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Repair of Type V TAAA Using Selective Celiac, Superior Mesenteric, and Renal Artery Perfusion

Tuesday, November 29, 2016


The patient was a 78-year-old male who presented with a symptomatic Type V thoracoabdominal aortic aneurysm. A left retroperitoneal approach via the 8th intercostal space was performed and the left common femoral artery and vein were cannulated. The aorta was mobilized at the level of the left inferior pulmonary ligament and below the renal arteries. The aortic cross-clamp was applied and distal aortic perfusion was initiated.


The aorta was cross-clamped distally a few centimeters below the left renal artery. The celiac, superior mesenteric, and right and left renal arteries were divided and cannulated. Selective perfusion with whole blood was instituted at the rate of 250 mL/min. A 22 mm graft with three previously constructed branches corresponding to the celiac, SMA, and right renal arteries was anastomosed to the descending thoracic aorta in a continuous fashion.  The branches were then anastomosed to the corresponding arteries. The distal anastomosis was completed to the infrarenal aorta, the graft was de-aired, the pump stopped, and flow re-established to the branches. The left renal artery was then anastomosed via a separate graft in an end-to-side fashion to the main graft and flow was re-established. 


The patient was closed in standard fashion and had an uneventful hospital stay. This technique allows for selective visceral and renal perfusion as well as distal aortic perfusion in patients with extensive Type V thoracoabdominal aortic aneurysms. 


In a 78-year-old patient I would not prefer thoracophernolaparotomy and cardiopulmonary bypass when there is an easier alternative such as abdominal de-branching (implantation of the both renal arteries, celiac and superior mesenteric arteries with the use of a self made quadrifurcated ringed PTFE graft to the distal infra-renal abdominal aorta) and endovascular stent grafting. It is less complicated, does not require visceral perfusion, can be performed without use of blood or blood products, ....etc with many additional advantages.
Dear Murat, That is another alternative for the case like that, however abdominal debranching is major undertaking and still requires reimplantation of celiac, SMA and renal arteries. In our experience this approach is still quite complex and that is why we prefer traditional surgery in appropriately selected candidates.

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