Thoracoabdominal aneurysmectomy: Operative steps for Crawford extent II repair

Abstract

Background: Open surgical repair remains the gold standard for treatment of thoracoabdominal aortic aneurysm (TAAA). Surgery aims to replace the whole length of the diseased distal aorta while protecting the spinal cord and the visceral organs to limit ischemia-related complications. The substantial associated surgical risks, including death, paraplegia, renal failure requiring permanent dialysis, and respiratory complications leading to prolonged intensive care unit stay, still outweigh the natural history of TAAA with conservative treatment.Methods: We describe in detail our current approach to open extent II TAAA repair with a step-by-step illustration of the technique and the surgical adjuncts.Results: We routinely perform left heart bypass with mild passive hypothermia (34 C), cerebrospinal fluid drainage, sequential aortic cross-clamping, monitoring of motor evoked potentials (MEPs) and cerebral, paraspinal, and lower limb oxygen saturation by near-infrared spectrometry, as well as selective visceral perfusion via the celiac and superior mesenteric arteries and renal protection with intermittent administration of Custodiol HTK (histidine-tryptophan-ketoglutarate) solution via the renal arteries. We advocate for individual branch reimplantation using a branched thoracoabdominal graft when possible, and we selectively reattach 1 or more pairs of the lower thoracic intercostal arteries and/or high lumbar arteries, even in the absence of a significant reduction in the MEPs signal. The distal anastomosis is usually constructed above the aortic bifurcation and occasionally to each iliac separately using a bifurcated graft.Conclusions: Favorable early outcomes and a durable TAAA repair can be achieved at experienced high-volume centers with standardized preoperative selection and multidisciplinary team-based intraoperative and postoperative management of these patients. (JTCVS Techniques 2020;3:25-36) Surgical picture of complete repair of Crawford extent II TAAA.

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.…”

Commentary: Break the barrier: An unexpected transesophageal echocardiography finding of pseudo-coarctation in thoracoabdominal aortic repair

“…The involvement of the LSA in the disease process may represent a challenge for the proximal aortic clamp placement due to limited space of intact aortic tissue distal to the artery. 1 In this issue of JTCVS Techniques, Tully and colleagues 2 present a case of extensive thoracoabdominal aortic repair of DeBakey type III chronic dissection extending from the LSA down to the iliac arteries. The proximal aortic clamp was placed just distal to the LSA.…”

Commentary: Thoracoabdominal aneurysmectomy: Operative steps for Crawford extent II repair: The devil is in the detail

“…Although open surgical repair remains the gold standard for treatment of thoracoabdominal aortic aneurysms (TAAA), it still carries significant mortality and serious adverse events, justifying efforts to protect the spinal cord and the visceral organs from ischemia-related complications. Lopez-Marco and colleagues 1 report a very interesting step-by-step illustration of their current approach to open extent II TAAA repair. The authors routinely use sequential aortic crossclamping under left heart bypass with mild passive hypothermia (34°C), selective visceral and medullar isothermic blood perfusion, as well as renal protection through intermittent administration of cold Custodiol solution (Essential Pharmaceuticals, LLC, Durham, NC) in the renal arteries, cerebrospinal fluid drainage, monitoring of motor evoked potentials, and near-infrared spectrometry of cerebral, paraspinal, and lower limbs oxygen saturations.…”