection using antegrade selective cerebral perfusion: a multicenter study". Ann. Thorac. Surg. 76 (4): 1181–8, discussion 1188–9. PMID 14530009. Unknown parameter |month= ignored (help)
  60. ↑ Di Eusanio M, Schepens MA, Morshuis WJ, Di Bartolomeo R, Pierangeli A, Dossche KM (2002). "Antegrade selective cerebral perfusion during operations on the thoracic aorta: factors influencing survival and neurologic outcome in 413 patients". J. Thorac. Cardiovasc. Surg. 124 (6): 1080–6. doi:10.1067/mtc.2002.124994. PMID 12447172. Unknown parameter |month= ignored (help)
  61. ↑ Di Eusanio M, Tan ME, Schepens MA; et al. (2003). "Surgery for acute type A dissection using antegrade selective cerebral perfusion: experience with 122 patients". Ann. Thorac. Surg. 75 (2): 514–9. PMID 12607664. Unknown parameter |month= ignored (help)
  62. ↑ Kazui T, Yamashita K, Washiyama N; et al. (2002). "Impact of an aggressive surgical approach on surgical outcome in type A aortic dissection". Ann. Thorac. Surg. 74 (5): S1844–7, discussion S1857–63. PMID 12440678. Unknown parameter |month= ignored (help)
  63. ↑ Kazui T, Yamashita K, Washiyama N; et al. (2007). "Aortic arch replacement using selective cerebral perfusion". Ann. Thorac. Surg. 83 (2): S796–8, discussion S824–31. doi:10.1016/j.athoracsur.2006.10.082. PMID 17257929. Unknown parameter |month= ignored (help)
  64. ↑ Numata S, Ogino H, Sasaki H; et al. (2003). "Total arch replacement using antegrade selective cerebral perfusion with right axillary artery perfusion". Eur J Cardiothorac Surg. 23 (5): 771–5, discussion 775. PMID 12754031. Unknown parameter |month= ignored (help)
  65. ↑ Sasaki H, Ogino H, Matsuda H, Minatoya K, Ando M, Kitamura S (2007). "Integrated total arch replacement using selective cerebral perfusion: a 6-year experience". Ann. Thorac. Surg. 83 (2): S805–10, discussion S824–31. doi:10.1016/j.athoracsur.2006.10.094. PMID 17257931. Unknown parameter |month= ignored (help)
  66. ↑ Strauch JT, Spielvogel D, Lauten A; et al. (2004). "Axillary artery cannulation: routine use in ascending aorta and aortic arch replacement". Ann. Thorac. Surg. 78 (1): 103–8, discussion 103–8. doi:10.1016/j.athoracsur.2004.01.035. PMID 15223412. Unknown parameter |month= ignored (help)
  67. ↑ Kamiya H, Hagl C, Kropivnitskaya I; et al. (2007). "Quick proximal arch replacement with moderate hypothermic circulatory arrest". Ann. Thorac. Surg. 83 (3): 1055–8. doi:10.1016/j.athoracsur.2006.09.085. PMID 17307459. Unknown parameter |month= ignored (help)
  68. ↑ Matalanis G, Hata M, Buxton BF (2003). "A retrospective comparative study of deep hypothermic circulatory arrest, retrograde, and antegrade cerebral perfusion in aortic arch surgery". Ann Thorac Cardiovasc Surg. 9 (3): 174–9. PMID 12875639. Unknown parameter |month= ignored (help)
  69. ↑ Okita Y, Minatoya K, Tagusari O, Ando M, Nagatsuka K, Kitamura S (2001). "Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion". Ann. Thorac. Surg. 72 (1): 72–9. PMID 11465234. Unknown parameter |month= ignored (help)
  70. ↑ Zierer A, Aybek T, Risteski P, Dogan S, Wimmer-Greinecker G, Moritz A (2005). "Moderate hypothermia (30 degrees C) for surgery of acute type A aortic dissection". Thorac Cardiovasc Surg. 53 (2): 74–9. doi:10.1055/s-2004-830458. PMID 15786004. Unknown parameter |month= ignored (help)
  71. ↑ Svensson LG, Nadolny EM, Kimmel WA (2002). "Multimodal protocol influence on stroke and neurocognitive deficit prevention after ascending/arch aortic operations". Ann. Thorac. Surg. 74 (6): 2040–6. PMID 12643393. Unknown parameter |month= ignored (help)
  72. ↑ Okita Y, Ando M, Minatoya K, Kitamura S, Takamoto S, Nakajima N (1999). "Predictive factors for mortality and cerebral complications in arteriosclerotic aneurysm of the aortic arch". Ann. Thorac. Surg. 67 (1): 72–8. PMID 10086527. Unknown parameter |month= ignored (help)
  73. ↑ Svensson LG, Crawford ES, Hess KR; et al. (1993). "Deep hypothermia with circulatory arrest. Determinants of stroke and early mortality in 656 patients". J. Thorac. Cardiovasc. Surg. 106 (1): 19–28, discussion 28–31. PMID 8321002. Unknown parameter |month= ignored (help)
  74. ↑ Coselli JS, LeMaire SA, Köksoy C, Schmittling ZC, Curling PE (2002). "Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial". J. Vasc. Surg. 35 (4): 631–9. PMID 11932655. Unknown parameter |month= ignored (help)
  75. ↑ Khan SN, Stansby G (2004). "Cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery". Cochrane Database Syst Rev (1): CD003635. doi:10.1002/14651858.CD003635.pub2. PMID 14974026.
