Adult

Open Repair of Thoracoabdominal Aortic

Aneurysm: Step-by-Step
Maral Ouzounian, MD, PhD,* Scott A. LeMaire, MD,†,z Scott Weldon, MA, CMI,† and
Joseph S. Coselli, MD†,z

Open surgical repair remains the gold standard operation for thoracoabdominal aortic aneurysm
(TAAA). Contemporary surgical approaches balance the need to maximize long-term benefit by
replacing as much diseased aorta as possible with limiting ischemia-related risk to the spinal
cord and other organs. Despite the formidable challenges that extensive aortic replacement
entails, excellent outcomes and a durable repair can be achieved at experienced centers. Here,
we describe in detail our current approach to open TAAA repair, which includes providing spinal
cord and end-organ protection by the use of surgical adjuncts such as cerebrospinal fluid drain-
age, mild passive hypothermia (32-33˚C nasopharyngeal), left heart bypass, sequential aortic
cross-clamping, selective visceral artery perfusion and, whenever possible, reimplantation of
segmental arteries and use of cold renal perfusion. We illustrate this approach in a case of Craw-
ford extent II TAAA repair with a branched graft.
Operative Techniques in Thoracic and Cardiovasculary Surgery 23:220 Ó 2018 Elsevier Inc.
All rights reserved.

KEYWORDS Aortic aneurysm, Thoracoabdominal, Neuroprotection, Surgery, Aortic dissection

Introduction learned directly from E. Stanley Crawford to our current

multimodal strategy, which uses an array of surgical
O pen surgical repair remains the gold standard opera-
tion for thoracoabdominal aortic aneurysm (TAAA).
These aneurysms can be caused by aortic dissection or by
adjuncts. Our strategies for organ protection during
TAAA repair have been previously described in detail.2-6
For spinal cord protection, we use cerebrospinal fluid
progressive medial degeneration without dissection. Con-
drainage,4 mild passive hypothermia (32-33°C nasopha-
temporary surgical approaches balance the need to maximize
ryngeal), left heart bypass,2 sequential aortic cross-
long-term benefit by replacing as much diseased aorta as
clamping, and selective reimplantation of segmental
possible with limiting ischemia-related risk to the spinal
arteries. The patient's mean arterial pressure is main-
cord and other organs. Despite the formidable challenges tained at 70-90 mmHg throughout the case, and the cere-
that extensive aortic replacement entails, excellent outcomes
brospinal fluid pressure is maintained at less than 15
and a durable repair can be achieved at experienced centers.
mmHg. To minimize ischemic damage to the kidneys, we
In the largest published series (n = 3309) of open TAAA
administer a 4 °C perfusate consisting of lactated Ring-
repairs,1 we observed an early mortality rate of 7.5% and
er's solution, mannitol (12.5 g/L), and methylpredniso-
low rates of permanent paraplegia (2.9%) and paraparesis
lone (125 mg/L) to the renal arteries. 5,6 To protect the
(2.4%). Postoperative stroke and permanent renal failure
abdominal organs, we perfuse the celiac axis and superior
occurred in 2.2% and 5.7% of patients, respectively.
mesenteric artery with isothermic blood from the left
Our technique for open TAAA repair has evolved from heart bypass circuit.
the simple unheparinized “clamp-and-sew” approach

Funding: This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
*Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto
General Hospital, Department of Surgery, University of Toronto, Tor-
onto, Canada.
y
Division of Cardiothoracic Surgery, Michael E. DeBakey Department of
Surgery, Baylor College of Medicine, Houston, TX.
z
Cardiovascular Surgery Service, The Texas Heart Institute, Houston, TX.
Address reprint requests to Scott A. LeMaire, MD, Baylor College of
Medicine, One Baylor Plaza, BCM 390, Houston, TX 77030. E-mails:
maral.ouzounian@uhn.ca, slemaire@bcm.edu, sweldon@bcm.edu,
jcoselli@bcm.edu
2 1522-2942/$see front matter © 2018 Elsevier Inc. All rights reserved.
Operative technique
The Crawford classification (Fig. 1) describes the extent of TAAA
repair, with Crawford extent II repairs being the most extensive
and therefore incurring the greatest risk of postoperative adverse
events. Here, we describe a case of Crawford extent II repair with
a branched graft (Figs. 2-15) to illustrate our current approach
to open TAAA repair with the use of surgical adjuncts for spinal
cord and end-organ protection. In addition, we provide some
examples of alternative reconstructions of the visceral and renal
arteries, as well as the distal aorta (Figs. 16 and 17).
https://doi.org/10.1053/j.optechstcvs.2018.07.002
Open repair of TAAA 3

Figure 1 The Crawford extents of thoracoabdominal aortic aneurysm (TAAA) repair. Extent I repairs involve most or all of the descending tho-
racic aorta and the upper abdominal aorta. Extent II repairs involve the entire thoracic and abdominal aorta. Extent III repairs begin in the
descending thoracic aorta, below the sixth rib, and involve varying portions of the abdominal aorta. Extent IV repairs involve the abdominal
aorta below the diaphragm. Used with permission of Baylor College of Medicine.
4 M. Ouzounian et al.

