Thoracoabdominal Aortic Aneurysm Repair - Part 1

CHAPTER 1

Hi, I’m Virendra Patel. I'm one of the vascular surgeons here at Massachusetts General Hospital. Today we're going to show you a video of a patient - a type 1 thoracoabdominal aortic aneurysm repair. This is a CT scan in the candy cane view of this patient's aneurysm. You can see that the aortic aneurysm starts just beyond the origin of the left subclavian artery and extends throughout her entire descending thoracic aorta and ends just at the level of her visceral segment. Our plan is to expose the entire thoracic thoracoabdominal and proximal infrarenal abdominal aorta. We will then perform - control of all of the visceral vessels. We will put the patient in a left atrial femoral bypass to take heart - blood from the left heart and perfuse the lower extremities and the spinal cord while performing the reconstruction. We will start with a proximal anastomosis here and finish our proximal - distal anastomosis somewhere in this region. We may elect to reconstruct the celiac artery and the left renal artery if they require it. At the completion of the reconstruction, we will remove the cannulas and allow the perf - periphery to perfuse on its own, and then we will do the abdominal closure.

CHAPTER 2

For an extent 1 through 3 thoracoabdominal aortic aneurysm, we prep the patient in a right lateral decubitus position. We allow the hips to fall back at about 45 degrees, giving us exposure to the chest and the abdomen. The patient is positioned such that the arm is taped forward. The spinal drain and motor evoked potential lines are here and there. Okay. Alright, you guys can prep.

CHAPTER 3

So our - our fellow is - Doctor English - is marking out the surgical incision. He is identifying the tip of the scapula and finding the midway point between the spine and the medial border of the scapula there. So the incision extends from the base of the neck along that line that he is marking below the tip of the scapula and then anteriorly parallel to the ribs and then down on - onto the abdomen below the umbilicus - somewhere b - midway between the symphysis pubis and the patient’s umbilicus. So he will extend that mark on to the front of the patient across the thorax.

We’ll get started. I'm going to take the other headlight here, gentleman. You're going to get onto the abdominal wall and not get into the fascia. We are now just opening the skin, getting into the subcutaneous fat of the back and the abdomen. We dry up any bleeders that we create so that, when the heparin is given, the blood loss is minimized. So this is the trapezius muscle here. The latissimus dorsi is here - chest muscles on the back. You're just going to get right onto fascia and wait, Sean. If you're already there, then help me with some rakes on this side. This is the latissimus dorsi being divided now. That was the end of the latissimus dorsi. I will just create some flaps underneath it so that I can help reconstruct it later. Okay. This is the trap now, so we're going to divide the trapezius muscle. And I take it apart in layers and put it back together in layers. So I don't take the traps and rhomboids together as one big layer; I take them separately just because it's easier to put them back together, but some people take them as a single layer and suture it back together that way. These are the rhomboids.

Let’s have a marketing stitch for the serratus. This is the serratus anterior. The posterior border is marked so that it can help us line up the repair later. Division of the serratus proceeds anterior - parallel to where the ribs are going. You can see it’s starting to have adhesions and fibrosis to the ribs to help prevent the scapula from being swinged. So usually, the first rib that you can feel up here is the second rib - it's not really the first rib. She's short. Her serratus is nicely adhered, so I don't really want to disrupt it. If you feel in here now - between the adhesions of the serratus, right there - is the first rib. It’s the flat first rib. So that's one, two, three, four, five - count and confirm. DeBakey to me. Okay, so we’ll mark the fifth rib. That’s going to be our entry point. I just want to dry things up up there and bef - before we let them all fall back down.

Okay come on out with the retractor now. We're going to go back to rakes and get this custom margin exposed. Here and here. Actually, we’re going over the top of the sixth rib, aren’t we? That’s - that would be a fourth interspace. Yeah. So I'll expose a rib for you so you can see, and then we'll just come across here, so. So we are slowly dividing the intercostal muscles here. So my initial error was trying to mobilize the fifth rib. It's really the - below the six rib that we're entering the chest.

