Anesthetic Management of Open and Endovascular Thoracoabdominal Aortic Aneurysm Repair: When, How, and Why to Use Intraoperative Transesophageal Echocardiography. A Narrative Review and Practical Framework.

Open surgical or endovascular thoracoabdominal aortic aneurysm (TAAA) repair induces abrupt and competing hemodynamic shifts, exposing patients to significant hemodynamic instability and procedure-specific complications. Although intraoperative transesophageal echocardiography (TEE) is a well-established adjunct for intraprocedural diagnostic and anatomic assessment, its role as a structured decision-making tool to support physiologic interpretation in the dynamic perioperative setting of aortic surgery remains insufficiently explored. This narrative review synthesizes current evidence and proposes a unified, stepwise, pragmatic algorithm for using TEE as a real-time intraoperative decision interface to support anesthetic management in both the open and endovascular settings. Following standardized baseline image acquisition, echocardiographic findings are subsequently interpreted dynamically (ie, linking specific patterns of ventricular loading, contractility, and flow to their clinical relevance and potential therapeutic implications). Within this framework, TEE may help translate hemodynamic data into clinical decisions by distinguishing preload depletion from contractile dysfunction, determining afterload excess or vasoplegia, and guiding fluid therapy, vasoactive modulation, bypass flow adjustment, and inotropic support. Likewise, in the setting of endovascular TAAA repair, TEE may further refine landing-zone optimization, confirm true-lumen wire positioning, and help detect endoleaks and raise suspicion of retrograde dissection. The proposed algorithm combines TEE imaging with real-time hemodynamic assessment to support intraoperative decision-making during open and endovascular TAAA repair.