FT10. Open Repair of Type IV Thoracoabdominal Aortic Aneurysm: Results of Passive Visceral Shunt and Two-Graft Technique

Abstract

Open repair of type IV thoracoabdominal aneurysms (TAAs) remains a surgical challenge because of the hazardous but necessary intraoperative visceral and renal ischemia. We report a novel approach with passive arterial shunt and two-graft technique to reduce these ischemic complications. A first bifurcated graft is anastomosed laterally to the distal descending thoracic aorta, before left renal artery bypass and intraoperative perfusion of both superior mesenteric and right renal arteries. A second graft is used for in-line aneurysm reconstruction. We herein present our experience of type IV TAA open repair using this technique. Twenty-four patients (mean age, 68 years) underwent elective open repair for type IV TAA with this technique between January 2011 and December 2017. The intervention was achieved through a left thoracophrenic lumbotomy, with retroperitoneal and retrorenal approach. A bifurcated graft was anastomosed laterally to the distal descending thoracic aorta to bypass the left renal artery before aortic cross-clamping. The second limb of this bifurcated graft was connected to a Y-shaped cannula to simultaneously perfuse both superior mesenteric and right renal arteries during supraceliac aortic cross-clamping (Fig 1). An additional tube or bifurcated graft was then used for in-line aneurysm reconstruction. The visceral aortic patch was anastomosed to the aortic graft with the Crawford inclusion technique. The prosthetic limb graft used as a temporary arterial shunt was ligated at the end of the intervention; the left renal artery bypass was preserved as part of the definitive arterial reconstruction (Fig 2). Patients’ records were analyzed for demographics, comorbidities, arterial lesions, operative variables, complications, and 30-day mortality. Mean left renal ischemia time was 10.5 minutes. Mean aortic cross-clamping was 31 minutes. The creatinine level at discharge was not significantly different from the preoperative level (15 vs 13; P = .01). Three patients (12.5%) had transient renal failure (Acute Kidney Injury Network stage 1) postoperatively. Prolonged ventilatory support (>2 days) was necessary in two patients (8%). No cardiac event, no dialysis, and no multivisceral organ failure have been recorded. The postoperative mortality rate was 4% (one patient). Type IV TAA repair with our passive shunt and two-graft technique provides short visceral and renal ischemia times and leads to low rates of end-organ ischemic damages. This technique could be an option to consider for visceral protection in type IV TAA open repair and spurs us on to maintain it for our future cases.Fig 2Arterial reconstruction.View Large Image Figure ViewerDownload Hi-res image Download (PPT)