Abstract
Chronic dissection of the thoracoabdominal aorta may require surgical repair for aneurysm, malperfusion, or rupture. Endovascular repair is made difficult by a noncompliant dissection septum, visceral vessels arising from different lumens, and the common use of diseased aortic landing zones. Thus, open repair remains the gold standard in terms of favorable outcomes and durability. During thoracoabdominal aortic repair, we use a multimodal strategy to prevent spinal cord and visceral or renal artery ischemia; key modalities include cerebrospinal fluid drainage, left heart bypass with and without visceral protection, cold renal protection, and aggressive reimplantation of intercostal or lumbar arteries. Patients with chronic dissection require lifelong surveillance, as there is a significant risk for subsequent intervention on unrepaired aortic segments.
Highlights
Aortic dissection begins as a tear in the intima that leads to a separation of the layers of the media and the propagation of blood along a false lumen
We describe the classification of aortic dissection, along with indications for repair, and highlight operative techniques for open repair of aneurysms related to chronic dissection of the thoracoabdominal aorta
Chronic aortic dissections of the thoracoabdominal aorta are vulnerable to aneurysmal degeneration, rupture, malperfusion, or symptoms related to compression of surrounding structures related to aortic expansion
Summary
Aortic dissection begins as a tear in the intima that leads to a separation of the layers of the media and the propagation of blood along a false lumen. Our operative technique for open repair of Crawford extent II TAAAs precipitated by chronic aortic dissection involves the placement of a four-branched replacement graft. If the proximal repair during the index DeBakey type I aortic dissection included only the ascending aorta and hemiarch, a redo sternotomy and total arch replacement with an elephant trunk extension may be performed before the TAAA repair because an aortic arch aneurysm would be difficult to replace through a left thoracoabdominal exposure. When a four-branched replacement graft is used, the distal anastomosis is performed before reattachment of the visceral and renal arteries to re-establish flow to the lower extremities while the visceral and renal organs continue to be perfused via the LHB and renal cooling circuit, respectively [Figure 10]. Higher MAP goals are maintained for 4-6 weeks after surgery to prevent late neurological complications
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