Thoracoabdominal aortic aneurysm repair with a branched graft.

Abstract

Many aspects of open thoracoabdominal aortic aneurysm (TAAA) repair are individualized according to patient-specific factors related to the type and extent of disease, comorbid conditions, and physiological reserve. One example of how surgeons can individualize the technical approach to this operation is the use of a prefabricated aortic graft with four side branches designed for reattaching the celiac axis, superior mesenteric artery (SMA), and both renal arteries (1-4). Using this branched graft in TAAA repairs is ideal when one of two conditions are met: (I) The patient has a connective tissue disorder (e.g., Marfan syndrome, Loeys-Dietz syndrome), and aortic tissue that remains after the procedure will be prone to aneurysmal dilatation, pseudoaneurysm formation, and rupture, eventually necessitating reintervention (5-7); or (II) the origins of the patient’s visceral vessels are far enough apart that an island patch reimplantation is not desirable. The ultimate goal of these operations is to balance the need to resect and replace as much diseased aortic tissue as possible with the need to protect the spinal cord and other organs and, thereby, prevent postoperative complications. Our strategies for organ protection have been described in detail elsewhere (8-14). To protect the spinal cord, we employ mild passive hypothermia, cerebrospinal fluid (CSF) drainage, left heart bypass (LHB), sequential cross-clamping, and selective reimplantation of intercostal or lumbar arteries (9-11,14). The renal arteries are perfused with cold crystalloid solution to protect the kidneys from ischemic damage (8,12,13). Perfusing the celiac axis and the SMA with isothermic blood from the LHB circuit minimizes the duration of abdominal-organ ischemia.