Scott A. Weldon

Thoracoabdominal aortic aneurysm repair with a branched graft

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.

Extent II repair of thoracoabdominal aortic aneurysm secondary to chronic dissection

Crawford extent II thoracoabdominal aortic aneurysm (TAAA) repairs generally involve replacing the full length of the thoracoabdominal aorta, from the left subclavian artery to the infrarenal abdominal aortic bifurcation, with a synthetic graft. Because of the extensive degree of aortic replacement involved, extent II repairs have been associated with the highest levels of risk for postoperative complications (1-6). To mitigate these complications, we routinely employ a multimodal approach to organ protection during these operations (7-9). To protect the spinal cord, we use mild passive hypothermia, cerebrospinal fluid drainage, left heart bypass (LHB), sequential cross-clamping, and selective reimplantation of intercostal or lumbar arteries (7,8,10,11). We intermittently deliver cold crystalloid solution to the kidneys to protect them from ischemic damage and prevent acute renal failure (12-14). We also deliver isothermic blood from the LHB circuit to the celiac axis and the superior mesenteric artery (SMA) to minimize ischemic times for the abdominal organs. To illustrate our technique for performing extent II TAAA repair, we present a video (Video 1) of such a procedure performed in a 55-year-old man with a symptomatic TAAA associated with chronic DeBakey type III aortic dissection (Figure 1). The patient had a history of hypertension, smoking, hepatitis B and C, and hepatic cirrhosis, as well as cocaine abuse, which is a risk factor for aortic dissection (15). At the time of his referral for surgical treatment, the patient was experiencing intermittent back pain. Preoperative imaging revealed a relatively normal-sized aortic arch with a dissection membrane starting just distal to the left subclavian artery. The true lumen was narrow, and the dissection extended into the celiac axis. The aneurysm measured 6 cm in diameter, and there was a large burden of thrombus in the infrarenal region. Figure 1 Preoperative anatomy. Illustration and sections from a computed tomography scan showing the patient’s thoracoabdominal aortic aneurysm, which was associated with chronic aortic dissection. Note the narrow true lumen (double arrows) and the extension ... Video 1 Extent II repair of thoracoabdominal aortic aneurysm secondary to chronic dissection Operative techniques The aneurysm was exposed through a standard thoracoabdominal incision, and the chest was entered through the 6th intercostal space. The entire thoracoabdominal aorta was exposed by performing medial visceral rotation and by circumferential division of the diaphragm. After heparin (1 mg/kg) was administered, cannulas for LHB were placed in the left inferior pulmonary vein (drainage cannula) and the distal descending thoracic aorta (inflow cannula). After LHB was initiated, the first aortic clamp was placed between the left common carotid and subclavian arteries. After a bulldog clamp was placed across the left subclavian artery, a second aortic clamp was placed across the mid-descending thoracic aorta, and LHB flows were increased. The isolated segment of proximal descending thoracic aorta was then opened, and the dissecting membrane was excised. All shed blood was collected via a cell-saving system and then returned to the patient through a rapid infusion system. Patent intercostal arteries were oversewn with 2-0 silk sutures. A 24-mm Dacron graft was selected, and the proximal anastomosis was completed by using 3-0 polypropylene suture. The anastomosis was reinforced with pledgeted polypropylene mattress sutures. After the proximal