Figure 2 Positioning, prepping, and draping. Immediately prior to positioning, a CSF drainage catheter is inserted. (A, B) The patient is placed
on top of a beanbag in a modified right lateral decubitus position, with the shoulders rotated to 60° from horizontal and the hips rotated to
30° from horizontal, which ensures that both groins are accessible. An axillary roll is placed under the patient's right axilla, and the beanbag is
suction-deflated and made firm to maintain the patient's position. The patient's left arm is placed on top of an elevated arm board and extended
at an angle above the shoulders in a freestyle-swimming-stroke position. (C, D) The patient's left chest and back, abdomen, groins, and upper
thighs are prepared and draped in a sterile fashion. An adhesive antimicrobial drape is placed over all exposed skin. ASIS = anterior superior
iliac spine; CSF = cerebrospinal fluid.
Open repair of TAAA 5

Figure 3 Incision and exposure. (A) A left thoracotomy is made, and the chest is entered through the fifth or sixth intercostal space. The inci-
sion is then curved inferiorly and extended across the costal margin and toward the umbilicus. Medial visceral rotation is performed through a
transperitoneal approach; electrocautery is used to dissect along the line of Toldt. (B) The diaphragm is divided circumferentially, and a 3- to
4-cm rim of diaphragm is left attached to the lateral and posterior chest wall, with 2-0 silk retraction sutures along the edge of the divided dia-
phragm.
6 M. Ouzounian et al.

Figure 4 Retraction. A table-mounted retractor is used for stable exposure throughout the procedure. The caudal aspect of the incision is
exposed posteriorly and to the left with 2 bladder blades. The cranial aspect of the incision is exposed with a large Richardson retractor under
the upper rib and an upper hand retractor under the scapula, both stabilized by the table-mounted ether screen.
Open repair of TAAA 7

Figure 5 Aortic exposure and preparation of aortic clamp sites and left heart bypass (LHB). The entire thoracoabdominal aorta is exposed with
electrocautery from the left subclavian artery to the aortic bifurcation. Care is taken to identify the origin of the left renal artery and to keep the
incision posterior to the left ureter and gonadal vein. The initial proximal and distal clamp sites in the thorax are developed. For patients under-
going Crawford extent II repair, LHB is used to provide isothermic self-oxygenated blood to the distal aorta while the proximal anastomosis is
being completed. The return line of the LHB circuit has a Y-connector attached that splits pump return between the line going to the distal aor-
tic cannula and another line leading to two 9-Fr Pruitt balloon-tipped perfusion catheters for later delivery of selective visceral perfusion to the
celiac axis and superior mesenteric artery. A separate system is set up with another two 9-Fr Pruitt balloon-tipped perfusion catheters attached
to the end of its line for later administration of 4°C cold renal solution to the renal arteries.
8 M. Ouzounian et al.

Figure 6 Venous drainage line of the left heart bypass circuit. Before cannulation, heparin is administered intravenously at a dose of 1.0 mg/kg;
the patient's activated clotting time is confirmed to be
280 seconds. The pericardium is reflected or opened near the pulmonary veins, away
from the phrenic nerve. A 3-0 pledgeted polypropylene suture is placed at the junction of the left atrium and the left inferior pulmonary vein
in a mattress fashion. For outflow, the left atrium is cannulated with a 24-Fr angled-tip cannula connected to the venous drainage of the left
heart bypass circuit and secured with a Rummel tourniquet.
Open repair of TAAA 9

Figure 7 Arterial return line of the left heart bypass circuit. To establish an inflow or arterial return line, a 4-0 pledgeted polypropylene suture is
used to secure a 22-Fr angled-tip cannula placed in either the distal descending thoracic aorta or the proximal abdominal aorta (ie, proximal to
the left renal artery origin). Selection of the aortic cannulation site is aided by careful examination of the preoperative imaging results to identify
and avoid areas with extensive intraluminal thrombus.
10 M. Ouzounian et al.

