Thoracoabdominal aortic aneurysms (TAAAs) are generally asymptomatic and are discovered incidentally on chest imaging. When they become symptomatic, these aneurysms manifest as abdominal pain related to ischemia of branches of the aorta. When they are identified, management is often expectant, depending on the size of the aneurysm and its rate of growth. Surgery is indicated for larger aneurysms and those that expand rapidly so as to avoid catastrophic rupture of the aneurysm. Here, we present the case of a 70-year-old woman with a TAAA whom we had been following with serial computed tomographic angiography scans. The decision to operate was made when the aneurysm began revealing growth in diameter. Her anatomy was not conducive to endovascular treatment; therefore, we repaired her aneurysm using a traditional open approach.
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1. Distal Descending Aorta Anastomosis
- Atrio-Femoral Bypass Removal
- Check Anastomosis For Leaks
- Sequentially Open Distal Clamps
2. Atrio-Femoral Bypass Removal
- Decannulate L. Inf. Pulmonary
- Close Purse String Suture of L. Inf. Pulmonary Vein
- Decannulate L. Femoral Artery
3. Celiac Artery Reconstruction
- Create Side-Arm Exit Point in the Aortic Graft
- Anastomose Side-Arm Graft to Aortic Graft
- Check Anastomosis for Leaks
- End-to-end Anastomosis of Celiac Artery to Side-Arm Graft
- Check Anastomosis for Leaks
- Close Aneurysm Sac Over Aortic Graft
- Repair Left Hemi-Diaphragm
- Insert Thoracic Drains
- Repair Thoracotomy
Let’s have four white towels. Sorry. You can let go of this. I wanted a red rubber and a snap on it, but - suck in there please. Thank you. Now it's your turn to not be able to see anything, Jahan. Another shod please. Shod please. Yep, give me a little. Let’s hold that - shod. I'm going to want some - I'm going to want some transition stitches with pledgets here, Bruce, okay? A squirt for the strands. We’re now pulling up v - we’re doing this very gently. Okay, stop there. Keep bouncing. Stop there. Shod. Pull on it. Pull on it. Stop for second there - don't pull on it when I - when you see a loop like that. Okay, pull. Hold it on tension now. Okay, shod, shod.
Let's have a transition stitch to me with a pledget. Just leave it out of my way, yep. Put that through the pledget. Pull your - let's put that other one through the pledget as well. Hold these two like this. Give me a driver. Nope - just give me a driver. Pickup to me. Nevermind - Jahan’s helping me out. Need a pickup. Hold that one on tension still, Sean. Come on guys - we have visceral ischemia time here. Hold this one. That's going to be my next runner. Let go. Shod that one to Jahan. We're going to do one of my side - actually, going to run up my side and do the same.
How long is it been on the visceral ischemia? 15 minutes. Thanks. Yes, cut it - don’t cut the other one though. Empty driver please. Suck in there. Put the pledget on that one. Give me the other stitch so we can put that pledget through it as well. The first runner. Give this one to me. Pull this one up on tension. Cut square please. Take this - too many of course. Take this one. Give me that. Empty driver - right hand. Take this. Shod that one. Give me the other one. Pull it up nice and snug please. Motors still good? Take the other one off to shod. Hold that one up on tension. Going to follow myself. Going to want a pledget, Bruce. Yeah, go ahead and put it on that.
K - visceral layer - visceral segment’s going to open up here in a second. Drop your pump - pump flows down, but don't turn it off. I'm going to give a little backward flush here. Okay. Okay, back up. Let’s have - you guys already have the pledget on? Good man. Let go. Cut, squirt please. Okay, we’re going take the distal clamp off now. We're going to gah - turn the pump flow down to 500 in a second here, okay? And you might have - if you need a squeeze on the graft because of the visceral and the legs are coming back, let me know though the legs have been fine, so it's just a viscera. Cut. Take this. Okay, turn your pump down please to 500. K - legs are open. Right renal is open, and SMA just opened. So everything is open.
How long was the clamp time? 20 minutes? Yeah, he had right renal SMA and celiac ischemia at the same time. How are we doing is far as distal perfusion? Good. Let's run a motor please. Do you know what? Warm him up a little bit and then - ‘cause I'm ready to take the cannulas out actually. Thank you. So distal perfusion - I want greater than 60 mil - mean of 65 at all times, but I want her blood pressure like systolic about 120 postop, okay - minimum. Let’s - I’m going to want some seprafilm on the field guys. Let’s have another dry lap. Okay, let’s have some thrombeanies if you don’t mind.
Let’s have another one. Let's get ready to decannulate here. Do you need more volume here? No. Let's get all the Bovie and the cell saver up here without losing it this time. There you go. Rotate towards me. I'm just gonna do - should we take the venous out and pump through, or are - you want on none of that blood? Should we dump it into the field, and then give you a cell saver? Do that? Okay.
