Most patients who are referred for surgery for a thoracoabdominal aneurysm present with no symptoms. However, when they do have signs and/or symptoms, they may present with pain in the chest, abdomen, or lower back; a mass in the abdomen, which may be pulsatile, or rigid abdomen; and evidence of atheroembolism distally. The aforementioned symptoms, with signs of hypovolemic shock, may indicate a ruptured aneurysm.

Uncomplicated descending aortic dissections are generally managed medically. However, if the dissection is complicated, such as when it is associated with significant symptoms or leads to visceral or distal malperfusion, rapid surgical intervention is warranted.

A more complete discussion regarding indications for intervention in aortic dissections and thoracoabdominal aortic aneurysm can be found in a number of relevant reference textbooks.

Imaging is used to determine the proximal and distal extent of repair required. It impacts the type of exposure required (i.e., thoracotomy vs. laparotomy vs. thoracoabdominal incision) as well as the level of incision.

If the exposure is for the repair of thoracoabdominal aortic pathology, all patients require adequate preoperative imaging, ideally consisting of a computed tomography aortography (CTA) with or without 3-D reconstruction. Magnetic resonance aortography (MRA) may also provide the necessary information, but this generally requires more time, is more expensive, and requires more extensive postprocessing. However, MRA is the study of choice when CTA is contraindicated or unsafe, such as in patients with a contrast allergy or renal insufficiency. Catheter-based invasive aortography has generally been supplanted by CTA and MRA as the primary preoperative imaging
modality of choice, as it is more cumbersome and does not provide a complete assessment of the aneurysm, including thrombus volume and adjacent anatomic structures.

If the surgery is elective, as in the case of an incidentally found aneurysm, extensive preoperative evaluations are necessary to minimize postoperative morbidity and mortality.

Thorough evaluations of the cardiac, pulmonary, and renal systems are necessary, especially because these systems are most commonly affected when there are complications. Depending on the risk factors and prior history, further testing may be required and patients should be referred to appropriate specialists for proper evaluation. A good neurologic evaluation is also warranted, particularly if the patient has a prior history or symptoms suggestive of a lower extremity weakness or spinal injury.

Determine the possible need for adjuncts such as cardiopulmonary bypass and neurophysiologic monitoring. In some instances, pulmonary artery catheters may be warranted for monitoring cardiovascular hemodynamics.

Assess the need for spinal cord protection, including the use of lumbar drainage of cerebrospinal fluid (CSF), distal aortic perfusion, epidural cooling, and distal aortic perfusion.

Given the expected amount of blood loss, a Cell Saver and rapid infuser should be available.

Double lumen endotracheal tube should be used for singlelung ventilation of the right lung. Bronchial blockers are not reliable adjuncts for this purpose.