Thoracic Aortic Surgery in the 21st Century: ADULT – Original SubmissionThoracoabdominal Aortic Aneurysm – The Branch First Technique
Section snippets
INTRODUCTION
Despite technical advances, use of adjuncts and endovascular stenting, repair of thoracoabdominal aortic aneurysms (TAAA) in particular Crawford type II TAAA, remains a morbid and technically demanding undertaking.
Centers of excellence have reported mortality of 5–13%, spinal cord injury of 3–16%, and renal failure rates of 5–10%.1, 2 However, real-world population series have been unable to replicate these exceptional results, in part due to lower surgeon and hospital volumes.3
The challenges
OPERATIVE STRATEGY
Adjuncts, including a CSF drain, neuromonitoring, and moderate hypothermia, are routinely used. Right radial and right femoral arterial lines are used for upper and lower body arterial monitoring and a dual lumen tube for single-lung ventilation.
The patient is positioned on a beanbag in a semi-right lateral decubitus position with the shoulder at 60° and pelvis at 30°. The upper third of the descending aorta is accessed via a high left thoracotomy to the third or fourth intercostal space. This
VISCERAL ARTERY DEBRANCHING AND ANTEGRADE PERFUSION
A trifurcation graft with an additional perfusion limb (TAPP, Terumo Aortic) is prepared with a connector secured to the main limb of the graft for subsequent antegrade perfusion. The left renal, superior mesenteric and coeliac arteries are then sequentially controlled, disconnected from the native aorta and anastomosed to and reperfused via the “perfusion” branch and second and third limbs of the TAPP graft respectively (Fig. 1). It is important to note that aggressive shortening of the limbs
ADVANTAGES AND DISADVANTAGES OF THE BF-TAAAR
The benefits and potential disadvantages of this technique are summarized in Table 2.
Hemostasis can be reassessed readily and without haste after each anastomosis and the viscera and spinal cord are being perfused almost continually.
While full heparinization is required for the full bypass circuit, aiming for an ACT >450 rather than the 200–300 seconds as for left heart bypass, we have not found this to be an adverse factor to achieving hemostasis. On the other hand, it has added the luxury of
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Cochrane Database Syst Rev
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Is there any benefit of neuromonitoring during descending and thoracoabdominal aortic aneurysm repair?
Innovations
(2015)