I'm - just leave it going for 500 for now. Let me - what? Yeah, let's not worry about that until I'm closing. I'm sorry, but - I know I did ask for it. Thanks for getting it so quick. Normally, no one ever has it. Now let's get this loosened up here. Let's get the - you can - you can let that go. It's not going anywhere. Let’s open up this and get this line out of here. Let’s have a Duval lung clamp please. Now, whoever is holding the clamp, which is going to be you - you’re gonna pull it on tension when we take it out, but then when I start to tie it down, you’re going to let it go so that I don't rip the vein, okay? Okay, Jahan, instead of this - yep, please. Spread your hands and - okay. Take this. Don't do anything. Not yet. Not yet.
Guys, get ready to hold your breathing here in a second. Let’s have a line clamp. Put the line clamp here. I can clamp down here. Okay, well we got it. Go ahead. Go ahead. Hold your pump. Clamp - all the way across. Click, click, click. Let's go. Sean, pull the cannula when I say. Go ahead - slide it out. Go ahead and breathe. Scissors.
So you don't want the volume? Yes, correct? Okay. Or can you take it now? Cut. K - rotate the table towards me. Drop to table height. Okay, let’s have an angled Gerbode and a pickups please. Let’s have an angled hydrogrip. K - put the venous cannula in the warm bucket of saline. Give me the arterial cannula here. Where is the arterial cannula? Okay let’s have the cell saver. Put that in there. Keep it on the bottom. Go ahead and - yes, take the clamp off. Take this please, Bruce - with the cell saver right in here. Right down there. Okay, I've got my clamp open here as well. Go ahead and pump slowly into the field. Yep, go ahead. Yep, put the cell saver down here. You can - that’s good. Yeah, keep going. Now, when we see - when we see the stuff turning clear, we’ll give you your lines. Let’s have a line clamp back to both me and Jahan. We're almost at the bottom - we’ve got about 400 cc. Okay, let’s give a little bit more. Okay that looks good. Clamp, clamp.
Okay, everybody move that way so we can give him his line clamps back or his lines back. Okay, you guys want to close this - this up? Jahan, you close it. You know how to do it right?
Okay. Let's have - let's have our retractors back, and we're going to put a little side biter on here and put this celiac artery in. Thanks. Do you have that 8 millimeter Dacron graft? We’ll do it right here - slightly over to the right line and just - K. Can I have Schnidt? Give him an 11 blade. Let’s have a side biting Satinsky clamp. I hope not. Let’s have a vessel loop and a snap. How - can you run a motor? It’s filling back up. See how it’s filling? Alright, squeeze it, and it fills. Okay, let’s put it on tension. Give me an 11 blade. Forceps. Let’s see that cut - Brett. We’re going to do a 4-0 please. K - let’s have four white towels. Give a - give Sean a 5-0 to get started - just to open this up a little. Stays - is exactly. Two 5-0s for stays and then with the 4-0 for the anastomosis. I'll take a shod. Thank you. And a little slightly longer driver. Even them out. Good. Go ahead. Right up the pike. A little less. Keep going - round the three. Put a - can we have a shod please? Move back for one second.
Did you flush well it proximally and distally first? Distally first then proximally? Good. I'll take a shod. Relax for a second on your side. Okay, bounce. Shod this one. Let’s have another stitch to me - lefty. Shod this one? Yes. Thank you.
Are we going to give more heparin? No. We're going to reverse once the celiac’s opened up, okay? I do 2-0 PDS and 3-0 PDS in the groin, guys. No vicryl? Nope. Tie this up. Oh - we got a hook. If you need to charge your battery, now is a good time. Okay, shod. Empty driver to Sean please. Take - cut, squirt to me please. Get ready to sew with your other side.
Do we have much in the way of a lactic acidosis after that clamp timer now? Probably not - 21 minutes. How are the coags and stuff? Okay. What? Thank you. Scissor. Yep, that’s what I am saying. Snap please. Actually, can I have a hydrogrip clamp? Can I have another stitch please, Bruce? Lefty. Another 4-0. I need that Satinsky back. Stitch to me please. Cut, squirt.
I had to reclamp partially here. Can you make sure that distal perfusion stays up ‘cause I've got like a 50% clamp on the aorta here? Cut this one. That’s - take this. Scissor. Please stop pulling up on it. It's going to keep ripping the graft. It’s got 5000 stitches in it now. Suck all that stuff out. Come. Can I have a fro - forceps, please? Forceps. How about a - yeah, thank you. Can I have another one of these? Do you have the renal forceps now? Can I have a Potts scissor? Let’s have a white sponge. Got it. And a marking pen. Let’s have another hydrogrip please. Let’s have a scissor. Let’s have a 5-0 Prolene stitch to me. You grab this corner and pull it - grab this corner. Pull it that way, yep. No. There we go. Let go. Suck on the surface here so I can see what's what, gently. Shod to me please. Shod right here. Squirt really well. You're going to hold this graft down. Just let that go - I’m going to sharp hook it back so that we don't tear this artery. So you’re going to hold this down like so. I'll take that sharp hook. Let’s have a blue towel for the - to put underneath the clamp. Let’s have another stitch to me please. We’re going to take three of these. Shod. Grab the black line with your forceps and push the graft down so that I can tie the toe down. K - go ahead and follow, Jahan. Don't pull hard now - this is a very delicate vessel. Let go. We’re going to want some more sutures here with pledgets. Round handle forceps to me.