Let’s have a large Kelly to me. Take this first, Sean. Now come underneath the costal margin. Rotate some more please. The diaphragm is attached here, and we’re going to just burn along the back edge of the bone there so we can get it off. There you go. Okay, that’s enough. Let’s have a large Kelly and a house heavy straight scissor. That's good - close. Close - don't scissor - just close. Watch where tips - lower tips going please. There you go. There you go.

You’re going to lift up here. You’re going to see if there are any bleeders underneath, and you’re going to grab them and kill them. Get your hand out of there - you don't need - I guess you do need it. Maybe a rake on there would be nice. Okay, you're going to lift the rib up here. I'm going to come underneath here and mobilize some of this peri - pericardial fat off. I'll take that DeBakey. Move your finger back here and lift up that way. There you go. I’ll have a pickup now. Take this away, Bruce. Now where’s our phrenic nerve? Hold on for a second. Right in there, I bet. Okay. Let’s have the marking stitch to me. Let’s make sure there's no phrenic nerve in here.

Okay, so this way I know where the GI stapler needs to go now. Okay, let’s have a GIA stapler to Sean. You’re going to pass it across this way. You’re going to keep away from the central diaphragm here. Right there - close. Cut. And don't change the angle as you're starting to come down, so - it's good. Get my blues fire. Needle back - another stitch. Jahan, keep it long just don’t - we’ll cut them at the end, so we can use them as a handle. Does that feel better? Yes. Thank you.

Let me have a pickup and Sean take a Bovie please. We’re going to take some of these lung adhesions up. We’re going to keep working away in the muscular portion of the diaphragm as we divide it. So Bovie the adhesions of the lung. The DeBakey, Bruce, please. Don't keep pushing on the heart. We're pushing on the heart guys, okay? Okay, that should be enough. Let's take another GIA stipe - stapler fire. Now that one's a little too central. I want you to come out that way. Let’s have a large bladder. Pick up the stuff I'm trying to divide. There’s the aorta. Dry that bleeder off there. It’s inferior pulmonary vein coming up. That’s enough. Do you have a Duval lung clamp for me please? Right angle back. Open that up. Pick that up and kill it.

So now we have exposure in the chest here. We still have to mobilize some more lung which is stuck to the aneurysm. Yeah, left lung looks great. Thank you.

CHAPTER 4

Now that we've opened this up, let's give this a little bit more retraction. Right angle back please. Pull, Sean. Char that branch that's crossing right now. Score right here. Keep going. Nevermind. Don’t burn the diaphragm - up here’s the fibrous stuff. You can see my fingers’ edge right underneath. Thank you.

Kidney is up now. Right angle. Rotate the table back towards me guys. Char it please. Let’s have the endo-GIA stapler to me. Let’s have a stitch. Another fire. Another stitch. Can you guys rotate the table towards me some more please? Take that out. Yep.

There's our inferior pulmonary ligament and vein. We’ve divided inferior pulmonary ligament. Schnidt please. Pick this up here. Right angle. She'll take the Bovie. Get this line out of my way - line. Wire. Let’s have a palm. I’ll have another Duval lung clamp. Grab this stuff down here - let me see if I can get a little bit more mobilized down there. It's going to start to be into pericardium soon.

Okay there’s pericardium. So when I did this with Josh, he used to say just get into the pericardium. The problem is when you take your stitch into the vein and you stick it into the pericardium you don't really get the vein, so we’ll probably put our cannulation purse-string right there. Subclavian is right here, so our proximal anastomosis is going to be right in here. Let’s shingle this rib. Pickup to me. Now take - you can get on the upper edge of the rib just Bovie right all the way through, right? To get a 1 centimeter to 1 and 1/2 centimeter hole on the upper edge of that rib. I'll take a right angle please. Bovie to me. Starting to see it coming through - keep coming.

