Thoracoabdominal aortic aneurysm repair in high risk cardiac patients: A modified grafting technique

Abstract

Severe cardiac disease is a major risk for early death following thoracoabdominal aortic aneurysm (TAAA) repair. Proximal aortic cross-clamping during TAAA repair dramatically increases left ventricular afterload risking myocardial ischemia. Although preoperative myocardial revascularization helps protect myocardium at risk during these periods of hemodynamic stress, in some patients myocardial revascularization is not feasible. Similarly, intraoperative shunting or bypass is not always practical. Under these circumstances we employ a modified multigraft technique during TAAA repair to reduce the risk of early death in high-risk cardiac patients. Case #1 is a 59-year-old male with end-stage ischemic cardiomyopathy (ejection fraction 15%), and recurrent admission for CHF, diagnosed with a 6 cm type III TAAA during evaluation for cardiac transplantation. Because of the potential need for intraaortic balloon support, he was not accepted for transplantation unless the TAAA could be repaired first. He underwent successful modified TAAA repair and subsequently had a successful cardiac transplant. He remains alive and well 3 years after TAAA repair. Patient #2 is a 70-year-old male who presented with an 8 cm type III TAAA. Cardiac evaluation revealed a history of prior myocardial infarction, severe nonreconstructable three-vessel coronary artery disease and inducible angina, left ventricular aneurysm, and ischemic wall motion abnormalities during dobutamine stress echocardiogram. Aneurysm size and multiple episodes of radiating central abdominal and back pain suspicious for aneurysm expansion precluded delays inherent to myocardial revascularization. He remains alive and well 10 months following successful modified TAAA repair. Patients with severe cardiac disease are at risk for early death following TAAA repair. Aortic cross-clamping contributes to this risk. The modified, multigraft technique of TAAA repair avoids aortic cross-clamping, minimizes myocardial risk, and may reduce early death.