Figure 8 Preparation and construction of the proximal anastomosis. (A) The proximal clamp site is prepared, and careful attention is paid to
preserving the left recurrent laryngeal nerve. If possible, the proximal clamp is placed distal to the left subclavian artery (LSCA) to preserve its
contribution to spinal cord blood flow. If there is a large distal arch aneurysm, however, the proximal clamp may have to be positioned
between the left common carotid artery and the LSCA. (B) The distal clamp site is most commonly at the junction of the upper and middle
thirds of the descending thoracic aorta and is developed anterior to the hemiazygos and intercostal veins. (C) After left heart bypass (LHB) is
initiated at a flow of 500 mL/min, a straight, padded aortic cross-clamp is applied to the aorta at the previously prepared site. A Crafoord clamp
is applied across the aorta at the distal clamp site. Once the aorta is clamped, the LHB flows are increased to a target of 1.5-2.5 L/min, with a
goal mean arterial pressure of 80 mmHg. The proximal aorta is opened between the 2 clamps, and all of the intercostal arteries in this segment
are oversewn. (D) The proximal anastomosis is constructed in an end-to-end fashion with 3-0 or 4-0 polypropylene suture. Note the small, stiff
bulldog clamp occluding the LSCA.
Open repair of TAAA 11

Figure 9 Preparation of the distal aorta. After the proximal anastomosis is complete, left heart bypass is weaned and discontinued. (A, B) The
distal aortic clamp is removed, and the thoracoabdominal aorta is opened longitudinally with electrocautery down to the aortic bifurcation,
cutting posteriorly to the origin of the displaced left renal artery. Shed blood is collected by a cell-saver system and rapidly auto-transfused
back into the patient. (C, D) The distal aortic segment is prepared, any large pieces of thrombus are removed, and the dissecting membrane is
excised in patients with chronic dissection.
12 M. Ouzounian et al.

Figure 10 Visceral and renal perfusion. Selective visceral perfusion with isothermic blood is given at a rate of 500 mL/min through 9-Fr Pruitt
balloon catheters inserted into the celiac axis and the superior mesenteric artery (SMA). The catheters are connected to the left heart bypass cir-
cuit via a Y-branch. To provide cold (4°C) renal perfusion, a separate pump, set of lines, and 2 balloon catheters are connected to a cooling
device; 9-Fr Pruitt catheters are placed in the renal arteries, and cold renal perfusion is delivered approximately every 6 minutes at a rate of
300 mL/min for 1-2 minutes. Nasopharyngeal temperature is carefully monitored to avoid hypothermia-induced arrhythmia. Our cooling per-
fusate consists of mannitol (12.5 g/L) and methylprednisolone (125 mg/L) with lactated Ringer solution.
Open repair of TAAA 13

Figure 11 Intercostal artery reattachment. Patent segmental arteries, particularly those between T7 and L2, are carefully inspected; any that are
large and have little back-bleeding are chosen for reimplantation, provided that the adjacent aortic tissue is suitable for anastomosis. (A) After
specific intercostal arteries are selected for reimplantation, the graft is trimmed appropriately, and a side-to-side anastomosis is begun. (B) To
limit back-bleeding, green (3-Fr) balloon occlusion catheters can be placed in the intercostal arteries. (C) The intercostal patch anastomosis is
completed, incorporating as little native aortic tissue as possible to reduce the likelihood of a late patch aneurysm. (D) The proximal clamp is
reapplied just distal to the intercostal patch anastomosis. To prevent a steal phenomenon of shunting blood away from the spinal cord, vigor-
ously back-bleeding intercostal and lumbar arteries are suture ligated in a figure-of-eight fashion with 2-0 silk sutures.
14 M. Ouzounian et al.

Figure 12 Visceral and renal artery configuration. Patients with extensive atheromatous disease (shown here) and those with chronic dissection
may have widely displaced origins of the visceral and renal arteries. The origin of each of these vessels is carefully inspected for stenosis, calcifi-
cation, or dissection. The dissecting membrane is often excised in cases of chronic dissection. Alternatively, the false channel may be obliterated
during the end-to-end anastomosis or with circumferential interrupted fine polypropylene sutures. Stenotic visceral arteries may need endarter-
ectomy, stenting, or both. If necessary, we typically use a 7- £ 15-mm balloon-expandable stent (Boston Scientific Corporation, Marlborough,
MA) and recommend a postoperative regimen of clopidogrel for 3-6 months. SMA = superior mesenteric artery.
Open repair of TAAA 15

Figure 13 Visceral artery patch reimplantation. The configuration of visceral artery reimplantation depends on multiple factors, including the
age of the patient, the presence of connective tissue disease, the quality of the aortic tissue, and the distance between the origins of the arteries.
In older patients with degenerative aortic disease whose 4 vessels are close to one another, all 4 arteries can be reattached in 1 patch. (A) A com-
mon variation is to reimplant the right renal, superior mesenteric, and celiac arteries together and the left renal artery separately. (B) In this con-
figuration, the left renal artery is separated from the aortic wall as a button and mobilized. It is reimplanted onto the aortic graft after the distal
anastomosis is constructed, either directly or with an 8-mm graft. Care is taken to ensure that the artery or bypass graft will not kink once the
abdominal organs are returned to their anatomical positions.
16 M. Ouzounian et al.