anastomosis was completed, the clamp on the left subclavian artery was removed, and the aortic cross-clamp was moved down onto the graft, thereby restoring blood flow to the left subclavian artery. Left heart bypass was discontinued, the aortic cannula was removed, and the remainder of the aorta was opened down to the bifurcation. The dissecting membrane was excised to provide exposure of all intercostal, visceral, and lumbar branches. Then, 9-Fr balloon perfusion catheters were placed in the renal arteries, the SMA, and the celiac axis. The renal arteries were infused with cold crystalloid solution, and the celiac trunk and SMA were perfused with blood from the LHB circuit (12). Suitable intercostal arteries, at the level of T10 and T11, were selected for anastomosis. An opening was created in the side of the graft, and the intercostal patch was sewn to the opening with 3-0 polypropylene suture. After this anastomosis was completed, portions of it were reinforced with pledgeted polypropylene mattress sutures. Then, another opening was made in the side of the graft adjacent to the visceral branches. In this case, all 4 vessels were incorporated into a single patch, although the left renal artery is commonly anastomosed separately. A fenestration was created in the dissecting membrane within the celiac trunk. The visceral patch was sewn to the opening with 3-0 polypropylene suture. At this point, the cross-clamp was moved distally to a position below the visceral patch, thereby restoring perfusion to the intercostal and visceral vessels. The graft was then cut to length, and the distal anastomosis was completed with 3-0 polypropylene suture. After the aortic reconstruction was completed (Figure 2), the aortic clamp was removed, restoring distal flow. Remaining intercostal and lumbar arteries were oversewn, and each anastomosis was reinforced as necessary. Protamine was administered and surgical hemostasis was achieved. After satisfactory perfusion to the liver, bowel, kidneys, and lower extremities was confirmed, the diaphragm was closed with #1 polypropylene suture. Before the wound was closed, two chest tubes were placed in the left pleural cavity, and a closed-suction drain was placed in the left retroperitoneal space. Figure 2 Completed aortic reconstruction. The completed extent II repair. Note the proximal anastomosis located just distal to the left subclavian artery; the intercostal patch incorporating 2 pairs of intercostal arteries; the single visceral patch incorporating ... Outcome and comments The patient had an uneventful recovery. He was supported by a ventilator until the next morning. Cerebrospinal fluid pressure monitoring and drainage were discontinued on postoperative day 1. The patient was transferred out of the intensive care unit on postoperative day 2. His spinal cord function and renal function were normal. He was discharged home on postoperative day 7. Although extent II TAAA repairs remain challenging procedures and are associated with substantial levels of postoperative morbidity and mortality, advances in perioperative care and surgical technique have markedly improved outcomes over the past 6 decades. As demonstrated throughout this special edition of Annals of Cardiothoracic Surgery, many different approaches to TAAA surgery have been developed in centers across the world. Although the specific strategies employed may differ, all of the approaches share the common goal of providing durable aortic repair while minimizing risks and optimizing outcomes. It is through the continued efforts of the surgical teams at these centers that further advances will be made to prevent adverse events and improve the long-term survival of patients afflicted with extensive aortic disease.

