Open thoracoabdominal aortic aneurysm surgery technique: how we do it

Open repair of thoracoabdominal aortic aneurysms under left heart bypass

BACKGROUND

Thoracoabdominal aortic aneurysm (TAAA) open surgical repair (OSR) is a highly complex procedure associated with significant mortality and morbidity. Despite advancements in surgical techniques and organ protection strategies, TAAA OSR remains a challenge. This study analyzes nearly 35 years of experience at a single center, with a focus on the evolution of surgical approaches and adjuncts, particularly the use of left heart bypass (LHBP) for organ perfusion maintenance.

METHODS

This retrospective study was performed on all the patients who underwent elective TAAA OSR at our institution between 1989 and 2024. Patients were divided into two groups: Group 1 (1989-2009), where adjuncts were used selectively, and Group 2 (2010-2024), where a systematic multimodal approach was implemented. Preoperative, intraoperative, and postoperative data were analyzed to assess the impact of evolving surgical techniques, adjuncts, and patient outcomes. Key adjuncts included cerebrospinal fluid drainage (CSFD), motor and somatosensory evoked potentials (MEP&SSEP), LHBP, renal perfusion strategy, and rotational thromboelastometry.

RESULTS

In total, 1211 patients underwent elective TAAA OSR, with 455 patients in Group 1 and 756 in Group 2. A modified surgical approach was employed in the two groups, with significant differences in terms of sites of aortic cross-clamping, techniques for vessel reconstruction, and approach in the management of intercostal artery. In addition, significant differences between the groups were observed for what concern the use of adjuncts. Regarding the outcomes, Group 2 demonstrated a significantly lower 30-day mortality rate (7.5% in Group 2 vs. 13.4% in Group 1; P=0.001), and a reduction in permanent spinal cord ischemia (SCI) (7.4% in Group 2 vs. 11.9% in Group 1; P=0.012). Additionally, Group 2 exhibited trends toward reduced respiratory failure and renal complications, but these differences were not statistically significant.

CONCLUSIONS

This single-center experience highlights the evolution of TAAA OSR over 35 years, demonstrating a significant reduction in mortality and SCI with the use of a comprehensive, multimodal approach. Although there were improvements in postoperative complications, further advancements are needed in this complex field to optimize outcomes. The ongoing refinement of surgical techniques and adjuncts continues to play a crucial role in improving patient care.

Techniques in hybrid repair of aortic arch and thoracoabdominal aortic pathologies

INTRODUCTION

Since the mid-1900s, techniques in the repair of aortic arch and thoracoabdominal aortic pathologies have drastically evolved. Open aortic surgical repair was once the sole option for both simple and complex aneurysmal degeneration. Today, a number of minimally invasive and hybrid approaches are now available to assist both the surgeon and patient in tackling this challenging problem.

AREAS COVERED

In this review, we discuss the most current techniques in the repair of these complex pathologies as well as new advances. These include aortic arch and abdominal aortic debranching with endovascular repair, branched stent graft repair, parallel grafting techniques, fenestration techniques, and a hybrid approach to the aforementioned. In addition, we discuss comparative outcomes of these techniques spanning disciplines of both cardiac and vascular surgery.

EXPERT OPINION

The most vital part of the treatment of complex aortic aneurysms is the tailoring of the treatment plan to each patient's unique anatomic and physiologic attributes.

Stent-Assisted Coil Embolization of a Saccular Visceral Aortic Aneurysm: Case Report and Review of the Literature

PURPOSE

We present the results of unconventional endovascular treatment of a voluminous (65 mm) saccular visceral aortic aneurysm in a 78-year-old woman. Patient was deemed unfit for open surgery due to comorbidities. Fenestrated or branched endografting was also excluded due to the small diameter of the aorta, the severe stenosis at the origin of celiac trunk, and the anomalous origin of superior mesenteric artery arising infrarenally.

CASE REPORT

After a preliminary selective angiography of the superior mesenteric artery showing valid anastomotic network with celiac trunk branches, an aortic self-expandable bare stent (Jotec E-XL) was deployed in the visceral aorta. Aneurysm sac embolization (Penumbra detachable Ruby Coils) in a coil-jailing technique was performed. Finally, an aortic cuff endograft (Gore) was deployed immediately above the origin of the left renal artery to cover the wide neck of the saccular aneurysm and improve sac exclusion. Hospital stay was uneventful, computed tomography (CT) at 12-month demonstrated aneurysm shrinkage to 62 mm without images of endoleak. Literature review showed how this technique has successfully been applied to manage similar cases of postsurgical and posttraumatic saccular aortic aneurysms in high-risk patients; however, long-term results are still unknown.

