Thoracoabdominal aneurysmectomy: Operative steps for Crawford extent II repair

BACKGROUND: Open surgical repair remains the gold standard for treatment of thoracoabdominal aortic aneurysm (TAAA). Surgery aims to replace the whole length of the diseased distal aorta while protecting the spinal cord and the visceral organs to limit ischemia-related complications. The substantial associated surgical risks, including death, paraplegia, renal failure requiring permanent dialysis, and respiratory complications leading to prolonged intensive care unit stay, still outweigh the natural history of TAAA with conservative treatment. METHODS: We describe in detail our current approach to open extent II TAAA repair with a step-by-step illustration of the technique and the surgical adjuncts. RESULTS: We routinely perform left heart bypass with mild passive hypothermia (34°C), cerebrospinal fluid drainage, sequential aortic cross-clamping, monitoring of motor evoked potentials (MEPs) and cerebral, paraspinal, and lower limb oxygen saturation by near-infrared spectrometry, as well as selective visceral perfusion via the celiac and superior mesenteric arteries and renal protection with intermittent administration of Custodiol HTK (histidine-tryptophan-ketoglutarate) solution via the renal arteries. We advocate for individual branch reimplantation using a branched thoracoabdominal graft when possible, and we selectively reattach 1 or more pairs of the lower thoracic intercostal arteries and/or high lumbar arteries, even in the absence of a significant reduction in the MEPs signal. The distal anastomosis is usually constructed above the aortic bifurcation and occasionally to each iliac separately using a bifurcated graft. CONCLUSIONS: Favorable early outcomes and a durable TAAA repair can be achieved at experienced high-volume centers with standardized preoperative selection and multidisciplinary team–based intraoperative and postoperative management of these patients.