Okay. You can see there's the - the notch that I've cleared for - up - where the intercostal vessel usually runs. Peel it off up towards me. Stay on the bone. Peel off the stuff on the back side. Good. Let’s have a scissor. And slide down and cut, and then slide up a centimeter and cut. Bovie. You can put some Bovie and bone wax or whatever you want there. Divide slowly - don't pass. Point deep cause that's renal artery underneath. Buzz. Buzz here - what I'm holding open. See what you're doing? Char slowly. Okay, one more. Here you go. Another stitch. Heavy scissor. Okay, get ready to buzz me Jahan. Buzz. Buzz. Buzz. Buzz. Buzz. Buzz here. I think that's the seal - the SMA - a lot lower than I thought it was going to be. Suck here as the celiac that leaves. Celiac’s got some small branch coming off of it early on. Suck, suck, suck. Suck. Let’s have a dry sponge and a pickup. Okay, suck here.

CHAPTER 5

Let’s see if we can get around the infrarenal aorta here. First the clamp is going to go in for - initially, we're going to do a clamp and a clamp for a sequential. Then I'm going to do clamp, clamp - take the celiac off - do a bevel distal anastomosis right here. I'm going to probably just do a bevel right below celiac and reimplant the celiac, okay? Nope. We don't need to go that low. No. Lot of inflammation back here. It's really stuck. So we were stuck. We have partially cut open one of those intercostals. There was the other pair that was adherent back there, so that's why I cut the other one to mobilize it this way - got behind both of them, was able to rotate the aorta around, and then repair it. Here you go. One more please. And remember - just don't be rough with the celiac artery ‘cause it will rip. And here. Yep, move the vessel north a little bit. Suck. Give me a buzz here, Jahan. You’re - you’re gonna need your - this… Suck here. Right angle please. Get a Surgicel? Snap. Vessel loop please. Shove it in there, yep. Do you have another piece? And another? And with that piece that was still back there - the lumbar that was still attached - if we kept rolling the aorta more, I was creating a larger adventitial hole, which is why I stopped and mobilized more - to prevent that. Toe in here. Suction. Can I have a Metz?

I'm going to do that side. Just grab opposite of me - below, in there. That's the first branch that we saw. Once that’s gone, we can mobilize more. Now don't keep pulling harder - just pull with your left hand. Hold that towards you. Let’s have a 15 blade. Let’s have a scissor. Let’s have a suction. K - tie that up, Sean. I need a fine right angle and a 3-0 silk tie back. Small clip. Small clip. Trying to prevent stuff from going down, you know? Metz. Can you nudge the artery that way with your forceps? Even that will help. Yep. And then tell when to put the sucker in there. Grab that stuff behind. That stuff right there. Much better to sew to. I said it looks like a much better vessel to sew to. Is it free? Let go. Okay, that's good enough. Rotate the table the other way now. Yep. I'm going to go to the other side now.

CHAPTER 6

Let’s see. One, two sequential clamp sites - sounds good. Pickups and Schnidt to me. Bovie to Sean. Let’s have a scoopy go around. Feel around with your finger - just put a finger right through. Feel that - I'm on adventitial the whole way around. You know, otherwise we’ll get the - let’s have another the string. Another string please. Grab it. Pull it. Drag it around. Feed it to yourself. Suction please. You guys rotate the table away from me some more. Now hang on one second. Just fold it, and put your hand parallel to the aorta - and just put your - that's nice. Let’s have a Schnidt. I'm going to want the large - the usual - the large straight big ugly. Going to want an angled one up here - maybe an angled one for down here, and then we'll just work our way down. Let’s have another string. Now we have to look for bronchial branches in here. Let’s have the scoopy go round. Buzz right hand. Buzz. Buzz.