Total arch replacement with frozen elephant trunk technique.

Our technique for replacing the aortic arch has evolved in recent years from femoral artery cannulation with retrograde cerebral perfusion and deep hypothermic circulatory arrest, to innominate artery cannulation as our first choice, combined with antegrade cerebral perfusion during systemic circulatory arrest with a nasopharyngeal temperature target of 24 °C, and a trifurcated Y-graft (1-3). We have recently reported in high-risk patients that endovascular technology facilitates the repair of arch aneurysms(4). With the help of endovascular stent grafts, we perform total arch replacement with a frozen elephant trunk (FET) in patients whose aneurysm extends through the upper or the entire descending thoracic aorta. If the aneurysm involves the aortic arch and the upper descending thoracic aorta, the repair is performed as a one-stage procedure with antegrade stent delivery of the endograft. If the aneurysm extends into the entire descending aorta, the repair is performed either in one stage with antegrade or retrograde delivery of the endograft or in two stages with retrograde delivery of the stent graft as the second stage of the repair. Our decision to proceed with one-stage versus two-stage repair is based on specific aortic arch anatomy, the complexity of the proximal repair, and the patient’s comorbidities.

Total aortic arch replacement: current approach using the trifurcated graft technique

Since the pioneering work of DeBakey, Cooley, and colleagues more than 50 years ago, surgical treatment of aneurysms involving the transverse aortic arch has been associated with substantial morbidity and mortality. Over the past 15 years, techniques for replacing the diseased aortic arch have evolved substantially. Previously, our approach to these operations involved femoral cannulation, profound-to-deep hypothermic circulatory arrest and retrograde cerebral perfusion, and the island technique for reattaching the brachiocephalic vessels. In contrast, we currently use innominate artery cannulation, deep-to-moderate hypothermic circulatory arrest with antegrade cerebral perfusion, bilateral cerebral monitoring with near-infrared spectroscopy, and the trifurcated graft (Y-graft) technique for reattaching the arch branches. Cannulating the innominate artery to provide an inflow site for cardiopulmonary bypass has facilitated the use of antegrade cerebral perfusion as a cerebral protection strategy; the left common carotid artery is additionally perfused to provide bilateral cerebral perfusion. Despite having a systemic circulatory arrest time that often exceeds 60 minutes, these improved perfusion strategies make it possible to consistently avoid cerebral circulatory arrest all together. A moderate temperature target of between 18 and 23 °C is now used; this appears to reduce the risk of hypothermic coagulopathy and improve hemostasis. Y-graft techniques, such as the trifurcated graft approach, have the advantages of eliminating residual aortic arch tissue and being easily tailored to the needs of the individual patient. This report describes total aortic arch replacement in patients with aneurysms that are confined to the ascending aorta and transverse aortic arch.

Laparoscopic repair of an incarcerated right indirect sliding inguinal hernia involving a retroperitoneal ileum

IntroductionLaparoscopic techniques for the repair of inguinal hernias have become an increasingly popular alternative to open techniques. No clear consensus has emerged as to the best laparoscopic technique, but the body of evidence increasingly favors a total extraperitoneal (TEP) approach.Results and discussionWe report the case of an adult man with an incarcerated right indirect inguinal sliding hernia involving the first known instance of a retroperitoneal ileum, and the novel use of a laparoscopic combined TEP approach and transabdominal preperitoneal (TAPP) approach to repair his hernia without complications. The literature is reviewed and TEP and TAPP techniques for the treatment of inguinal hernias are discussed and compared.ConclusionWhen faced with an unforeseen anomaly during herniorrhaphy in which improved abdominal visualization is necessary, a surgeon may convert from a TEP to a transabdominal laparoscopic approach safely and effectively.

Hybrid thoracoabdominal aortic aneurysm repair: is the future here?

Open surgical repair has been the gold standard for thoracoabdominal aortic aneurysm (TAAA) repair for more than 6 decades, but 2 additional options have emerged: total endovascular TAAA repair and a hybrid approach that combines open and endovascular repair. Despite the optimism for an endovascular approach, long-term results for these repairs are still lacking. Some of the issues with this emerging technology include the risk of paraplegia after extensive endovascular repair, the need for multiple reinterventions, continuous stent-graft surveillance, endograft branch stenosis, as well as the significant learning curve. Interest in a hybrid approach has resurged despite the non-superior results compared to open TAAA. Commonly, the focus of the hybrid approach is now on performing a less extensive open TAAA repair, which is then extended with a stent-graft or vice versa. Moreover, this approach is now often performed in two stages in an effort to decrease the associated spinal cord ischemia. Open surgical repair after endovascular aortic repair is increasingly being performed to address serious complications, such as infection or fistula, that cannot be repaired by further endovascular intervention. As with any new technology, there will be an increase in the number of procedure-related complications and a decrease in the number of surgeons who can perform the traditional open operation with good results.

Aortic Valve Leaflet Entrapment by a Percutaneous Closure Device

Iatrogenic aortic valve leaflet perforation and aorto-right atrial fistula are rare adverse events of transcatheter interventions and transseptal radiofrequency ablations, respectively. We present the case of a 62-year-old man who experienced acute, severe aortic insufficiency as a result of leaflet entrapment by a septal occluder device during attempted percutaneous closure of an iatrogenic aorto-right atrial fistula. This rare adverse event emphasizes the need for a thorough understanding of cardiac anatomy to minimize transcatheter adverse events and to recognize and treat them appropriately when they occur.