Continuous Visceral and Distal Perfusion During “Off-pump” Open Thoraco-abdominal Repair

Abstract

In an emergency, as in the case of a ruptured thoraco-abdominal aortic aneurysm (TAAA), when endovascular options (e.g., off the shelf devices) are not available or morphologically not suitable, open surgical repair (OSR) is indicated. Systems for extracorporeal circulation to maintain visceral and distal perfusion during OSR are not always present. In this example a patient with a chronic type B aortic dissection, who had previously undergone thoracic endovascular aneurysm repair and open infrarenal bifurcated graft implantation, presented with a contained rupture of a progressive residual type II TAAA (Fig. 1A). Owing to the morphology of the visceral segment, no sequential clamping or en-bloc re-implantation of side branches was possible. After placing the patient in right lateral position, with the table tilted the to the left, almost reaching a supine position, a right sided 10 mm temporary non-tunnelled extra-anatomical axillo-external iliac bypass is implanted. Thereafter, two entire bifurcated prostheses, size adapted to the visceral vessels, are sutured to the bypass in end to side fashion (Fig. 2A). In the next step thoraco-abdominal exposure, including all visceral arteries, is performed, with the table tilted back to the right. Then, the latter are disconnected from their aortic perfusion and sutured one after another to the four branches of the two standard bifurcated polyethylene terephthalate (PET) prostheses (end to end anastomosis; clamping time required 10–12 min per branch). This ensures a sufficient and safe perfusion of the lower half of the body, as well as the visceral arteries. After clamping the thoracic and infrarenal aorta a size adapted tube graft is implanted. Thereafter, the visceral arteries are re-implanted into the aortic tube graft using the PET branches after transecting each one from the bifurcated graft, while partially clamping the aortic graft (Figure 1, Figure 2B). Each anastomosis again requires a clamping time of about 10–12 min, making adjuncts such as ice cold saline boluses unnecessary. Finally, the axillo-iliac bypass is explanted and the arteriotomies are closed. In the further course, the patient had adequate renovisceral perfusion in the post-operative period. When extracorporeal circulation is not available or possible, this novel “off-pump” technique is a feasible and safe alternative for open rTAAA repair.