Deep Dive Into Aortic Surgery: Mega-Thoracic Aortic Aneurysm Repair

Surgical exposure by median sternotomy or posterolateral thoracotomy for giant thoracic aortic aneurysms may not be adequate. In these cases, sternotomy-thoracotomy offers better access for the entire thoracic aorta.

A sixty-nine-year-old man presented a sudden onset of chest pain and left recurrent laryngeal nerve palsy due to a mega-thoracic aortic aneurysm. He required a two-stage operation, including carotid-carotid-subclavian artery bypass and open repair of this thoracic aortic aneurysm via a trapdoor incision. This provided full exposure of the entire thoracic aorta.

The patient was positioned semisupine on the operating table, with a large bean bag tucked under the left scapula, and the left arm secured on a frame over the patient’s head. This position exposes the sternum, as well as the left anterior-lateral chest wall.

A sternotomy was performed from the sternal notch to the xiphoid. To further expose the origin of the subclavian artery and the entire descending aorta, a left anterior-lateral thoracotomy was performed. The best intercostal space to expose the descending thoracic aorta was determined by palpating the widest intercostal space along the anterior axillary line. The widest intercostal space along the anterior axillary line usually corresponds to the oblique fissure of the lung and the apex of the heart. By opening the thoracotomy gradually with a retractor, the superior portion of the chest wall was lifted upward. This access generally provides adequate surgical exposure of the aortic arch and the descending thoracic aorta.

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