  76. ↑ Safi HJ, Miller CC, Huynh TT; et al. (2003). "Distal aortic perfusion and cerebrospinal fluid drainage for thoracoabdominal and descending thoracic aortic repair: ten years of organ protection". Ann. Surg. 238 (3): 372–80, discussion 380–1. doi:10.1097/01.sla.0000086664.90571.7a. PMC 1422700. PMID 14501503. Unknown parameter |month= ignored (help)
  77. ↑ Estrera AL, Miller CC, Chen EP; et al. (2005). "Descending thoracic aortic aneurysm repair: 12-year experience using distal aortic perfusion and cerebrospinal fluid drainage". Ann. Thorac. Surg. 80 (4): 1290–6, discussion 1296. doi:10.1016/j.athoracsur.2005.02.021. PMID 16181856. Unknown parameter |month= ignored (help)
  78. ↑ Safi HJ, Hess KR, Randel M; et al. (1996). "Cerebrospinal fluid drainage and distal aortic perfusion: reducing neurologic complications in repair of thoracoabdominal aortic aneurysm types I and II". J. Vasc. Surg. 23 (2): 223–8, discussion 229. PMID 8637099. Unknown parameter |month= ignored (help)
  79. ↑ 79.0 79.1 Hollier LH, Money SR, Naslund TC; et al. (1992). "Risk of spinal cord dysfunction in patients undergoing thoracoabdominal aortic replacement". Am. J. Surg. 164 (3): 210–3, discussion 213–4. PMID 1415916. Unknown parameter |month= ignored (help)
  80. ↑ Svensson LG, Khitin L, Nadolny EM, Kimmel WA (2003). "Systemic temperature and paralysis after thoracoabdominal and descending aortic operations". Arch Surg. 138 (2): 175–9, discussion 180. PMID 12578415. Unknown parameter |month= ignored (help)
  81. ↑ Cambria RP, Davison JK, Carter C; et al. (2000). "Epidural cooling for spinal cord protection during thoracoabdominal aneurysm repair: A five-year experience". J. Vasc. Surg. 31 (6): 1093–102. PMID 10842145. Unknown parameter |month= ignored (help)
  82. ↑ Cambria RP, Davison JK, Zannetti S; et al. (1997). "Clinical experience with epidural cooling for spinal cord protection during thoracic and thoracoabdominal aneurysm repair". J. Vasc. Surg. 25 (2): 234–41, discussion 241–3. PMID 9052558. Unknown parameter |month= ignored (help)
  83. ↑ Woloszyn TT, Marini CP, Coons MS; et al. (1990). "Cerebrospinal fluid drainage and steroids provide better spinal cord protection during aortic cross-clamping than does either treatment alone". Ann. Thorac. Surg. 49 (1): 78–82, discussion 83. PMID 2297277. Unknown parameter |month= ignored (help)
  84. ↑ Schurink GW, Nijenhuis RJ, Backes WH; et al. (2007). "Assessment of spinal cord circulation and function in endovascular treatment of thoracic aortic aneurysms". Ann. Thorac. Surg. 83 (2): S877–81, discussion S890–2. doi:10.1016/j.athoracsur.2006.11.028. PMID 17257945. Unknown parameter |month= ignored (help)
  85. ↑ Ogino H, Sasaki H, Minatoya K, Matsuda H, Yamada N, Kitamura S (2006). "Combined use of adamkiewicz artery demonstration and motor-evoked potentials in descending and thoracoabdominal repair". Ann. Thorac. Surg. 82 (2): 592–6. doi:10.1016/j.athoracsur.2006.03.041. PMID 16863770. Unknown parameter |month= ignored (help)
  86. ↑ Guerit JM, Witdoeckt C, Verhelst R, Matta AJ, Jacquet LM, Dion RA (1999). "Sensitivity, specificity, and surgical impact of somatosensory evoked potentials in descending aorta surgery". Ann. Thorac. Surg. 67 (6): 1943–6, discussion 1953–8. PMID 10391345. Unknown parameter |month= ignored (help)
  87. ↑ Perdue PW, Balser JR, Lipsett PA, Breslow MJ (1998). ""Renal dose" dopamine in surgical patients: dogma or science?". Ann. Surg. 227 (4): 470–3. PMC 1191298. PMID 9563531. Unknown parameter |month= ignored (help)
  88. ↑ Hager B, Betschart M, Krapf R (1996). "Effect of postoperative intravenous loop diuretic on renal function after major surgery". Schweiz Med Wochenschr. 126 (16): 666–73. PMID 8658094. Unknown parameter |month= ignored (help)
  89. ↑ Jacobs MJ, de Mol BA, Legemate DA, Veldman DJ, de Haan P, Kalkman CJ (1997). "Retrograde aortic and selective organ perfusion during thoracoabdominal aortic aneurysm repair". Eur J Vasc Endovasc Surg. 14 (5): 360–6. PMID 9413376. Unknown parameter |month= ignored (help)
  90. ↑ Köksoy C, LeMaire SA, Curling PE; et al. (2002). "Renal perfusion during thoracoabdominal aortic operations: cold crystalloid is superior to normothermic blood". Ann. Thorac. Surg. 73 (3): 730–8. PMID 11899174. Unknown parameter |month= ignored (help)
  91. ↑ Svensson LG, Coselli JS, Safi HJ, Hess KR, Crawford ES (1989). "Appraisal of adjuncts to prevent acute renal failure after surgery on the thoracic or thoracoabdominal aorta". J. Vasc. Surg. 10 (3): 230–9. PMID 2778885. Unknown parameter |month= ignored (help)

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