I want to see where I cut here, Sean, ‘cause the only other structure that's here, and I don't want to poke in there. There’s the end of the pulmonary artery, okay? Suck here. Here's the ligament. Now if you can grab with a forceps here and hold this up, so I can see where the structures are underneath, and then somebody else can Bovie. How’s this? All this lymphatic in the mediastinum. You can see maybe recurrent laryngeal nerve going back down that way. The pulmonary artery is going to be on that side. Scissor. Move the vetted nerve out of the way like this with just with the closed forceps. Buzz please. Take this please. Pull this up with your one hand.

That’s the pulmonary ligament that I'm tying somehow. Please. Forceps. You’re just going to gently hold there. We’re - I’m going to work on the above and cephalad portion of the structures here. There's your subclavian artery. There’s subclavian. Pick it up and hold it out. Thank you. Put a dry sponge on the arch and gently drag it with your fingers. Alright, hold on to this.

Subclavian’s right there. So this is where I clamp goes full show, and our anastomosis is going to have to be right here. Jahan, gently pull on aorta here. You have the arch in your hands. Okay, let’s feel that now - it’s a little much more looser. We got our vagus - our recurrent laryn - laryngeal is running - going to be running back in here ‘cause we didn't cut anything. There’s our ligament. There’s our phrenic. Okay. Okay, let’s have a la - Duval lung clamp for me. Hold here. Let's have a dry lap. Pickups to me. Another branch coming up there. And can I have a dry sponge please first? And you're going to hold it up just like that. That's perfect. Stop moving around please. When you’re pulling too hard, things are ripping up here - you see that? Okay. Let's have that stitch. Let's put this one through a pledget here.

Can you push your fingers in a little more, Sean? You can see the needle sticking into the heart. It would be nice if you can get your fingers down there and help ‘cause this vein is so damn small. I need to get really wide bites here. Hold it like this. I'm going to hook it here. You’re going to feed it in, and then when the needles are - when I get - when I get these strands on my side of the blue thing, you're going to hold at the needles. That's why I asked to do that. Now you’re going to feed in - feed me, feed me, feed me, feed me - cut the needles right next your finger. Snap please. K - take the Duval lung clamp off for now. Bovie this stuff off. Buzz here. Right angle back. There it is. Suction would be nice, guys. Take that other one and put it through a pledget please. Okay, let’s stop there. Yep.

Let me know when it's been 5 minutes. Let's have a pickup to me. Let’s have those cannulas real quick. Scissor - cut this. Let's have the venous. Heavy silk. So it’s usually the 5 or the 10. The 5, right? Yup. K - let’s have a little T-Berg. Give Sean a line clamp now, and when I tell you - so we're going to put the cannula in. Then you're going to put this down - actually, maybe just keep it right here for a second. You're going to hold a cannula here and not let it slide down while I sinch down on it, okay? I'm going to tie these two together, and then you're going to take that inner cannula out. And you're going to keep the catheter down so that the left atrial blood can come up into it. And then I'll clamp below, and then we'll bring it underneath, okay? Can you give me a little bit more T-Berg? And you're going to keep tension on this, so I can come against you to push in here, okay? And then let's have a suction now please. And then that schnitz is next. Okay, hold your breathing please. Schnidt. Schnidt. Cannula. Okay, stop for a second. Give this to me. Okay, hold it down here, Sean, with your left hand. I guess - here, give me the line clamp. Tension up on that schnidt now - there you go. Slide it back, Bruce. Hold this with your - actually, can you hold this right here, Bruce? You can breathe. Okay, let’s have a heavy silk stitch. No just a tie, sorry. There you go. Somebody have a scissors ready. Yep, that's not for you. I'll take a scis.