CONCLUSION

Coil-jail technique for the treatment of saccular aortic aneurysms can be considered an alternative when open surgery or conventional endovascular treatment is not feasible. Technical success and mid-term outcomes are promising but strict follow-up is recommended.

CLINICAL IMPACT

This study aims to share the unconventional endovascular treatment of a visceral aortic aneurysm in a patient unfit both for open and traditional endovascular surgery. To the best of our knowledge this is one of the first cases published in Literature, for this reason, a step-by-step video has been created to describe the procedure. Literature review was then performed to analyze midterm results of this technique. Despite being a treatment that is not recommended for conventional cases, the knowledge of endovascular devices and techniques may help to manage or simplify complex aortic diseases.

Outcomes following Management of Complex Thoracoabdominal Aneurysm by an Open Approach

BACKGROUND

In the last decade, advances in surgical techniques, and the introduction of adjuncts for organ protection, have modified the approach for thoracoabdominal aortic aneurysm (TAAA) surgical repair. The aim of this study is to determine whether the contemporary approach influenced the outcomes.

METHODS

From 1989 to 2022, patients who had received elective open surgical repair (OSR) for TAAA at our institution were retrospectively analyzed. This series has been divided in two groups: Group 1 (1989-2009), and Group 2 (2010-2022). Patients included in Group 1 were those treated with a selective use of adjuncts, and Group 2 included patients treated with the systematic use of adjuncts.

RESULTS

A total of 1107 patients were treated (Group 1: 455; Group 2: 652). The surgical management was significantly different between the two groups. The in-hospital mortality was significantly different between the two groups (Group 1: 13.4%, Group 2: 8.1%; p 0.004), as was the rate of permanent spinal cord ischemia (Group 1: 11.9%, Group 2: 7.8%; p 0.023). Renal and respiratory failure were reduced in Group 2, but not significantly.

CONCLUSIONS

The use of the adjuncts enabled the achievement of improvement in mortality and SCI prevention in TAAA OSR. Although a refined surgical technique, mortality and morbidity are still noteworthy in this complex aortic field.

The application of modular multifunctional left heart bypass circuit system integrated with ultrafiltration in thoracoabdominal aortic aneurysm repair

Open thoracoabdominal aortic aneurysm (TAAA) repair is a complex and challenging operation with a high incidence of serious complications, and high perioperative mortality and morbidity. Left heart bypass (LHB) is a circulatory support system used to perfuse the distal aorta during TAAA operation, and the advantages of LHB include guaranteeing distal perfusion, reducing the use of heparin, and diminishing the risk of bleeding and postoperative neurological deficits. In China, the circuit for TAAA repair is deficient, and far from the perfusion requirements. We designed a modular multifunctional LHB circuit for TAAA repair. The modular circuit consisted of cannulation pipelines, functional consumables connection pipelines, and accessory pipelines. The accessory pipelines make up lines for selective visceral perfusion and kidney perfusion, suckers and rapid infusion. The circuit can be assembled according to surgical requirements. The ultrafilter and heat exchanger are integrated into the circuit to fulfill the basic demands of LHB. The LHB circuit also has pipelines for selective visceral perfusion to the celiac artery and superior mesenteric artery and renal perfusion pipelines. Meanwhile, the reserved pipelines facilitate the quick switch from LHB to conventional cardiopulmonary bypass (CPB). The reserved pipelines reduce the time of reassembling the CPB circuit. Moreover, the rapid infusion was integrated into the LHB circuit, which can rapid infusion when massive hemorrhage during the open procedures such as exposure and reconstruction of the aorta. The ultrafiltration can diminish the consequent hemodilution of hemorrhage and rapid infusion. A hemoperfusion cartridge also can be added to reduce the systemic inflammatory during operation. The circuit can meet the needs of LHB and quickly switch to conventional CPB. No oxygenator was required during LHB, which reduce the use of heparin and reduce the risk of bleeding. The heat exchanger contributes to temperature regulation; ultrafiltration, arterial filter, and rapid-infusion facilitated the blood volume management and are useful to maintain hemodynamic stability. This circuit made the assembly of the LHB circuit more easily, and more efficient, which may contribute to the TAAA repair operation performed in lower volume centers easily. 26 patients who received TAAA repair under the modular multifunctional LHB from January 2018-March 2022 were analyzed, and we achieved acceptable clinical outcomes. The in-hospital mortality and 30-day postoperative mortality were 15.4%, and the postoperative incidences of paraparesis (4%), stroke (4%), and AKI need hemodialysis (12%) were not particularly high, based on the limited patients sample size in short research period duration.