Fig. 7.17. Thoracoabdominal aneurysm resection. (a) Left atrial-femoral bypass established. Cross-clamps placed proximally at [A] and [B] while perfusing visceral and spinal vessels. The proximal anastomosis is performed during left atrial-femo-ral bypass. (b) After the proximal anastomosis has been performed, the bypass pump is turned off, the clamp at [B] is removed and the clamp at [A] is removed and placed on the graft. (c) The visceral vessels are implanted in the graft. (d) After the visceral vessels are reimplanted, the distal graft is clamped and the proximal clamp at [A] is removed. The distal anastomosis is performed while the visceral and spinal vessels are reperfusing. (e) Completed repair.

Fig. 7.18. Thoracoabdominal aneurysm resection: inclusion of visceral vessels within the distal anastomosis.

Fig. 7.18. Thoracoabdominal aneurysm resection: inclusion of visceral vessels within the distal anastomosis.

involved, it is replaced under profound hypothermia and circulatory arrest (Fig. 7.14a,b). There are some instances of localized transverse arch aneurysms which can be managed by patch repair without circulatory arrest (Fig. 7.14c).

For descending thoracic aneurysms, the level of the thoracotomy depends on the level of the aneurysm. Generally, a left fifth interspace thoracotomy is performed. Partial bypass using a centrifugal pump is used to route oxygenated blood from the left atrium to the femoral artery (Fig. 7.15). This enables perfusion of the spinal artery of Adamkiewitz to limit the incidence of paraplegia. Only partial heparinization is required (1 mg/kg). The mortality and paraplegia incidence for the repair of a descending thoracic aneurysm is on the order of 10% and 5% respectively. More recently profound hypothermia with circulatory arrest has been used for descending thoracic aneurysms with great success. Another alternative for managing aortic aneurysms is endocascular stent placement. These generally

Fig. 7.19a-b. Chest films of a patient with mega-aorta syndrome and aortic insufficiency showing the massively dilated aorta.

Fig. 7.19c. The aneurysmal portion includes the ascending and transverse aorta.

Fig. 7.19d. Descending aorta.

Fig. 7.19e. Thoracoabdominal aorta. Anatomically, this is an ideal candidate for a staged elephant trunk procedure. Courtesy Dr. Hans Borst, Medizinische Hochschüle, Hannover.

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