Okay, Sean, you can let go now. Switch hands - switch hands - so that this here - right here - holds this here, and this holds this here. I’ll take an asepto next and then three snaps. Scissor first. K - let’s have a stitch. Let’s have a vessel loop and a snap. Take this with your right hand, Jahan, the snap please. Move it out of my way so I can stitch the cannula here. Here you go. Just hold the wires taut - don't pull it out. K - walk this off over wire. I got wire. Like - let it go. Pull it off. Let's go. Let's have the next dilator. Hold it down a little bit. Push wire in. Pull. Walk it off. Next - next level dilator please. Walk it off. Let’s have the cannula next. Just hold this. Jahan, you're going to hold wire, and Bruce, you're going to hold the red and the white together. Okay, just stay right there for a second. Okay, let's have a line clamp please. You’re going to put your thumb over the hole when the wire comes out. Don't pull my cannula out please as you're grabbing it with the - okay. Now you’re going to take the dil - white dilator out.

Does this pop out, or is it's - going to go? You got to come out a little faster, guys. Let go. Okay, let’s have an asepto please. Help me out here. Let go. It’s - I just want you to help me out and get it in my view. I got some air here. Can I have a syringe please? Okay, take it off. Let's have a little bit of saline to drip, drip here. Okay your line’s open. Start to run at 500 an hour. Let's have a hepa - antibiotic silk sponge. Let’s have a half-sheet here, and let's have a stitch for me. Let's have a tie please, first. Hold this up. I need it on the right angle please, like the usual.

Alright, your flows are good? Okay, we're going to shoot for a distal perfusion of about 70 mean. Let's have a heavy scissor to me. Go ahead - and a stitch. Let that fall please. Help me out with your other hand. You - you see me getting caught - let go. Let’s have another one of these. There.

CHAPTER 7

We’re going to lay flat the whole time now. Yeah. Line clamp is back to you, Bruce. Let's see my clamp. Can you load up my - can you look at the kid’s CT scan and let me know where her thrombus ends? Is it - I think it's all in this bubble, right?

And relax here one second ‘cause I want to be a little higher up. How you doing as far as flows there, Raf? You ready for a clamp? Okay, give me a few minutes. Up in there. I need a straight hydro, and then - yeah - you're going to hook these and do that so I can put the clamp up near the subclavian artery, okay? Can I see the clamps? And where's that suction, or where’s that debris, Mike? Pickup to me. This is PA - leave it alone. Sucks - I'll take a pickup please, B - Bruce. Okay, turn your flows down for a second. Okay, back up. Can I have a clamp on the intrareal - the mid-descending - proximal descending thoracic. Let’s have the proximal here. Suck. K - scissor. Metz - you got to move back little bit, Sean - I can't feel here. And we're going to have a - suck in here please. Move back. Try to give him the sucker - might help you. Yeah, please. Pick up this aorata here for me please. Suck and toe in towards you so we can see what we're cutting - make sure it's not goose, right?

Let’s have a silk 2-0 silk stitch. You now clamp. Take this. That's good here. Let's have a Metz. Please hold this lower aorta for me. Okay, relax for a second. That means you Sean. Okay, let's have a - four white towels. Get another one. I need you down here, and now that’s - your fingertips are on PA, so don't dig in - just flat. Grab a forcep, Sean. You grab yours - Jahan’s side of the graft. Thank you. K - let’s have a shod please. Wait, does this 3-0 come in a longer stitch than this? Forceps in your hand, Sean. Bruce, can you hold the graft back here for me? Hold here. Keep it on tension for me. Shod please. Shod. Do you want me to follow you? Yeah, that would be good. K - Bruce, just put a snap on it please. Get me another DeBakey please. Let's have a sharp hook. That’s enough there - no more. Don’t pull any harder. Okay, hold that on tension. Now stop pulling it up this way ‘cause we have to come around that way with ‘mosis. K - so Jahan, put the suction down. Give that to Shawn, and you follow from your angle. Driver. Thanks for keeping the needle out of the PA. Pull up on tension. You know Sean, let’s just let it go so I can orient properly. Otherwise, we are going to create a big pucker right in there. Okay Sean, driver. You keep that on tension. Here you go. Come closer to me. Got it on tension.