Figure 14 Visceral branch anastomoses with 4-vessel branch graft. In a younger patient with connective tissue disease or a patient whose arterial
origins are significantly displaced as in Fig. 12, we use a graft with 4 presewn branches to reimplant each vessel separately.79 When using a
multibranched graft, we generally perform the distal aortic anastomosis before reattaching the visceral branches; this enables restoration of
blood flow to the iliac arteries that provide collateral perfusion to the spinal cord. Then, each of the branches of the graft is trimmed to appro-
priate length and anastomosed to its corresponding artery. (A) The right renal artery is generally reattached first via the right-sided 8-mm
branch in an end-to-end fashion with 5-0 polypropylene. (B) The left renal artery is reattached via the left-sided 8-mm branch. (C) The supe-
rior mesenteric artery (SMA) is reattached via the more inferior 10-mm branch. (D) Finally, the celiac artery is reattached via the more superior
10-mm branch. The graft to the SMA remains clamped to avoid celiac back-bleeding during the anastomosis.
Open repair of TAAA 17

Figure 15 Distal aortic and limb anastomoses. The location of the distal anastomosis depends on the degree of aneurysmal dilatation of the distal aorta,
iliac, and femoral vessels. (A) If the aorta is of adequate quality and caliber proximal to the bifurcation, an end-to-end anastomosis is made at this level.
(B) Alternatively, if the vessels beyond the bifurcation are involved, we sew an end-to-end anastomosis to a bifurcated abdominal aortic graft. The limbs
of this graft are anastomosed to the common iliac, external iliac, or common femoral arteries, targeting on each side the most proximal level where distal
arteries of sufficient quality and caliber are encountered. Flow into the internal iliac arteries is preserved whenever possible.
18 M. Ouzounian et al.

Figure 16 Completed thoracoabdominal aortic repairs. Several examples of completed aortic repairs are depicted. (A) Tube graft sewn to previous ele-
phant trunk graft. (B) Tube graft with direct reimplantation of left renal artery. (C) Bifurcated abdominal graft. (D) Multibranched thoracoabdominal
graft. After the aortic replacement is completed, intravenous protamine and indigo carmine are administered to reverse the effect of heparin and assess
the adequacy of renal perfusion, respectively. Each anastomosis is inspected for bleeding and repaired as necessary by using reinforcing sutures with felt
strips or pledgets. The left atrial cannula is removed, and the venotomy is repaired. The field is irrigated with warm water, and blood products are admin-
istered as necessary. Satisfactory perfusion to the abdominal organs and the iliac and femoral arteries is confirmed. The spleen is assessed to ensure that
there are no capsular tears or subcapsular hematomas. SMA = superior mesenteric artery.
Open repair of TAAA 19

Figure 17 Closure. (A) A 19-Fr closed-suction abdominal drain is placed over the psoas muscle in the upper left retroperitoneum. (B and C)
The diaphragm is reapproximated with a continuous #1 polypropylene suture. (D) The thorax is closed with braided #2 pericostal sutures and
2 #7 surgical-steel wires. Two pericostal analgesia catheters are placed along the thoracotomy incision. The abdominal fascia, serratus anterior,
and latissimus dorsi are each closed with separate continuous #1 polypropylene suture.
20
Conclusions
Our approach to open TAAA repair has evolved over several
decades and now includes a multimodal strategy of surgical
adjuncts based on the extent of aortic repair required and
the overall risk of ischemic complications to the spinal cord
and abdominal organs. Although extent II TAAA repairs
remain challenging, contemporary techniques afford a good
outcome and a durable repair in experienced centers.
Disclosures
Dr. Coselli serves as a consultant for Terumo Aortic and
receives royalties related to Vascutek Gelweave Coselli thora-
coabdominal grafts. Dr. LeMaire has served as a consultant to
Vascutek Terumo and has received research support as princi-
pal investigator and co-investigator for clinical studies. None of
the remaining authors has any potential conflict of interest with
regard to the work described in this manuscript.
Acknowledgments
We thank Stephen N. Palmer, PhD, ELS, and Susan Y. Green,
MPH, for contributing to the editing of the manuscript. Figures
used with permission of Baylor College of Medicine.
M. Ouzounian et al.
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