Open Repair of Thoracoabdominal Aortic Aneurysm: Step-by-Step

Abstract

Open surgical repair remains the gold standard operation for thoracoabdominal aortic aneurysm (TAAA). Contemporary surgical approaches balance the need to maximize long-term benefit by replacing as much diseased aorta as possible with limiting ischemia-related risk to the spinal cord and other organs. Despite the formidable challenges that extensive aortic replacement entails, excellent outcomes and a durable repair can be achieved at experienced centers. Here, we describe in detail our current approach to open TAAA repair, which includes providing spinal cord and end-organ protection by the use of surgical adjuncts such as cerebrospinal fluid drainage, mild passive hypothermia (32-33˚C nasopharyngeal), left heart bypass, sequential aortic cross-clamping, selective visceral artery perfusion and, whenever possible, reimplantation of segmental arteries and use of cold renal perfusion. We illustrate this approach in a case of Crawford extent II TAAA repair with a branched graft. Operative Techniques in Thoracic and Cardiovasculary Surgery 23:2À20

Mind the gap: Transesophageal echocardiography aids detection of pseudo-coarctation during thoracoabdominal surgery

“…The presence of a large distal arch aneurysm, mandates clamping the arch, which also increases the risk of iatrogenic retrograde type A aortic dissection related to a sudden increase in the proximal blood pressure. [1][2][3] Another potential complication of the proximal clamp and transection of the aorta at the proximal and mid-DTA level is a lesion in the esophageal wall, which would be devastating. [1][2][3] Other intraoperative methods to detect this complication are epiaortic ultrasound and direct pressure measurement with a gauge needle and pressure line inserted in the Once the left heart bypass was discontinued, a large pressure gradient (72 mm Hg) was noticed between the right radial and femoral arterial lines.…”

“…The aortic repair was conducted per our standard technique described elsewhere. [1][2][3] Once the LHB was discontinued, a large pressure gradient (72 mm Hg) was noticed between the right radial and femoral arterial lines ( Figure 4). The distal aortic graft pressure was measured directly inserting an 18-gauge needle connected to a manometer line into the Dacron (DuPont, Wilmington, Del) graft at the mid-descending thoracic level, confirming the pressure gradient.…”

Narrative review: open surgery for thoracoabdominal aortic aneurysm—is it still a horrible surgery?

“…Our surgical approach to open repair of TAAAs has been described previously (5,29). In brief, a sigmoid-shaped skin incision is made from behind the left scapula, along the 7th rib, across the costal margin, and toward the left periumbilical region (Video 1, Figure 2).…”

Left heart bypass versus circulatory arrest for open repair of thoracoabdominal aortic pathologies

“…3 Open TAAA repair remains the gold standard operation for TAAA, but it is an extensive and complex surgical procedure with significant mortality and morbidity. 4 In the past decades, techniques of open TAAA repair have moved from 'clamp and sew' techniques to perfusion-assisted techniques with the help of cardiopulmonary bypass (CPB) machines with various degrees of hypothermia.…”

“…The natural history of TAAA has been studied extensively, and indications for repair were proposed by Elefteriades and Botta to prevent complications of untreated TAAA such as rupture, dissection, local compression, thromboembolic events or organ malperfusion 3 . Open TAAA repair remains the gold standard operation for TAAA, but it is an extensive and complex surgical procedure with significant mortality and morbidity 4 . In the past decades, techniques of open TAAA repair have moved from ‘clamp and sew’ techniques to perfusion‐assisted techniques with the help of cardiopulmonary bypass (CPB) machines with various degrees of hypothermia.…”