Hang on I’ll - I'll follow you. Get a forceps in your hand. Take a bite of that. Yep. Bring it through. Now your next one's going to go that way, and you're going to Creech it over onto itself. And you get a nice deep bite with that thing without grabbing the - now Creech it towards yourself instead of up the aorta. So if you can't do it, then let it go and Creech back. Like, I want this to suture line to be up here near the clamp - is what I'm trying to say. Deeper. There you go. Now bring it back. There - it's nice. Deeper. There you go. Creech it back ‘cause that's all dilated up there. You need to bring it as close to the clamp as possible. Deep. Roll back. Get in there - that’s nice. Don’t raunch on the aorta. Now take it out - grab it. Now orient it so you come way out there. Don't stick this thing ‘cause I want to leave it behind. And if you can, great. If you can't, then come back in a second bite. You have to grab - yeah, I am, but you have to grab a little bit further back on the needle, so we're not struggling like that. Sure. Drive - roll the needle back - drive higher up. Yeah - yes, I am, and I’d like you to come all the way through with the big needle on the back. There you go. Now flip it over, and stick it through - and just hold your left forceps there. And just grab the needle out, and readjust it with your hands.

What's the time guys? No, there's no cross-clamp time ‘cause we don’t have ischemia anywhere. I want to know the ischemia time later for the visceral segment.

Drive the needle back. Drive it up. Now just let it go and bring it through - the needle. Let your forceps go. Grab the needle. Roll it out and then Creech it back so that as it gets here it's going to be a little tight, so learn to show some respect. We’re right next to the clamp here. You’ve got to Creech - there you go. That's all you need - you don't need a... It’s like two more bites here. Drive it right across.

You can see the subclavian artery and that knob up there above our - to the left side of our clamp, Jahan, is this subclavian artery. That's a good sign that it's not clamped off. And you’ve got nice long - nice tension there, Jahan, and that's going in there right - right across - right - yeah, right across it or come in the middle? I'd rather you just go right to it, and then maybe if you want to cross it, you could do that too. Okay come through. Tie it up. Let's have an asepto. Watch the pulmonary artery. Give him a cut, squirt. Trig, trigger, trigger. Good. Scissor. Now the asepto to me. So this is a good way to test the ‘mosis. And the suction up here please. Okay move the white towels back a little bit. Jahan, move your hand back a little. Proximal clamps coming off here. Of course. Let’s have a Crayford cowork. Take this. I need a pledgeted 4-0 stitch please. Let go. Cut, squirt please, Bruce. Squirt the right hand. Scissor. Okay, when you're doing that, you’ve got to show this artery respect. The slightest torquing to get your Creech right is tearing a hole somewhere else that's more important than your Creech. You can always do your Creech in two.

There’s something else bleeding back there now. Cut. Here you go. Let's have another angled hydro slip clamp if we can have it please. Let’s have a dry lap pad. We don't have the big ugly. Give me the big ugly and a pickup. You have those thrombeanies? Thrombeanies - let’s have them. Dry it up in there. I want to see what's bleeding. Nothing. Alright, let’s have some more. Let’s I have a dry lap again.

CHAPTER 8

Let's have you hold here gently now your heart and lungs. You have that straight hydro slip clamp? Come down on your flows please. Down. Okay and backup. Run a motor again. Now we have the mid descending thoracic aorta clamped. I'm going to take this clamp off. We’re going to buzz this - Bovie this open. And you're going to suck in there and show me where the bleeders are, and I'm going to tie them all off, so. I'll take that Bovie, and then we’ll take some 2-0s. Put the sucker in there and open it up. There you go. Grab more, Sean, help me out. K - let’s have a stitch next. DeBakey's please. You get a scissor in your hand, Jahan. Move the - your forceps out of my way. It’s not helping me. So here? Sure. Make sure the goose is not in there. Cut here.

