Perioperative and Anesthetic Management of Coarctation of the Aorta.

Isolated coarctation of the aorta is a relatively common form of congenital heart disease that is characterized by variable degrees of obstruction to aortic outflow. The clinical presentation varies from asymptomatic arterial hypertension to cardiogenic shock. The treatment options include surgical repair or interventional therapy with aortic balloon dilation and stent placement. This article will summarize the pathophysiology as well as describe the surgical and interventional procedures. The anesthetic management for those interventions will be reviewed.

Delayed intervention of sporadic renal masses undergoing active surveillance.

BACKGROUND: Prompt surgical management remains the standard of care for renal cell carcinoma (RCC). Occasionally, it is necessary to postpone or delay surgical treatment. The authors of this report assessed whether delayed intervention following a period of active surveillance altered minimally invasive or nephron-sparing treatment plans, increased the risk of stage progression, and/or decreased recurrence-free survival rates. METHODS: The authors searched their institutional kidney cancer database to identify small (< or =4 cm in greatest dimension on presentation), enhancing renal masses for which treatment initially was delayed or refused. Clinical, radiographic, and pathologic records were reviewed to determine linear tumor growth kinetics, alterations in treatment plan, stage migration, and cancer-specific outcomes related to delayed intervention. RESULTS: Eighty-seven sporadic, localized, enhancing renal masses were identified in 82 patients who had management postponed for a median of 14 months (mean, 21 months; range, 6-97 months). Median tumor diameter was 2.0 cm on presentation. Treatment in 60 of 87 tumors (69%) was delayed for > or =12 months, and treatment was delayed for > or =24 months in 29 of 87 tumors (33%). Overall, 66 of 87 tumors (76%) underwent nephron-sparing approaches. In addition, 52 of 87 tumors (60%) were treated in a minimally invasive fashion. Pathology confirmed RCC in 73 of 87 treated tumors (84%). Fourteen of 54 tumors (26%) that were treated by surgical extirpation were high-risk tumors, and 3 of 54 tumors (6%) were upstaged on pathologic review. CONCLUSIONS: The majority of small, sporadic, clinically localized renal tumors demonstrated slow interval growth. The management of these lesions may be delayed cautiously without limiting or complicating the available treatment options or incurring a high risk of disease progression.