Thoracoabdominal Aneurysms—Operative Steps for Crawford Extent II Repair

Abstract

Open surgical repair remains the gold standard for treatment of thoracoabdominal aortic aneurysms (TAAA), aiming to replace the whole length of the diseased distal aorta while protecting the spinal cord and visceral organs to limit ischemia-related complications. This surgery carries significant risks, including death, paraplegia, renal failure requiring permanent dialysis and respiratory complications leading to prolonged ICU stay, but these still outweigh the natural history of TAAA with conservative treatment. We describe in detail our current approach to open extent II TAAA repair by a step-by-step illustration of the technique and the surgical adjuncts. We routinely use left heart bypass with mild passive hypothermia (34°C), cerebrospinal fluid drainage, sequential aortic cross-clamping, monitoring of motor-evoked potentials (MEPs), cerebral, paraspinal and lower limbs oxygen saturations by near-infrared spectrometry as well as selective visceral perfusion via the coeliac, superior mesenteric and renal arteries. We advocate for individual branch reimplantation using a branched thoracoabdominal graft and when possible and we selectively reattach one or more pairs of the lower thoracic intercostal arteries and/or high lumbar arteries, even in absence of a significant reduction on the MEPs signal. The distal anastomosis is usually constructed above the aortic bifurcation and occasionally to each iliac separately using a bifurcated graft. Favorable early outcomes and a durable repair can be achieved at experienced high-volume centers, with standardized pre-operative selection and multidisciplinary team based intraoperative and postoperative management of these patients. Open surgical repair remains the gold standard for treatment of thoracoabdominal aortic aneurysms (TAAA), aiming to replace the whole length of the diseased distal aorta while protecting the spinal cord and visceral organs to limit ischemia-related complications. This surgery carries significant risks, including death, paraplegia, renal failure requiring permanent dialysis and respiratory complications leading to prolonged ICU stay, but these still outweigh the natural history of TAAA with conservative treatment. We describe in detail our current approach to open extent II TAAA repair by a step-by-step illustration of the technique and the surgical adjuncts. We routinely use left heart bypass with mild passive hypothermia (34°C), cerebrospinal fluid drainage, sequential aortic cross-clamping, monitoring of motor-evoked potentials (MEPs), cerebral, paraspinal and lower limbs oxygen saturations by near-infrared spectrometry as well as selective visceral perfusion via the coeliac, superior mesenteric and renal arteries. We advocate for individual branch reimplantation using a branched thoracoabdominal graft and when possible and we selectively reattach one or more pairs of the lower thoracic intercostal arteries and/or high lumbar arteries, even in absence of a significant reduction on the MEPs signal. The distal anastomosis is usually constructed above the aortic bifurcation and occasionally to each iliac separately using a bifurcated graft. Favorable early outcomes and a durable repair can be achieved at experienced high-volume centers, with standardized pre-operative selection and multidisciplinary team based intraoperative and postoperative management of these patients.