As I tie this down, you find the next bleeder that I need to tie off. Cut this, Jahan. Pickup - another stitch. Where's the goose here? Out there. Okay. Make sure I don't stick it on the other side, Jahan. I'm good. Flip it over and check. Good - let go, and then get out of my way. And then we’re going to find the next one, yep. DeBakey. Pickup. Yeah, I know, so, Jahan, more the goose over. Lift up. I'll just take a small bite. That’s how you get an aorta. Cut. I got it. Can I have a new right glove please? Where’s our next one, Sean? One here. Okay, pickups and another stitch. Suction and show me where the next one is. So this - the goal - the nice thing about the sequential clamp technique is you minimize the blood loss and work in a small segment here. Cut. Let’s have a - what's the distal perfusion? Here you go. Stitch. Pickup. Suck. Here you go. Cut. Suck, suck, suck. Find the next one. Pickup. Cut please, Bruce.

Okay turn your pump down for a second please. Yep. Go back up. No, we're still - we're just doing sequentials down. Check another motor please. Let’s have a Bovie. Great - grab here and pull out. Griffith - give me the - give me a pickup. You can just take back to the office. Can you take this off in a second there - Jahan or one of you? Go ahead. They're good? Thank you.

Let’s get sucking in there please. K - let’s have a pickup and a stitch. Yeah. Cut. Stitch. Show it to me and then keep it showing. Let’s warm the room up a little bit for her please. What is her temp, Raf? 10-34. Okay. Is that one right there, or is that coming from the clamp? Cut. Let’s have a stitch. Okay, Sean’s going to go to the other side now. Scissor. Actually, give me a medium clip please. And let's have a scissors. You want to wedge here, like that. Can I have a cray - Crayford cowork?

This is going to be the visceral ischemia time. Marking pen to me. Okay, let’s have a Kelly. I'm sorry - not a Kelly - a 2-0 silk stitch and a Kelly. Raf, what’s our - BP’s good? Here you go. Distal perfusion’s good? Yeah, I'm going to give you - I’m going to ligate the celiac artery here for you, okay? Fine right angle.

CHAPTER 9

And then let’s have a bulldog - three bulldogs. K- you ready for visceral ischemia time? Here it comes. Celiac is ligated. Get a scissor in somebody's hand quickly. K - celiac is clamped. Let’s have the straight bulldog. Cut. Let’s have that straight hydro slip clamp now. Turn your flows down. Suck in here. Show me what I'm clamping. Okay, go back up please. Visceral segment is completely ischemic. Run another motor. Let’s have a red rubber and stuff here like we did before, and get your suction in your hand. Get that to him - he can do that. Put a forceps in your hand ‘cause we need to open this and get this open. I'm going to need those 2-0 silk ties. Ready? Here we go. Scissors. Stitches - sorry, pickups and Metz. Come on. Suck in here - show me on this side so I can get this aorta divided. Show me where the right renal artery is in here. There it is right there. Okay. Can I have that Metz? Okay, let’s have the heavy straight scissor. Pickups to me, yep - and four white towels up. Actually, let's have a 2-0 silk before we get that going. Cut. Yes. Another Stitch. We need a few more of these stitches, Bruce, okay? And then we’ll get to rest. Motor’s are okay?

These are the critical intercostals. The motors are okay from the distal aortic perfusion. They go. If you were worried about them, you can cut - let's go - you could put Pruitts in them. You have some Pruitts? That's good. If you give me the countertraction, that helps. Cut. Put your - put the suction on there, and hold it there under pressure - tamponade it off. Cut. Let’s have the Pruitt and a forceps. Rock it. Now if you're worried about that intercostal, you could. I'm not really, but - see, we’ll just leave it there for now. Nope, that didn't work - okay, let’s have the stitch. You can see what happens if you're worried about the distal segment. Remind us - if there's ever issues, that's the one we're going to reimplant. Run a motor please.

What's the distal pressure guys? Cut. How long since the clamp went on? Thank you. Let's have a stitch for the aorta next. Scissors first. Got it. Okay.