James C. Eisenach, M.D., Editor

Anesthesia for Aortic Surgery. By Joseph L. Simpson. Butterworth-Heinemann, 1997. Pages: 394. Price:$95.00.

As the preface states, this book is not intended to be a “how to” book. Its goal is to provide a solid background on the pathophysiology, epidemiology, and surgical treatment of diseases of the aorta. It correctly notes that aortic surgery chapters are part of cardiac, pediatric, and vascular anesthesia textbooks but that no book combines the information in one source. The first five chapters cover subjects applicable to all types of aortic surgery, including anatomy, preoperative risk assessment, monitoring, radiologic evaluation, and coagulation. The next five chapters deal with specific areas of aortic disease, including ascending, arch, descending, coarctation, and abdominal aorta. Finally it concludes with chapters on postoperative care and pain management.

The editor has attempted to decrease the redundancy of information and the inconsistent styles frequently found in multiauthored texts. As can be expected, this goal was not totally accomplished; there is redundancy on topics such as management of clamp manipulation and the effects of hypothermia on coagulation. The style varies significantly; some chapters are excessively detailed (the use of gold vs. silver electrodes for somatosensory-evoked potential monitoring), and others could be more thorough (no presentation of data regarding the advantages and disadvantages of mannitol or corticosteroids during hypothermic circulatory arrest).

Despite these shortcomings, the book provides excellent detail that is seldom found in large generalized textbooks. It is rare to find a chapter in an anesthesia textbook that covers the pathology of aortic disease as completely as the one with which this book begins. Preoperative risk assessment is covered with an unbiased presentation of data on topics such as the use of transesophageal echocardiography for cardiac ischemia monitoring, electroencephalography for spinal cord ischemia monitoring, and a comprehensive review of somatosensory- evoked potentials, with additional information on the advantages and disadvantages of motor-evoked potentials. The chapter on radiologic evaluation includes almost 50 photographs to demonstrate pertinent findings, including transesophageal echocardiography data.

Chapters 6 - 10 discuss surgery of specific areas of the aorta. The chapters on management of ascending and descending aortic disease and on coarctation are well written and comprehensive. There is plenty of discussion regarding controversial topics such as the use of lumbar drains, shunts, and nitroprusside. They also include reviews of the surgical options and surgical considerations. The chapter on arch repair is short considering all of the topics that could have been discussed. It briefly mentions that some anesthesiologists use mannitol or corticosteroids before deep hypothermic circulatory arrest, but it does not present any data to support or refute this practice. Finally the chapter on aortic abdominal aneurysms is complete but lengthy and redundant in its section on monitoring, manipulation of clamps, and spinal cord risk.

There are two chapters on postoperative management. The first is simple and thus helpful for students and residents. The second, on end-organ integrity, has much useful information for practicing anesthesiologists, although some of it is dated ("the mechanism of action of aprotonin is unknown"). The last chapter, on pain management, is excellent and would be helpful for most anesthesiologists who have to decide whether to use lumbar epidurals, intrathecal opioids, or continuous intrathecal catheters for aortic surgery.

Overall, anesthesia for Aortic Surgery has many excellent chapters that will prove invaluable for senior residents and practicing anesthesiologists. It is not a “how to” book, but it gives the reader an understanding of the issues and lets them decide how best to care for their patients.

Sanjay K. Anand, M.D.

Assistant Professor; Division of Cardiac Anesthesia; Department of Anesthesiology; University of Texas Medical Branch; Galveston, Texas 77555