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Postoperative Anticoagulation

Postoperative anticoagulation should be held if the patient has a lumbar drain in place to reduce the possibility of epidural hema- toma; however, venous thrombo- embolism (VTE) prophylaxis is routine.8,26

Renal complications. Many patients with thoracic aneurysms often have chronic kidney disease. Contrast-induced nephropathy (CIN) and hypotensive injuries may result in further damage to renal function.2,27 Renal com- plications have been associated with a seven- to ninefold mortal- ity increase in patients with TAA repairs.27,28 Patients undergoing TEVAR require lifelong surveil- lance imaging with repeated contrast exposure to identify endoleak and graft migration.

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Therefore, the management of CIN in these patients remains complex.

Hydration with sodium bicar- bonate has been used to try to reduce CIN. Other proposals for management of these patients include stopping all angiotensin-

converting enzyme inhibitors and angiotensin II receptor blockers 48 hours prior to TEVAR, admit- ting patients with a creatinine greater than 2.0 mg/dL (normal serum creatinine level 0.5 to 1.2 mg/dL) for hydration preop- eratively, minimizing iodinated contrast media and/or using low or iso-osmolar contrast agents when possible, and avoiding nephrotoxic agents.5,28 The use of N-acetylcysteine, which is sometimes used to decrease renal complications in patients under- going cardiac catheterization, has not been proven effective in TEVAR.9 These patients require complex management pre- and postoperatively.

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