K - give her protamine, and start reversing her please. Okay well, let’s tank her up ‘cause that's not acceptable - that pressure. Run a motor please. Okay. K - we got most of the bleeding stopped here. Lots of FFP and platelets now, guys, okay? Let’s - can we have some warm irrigation in the room? Let's take this, guys. Can you rotate the table away from me? Let’s have some more warm irrigation. Rotate away from me some more. K - lots of protamine, coags, and platelets now, guys. Last chance to look at the anastomosis.
Alright, we’re seeing clot in the field, so thank you. K - let’s have Bonnie's and a 2-0 silk. Let’s see, is that going to narrow that graft? Try it. Don't close it completely then. Yeah, that's good. That's fine. We're gonna close it up here. There's a good one here and one under Sean's left hand. Did she have a PET CT? Suck up here so it doesn't drip all over my legs. 68-69-70-71-72. Let’s have another long silk runner please. Shod this or snap it. Yeah, small clip please, Laura. Can I have a Bonnie's?
Where is all this blood coming from? I need a - slack on that, guys. Some more irrigation here. And the coags are okay, or are you waiting on those? Can you get some more FFP as well please? Thank you. Far and away - far enough away from goose there. That’s good. Okay, let’s take this. I'll take another one of those heavy vicryl runners for the aneurysm sack. Now it should be dry as a chip up here, and it is. Relax for one second please. There’s a lot of mediastinum opened up here. Can I have the Bonnie's back please? If anyone has to re-explore this later, remember I put that stitch there. Grab this with a Bonnie, and pull it over so that it doesn't rip out. I’m going to try to tie it down.
There’s still a lot of oozing up here. Alright, keep doing - working on the coags and platelets and stuff, guys. There’s still a lot of raw surface that's just oozing now. Bonnie’s - thank you. Yeah. Especially up near the neck. Let’s run up this one. Let’s see can I have a vicryl stitch? You can stop doing it - we're done. Thank you.
What's the blood pressure been? 120s? That's perfect. No, 120 is fine. Do like 120 to 140 - don't overshoot, but...
Okay, let's do this, and let's just close this up a little bit to get a little tamponade. You have that vicryl stitch and another thrombeanie for me? Okay, I'll take that vicryl stitch next. Cut that one. Follow with your other hand for me. Let it go. Ease up with the pull on your right hand as you pull up. Ease up on the pull. Okay. I mean, it will - it will tamponade nicely if we can get it closed up. That’s going to be good enough. Tie it up. Pull up on it. Here you go. Let’s take this off. Actually, let’s take it off just - yep, go ahead. Let’s have heavy silk stitch for me. We'll look at this wing in the second. Let's have a Bonnie's. Give us head up in Berg. That’s good. Too much. Cut this please. Cut.
Let’s check that pulse in the celiac artery. You have a doppler on? You take it out of - less - head down, up in Berg and give me a little rotation towards me please? You want her set down? Yeah, just a little more flat - the other way. Okay, let's have that heavy Ethibond runner. Let's do a little bit head down and drop the table height all the way if you can. Let’s have that Ethibond runner. Just hold the spleen and kidney over gently. I'll take that Ethibond - Bonnies. Cut. Take that. Driver. Yep. Yep. Jahan, can you cut these out?
It’s preserved the central trend, but does that - and the phrenic nerve, but does that really preserve function? Who knows. Let me tie myself. Okay. Don't p - don’t poke a skunk. Kocher please. Suction. Feet down in Berg. That's good, right there. Get your fingers deeper down in there. Hold this for second. Pull yourself up. Let's have a Kocher to me. K - Jahan, you hold this. Yep, pop through. Closer up. Yep, that's good. Don't stretch the tissues to get your needle in. Move your needle to get your tissues. This one is supposed to be down here, so you've got to make more. That one’s headed it up to there. See how much travel you - this one's got to be made to here. It's a smaller travel there - bigger travel on that side. Scissor. You guys start taking a little break out of the table. We do that first and then close it. Watch your fingers. There you go. Now this fram’s got to go all the way to there. So it’s much smaller bites, much bigger travels. Okay. I'll take a - keep going. You’re following yourself. I’m not following you anymore. I’m - let’s have a Kocher to me. Let's have a knife positioned at 2. Okay, knife. K - easy for second now. You got to make up this all the way to there, okay? Can you give us a little head down in Berg? Okay. Get another stitch please another via - just tie it - tie this. Yeah - no - another Ethibond - long running Ethibond. Good bite. Don't stick the heart. Now we're not going to pull it up; we’re just going to sort of keep running it. Ah - I pulled it out sorry. Rotate towards me. Can we go anymore or no? Keep going all the way, Raf. Jahan, get a forceps and a scissor and cut this - this marker stitch out.
Just the edge now. That and that - let’s have that heavy vicryl runner please. Scissor. Bonnie’s. And then follow here. Here you go. Let’s have the rake back. Another one of these heavy vicryls. You close them up just as nicely as you opened them up, and everything works out just fine.