CHAPTER 1

Hi, 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 distal vessels. We will put the patient on left atrial femoral bypass to take heart from blood from the left heart and perfuse to lower extremities and the spinal cord while performing the reconstruction. We will start with a proximal anastomosis here and finish your 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 periphery to a profuse 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 allowed to hips to fall back at about 45 degrees is 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 vote potential lines are here and there. Okay. You guys can prep.

CHAPTER 3

So our fellow is, Doctor English, is marking out the surgical incision. He is identifying the tip of the scapula end 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 onto the abdomen below umbilicus somewhere 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 of 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. If you're already there then help me with her some rakes on this side. What's the deal 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 reconstructed later. Okay this is the trap now so we're going to divide the trapezius muscle. 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 because it's easier to put them back together, but some people take them to the 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 anteriorly 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 wing. 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 of 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. So mark the fifth rib. That’s going to be our entry point. I just want to dry things up up there and 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 in here. Actually we are going over the top of the 6 Rib. Aren’t we? That would be the fourth interspace. Yeah. So I'll expose a rib for you so you can see,and then we'll just come across here. 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 ribs at we're entering the chest.

Let’s have a large Kelly to me. Take this first Sean. Now come under neath 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 and go. Okay that’s enough. Let’s have a large Kelly and house heavy straight scissor. That's good. Close. Close. Don't scissor. Just close. Watch the tips lower tips going please. There you go.

You’re going to lift up here going to see if there are any bleeders underneath. 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 pair 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 pick up now. Take this away. Push. Where’s our phrenic nerve? Hold on for second. Right in there I bet. 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 GI stapler to Sean. You going to pass it across this way. You are going to keep away from the central diaphragm here. Right there close. Cut and don't change the angle if you're starting to come down so. It's good. Get my blues fired. Needle back. Another Stitch. Jahan keep it long just. We’ll cut them at the end, so we can use them as a handle. Yes. Thank you.

Let me have a pick up and Sean take a bovie please. We’re going to take some of these lung adhesions off. We are going to keep working away in the muscular portion of the diaphragm as we divide the adhesions off of the lung. DeBakey, Bruce, please. Let me have a pickup and Sean take a bovie please. We are going to take some of these lung adhesions off and we are going to keep working away in the muscular portion of the diaphragm as we divide it so over the adhesions of the lung. 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 GI 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. Sense your pulmonary vein coming up. That’s enough. Do you have a Duval lung clamp for me please? Right angle back. Mhmm 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. The left lung looks great. Thank you.

CHAPTER 4

Now that we've opened this up, let's give this a little bit more retraction. Hold this back please. Pull, Sean. Char that branch that's crossing right now. Score right here. Divide. Dont 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 GI 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. Yup.

There's our inferior pulmonary ligament and vein with divided inferior pulmonary ligament. Please pick this up here. Right angle. She'll take the bovie. Get the line out of my way. Line. Wire. Let’s have a palm. I’ll have another Duval lung clamp. Grab this stuff down here on the see if I can get a little bit more mobilize down there.It's going to start to be into pericardium soon.

Okay there’s pericardium. So when I did this with the Josh 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. Shingle this rib. Pick up to me. Now 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 CM hole on the upper edge of that rib. I'll take a right angle please. Bovie to me. Start to see it coming through. Keep coming.

Okay you can see there's 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 or bone wax or whatever you want in there. Divide slowly don't pass. Point deep cause that's wearing order 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 here. I think that's the seal SMA a lot lower than I thought it was going to be. Stuck here at the Celiac that means. 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. I'm going to do clamp, take the Celiac off to 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 and 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 don't be rough with the celiac artery cause it will rip. And here. Yup move the vessel north a little bit. Suck. Give me a buzz here Jahan. If you can meet here. Suck here. Right angle please. Can I have the surgisil? Snap. Vessel loop please. Shove it in there. Do you have another piece and another? And with that piece that was still back there in the lumbar though 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 mets?

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. Pull that towards you. Let’s have a 15 blade. Let’s have a scissor..Let’s have a suction, a suction. Okay let’s tie that up sean. I need to fine right angle and a 3-0 silk tie back. Small clip. Small clip. Trying to prevent stuff from going down you know. Mets. Can you nudge the artery that way with your forcep? Even that will help. Yup. Now tell when to put the sucker in there. Grab that behind. That stuff right there. Much better to sew to. Looks like a much better vessel to sew too. 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 snitz 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 or otherwise we will get the let’s have another the string. Another string please. Grab it. Pull. 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 and put your hand parallel to the aorta. Just put your. That's nice. Let’s have a schnit. 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 is the only other structure that's here and I don't want to poke in there and is the pulmonary artery okay. Suck here. Here's the ligament. If you can grab with a forcep here and hold this up so I can see where the structures are underneath and then somebody else can bovie. How’s this? Tallest lymphatic in the mediastinum. You can see maybe recurrent laryngeal nerve going back down that way with pulmonary going to be on that side. Scissor. Move the ventin nerve out of the way like this with just with the closed forcep. Buzz please. Take this please. Hold this up with your one hand.

Let's see the pulmonary ligament that I'm tying somehow. Please. Forceps. You’re just going to gently hold there. We’re 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 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. John gently pull on aorta here. You have the arch in your hands. feel that now is a little much more looser. We have our Vegas and recurrent laryngeal running going to be running back in here cause we didn't cut anything. There’s our ligaments and our frontech. Okay. Let’s have a duval lung clamp for me. Hold here. Let's have a dry lap. Pick up to me. Another branch coming up there. Can I have a dry sponge please first? 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. 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 there - when I get these strands of 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 then feed me feed me feed me feed me and cut the needles right next your finger. Snap please. Take the Duval on clamp off for now. Bovie this stuff off. Buzz here. Right angle back. Oh my goodness. Suction would be nice. Take that other one and put it through a pledget please. Okay let’s stop there.

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 Venus. Heavy silk. Usually the 5 or the 10? The 5. Yup. Let’s have a little T-Bird. Give Sean the 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 not let it slide out while I sinch down on it okay? I'm going to tie this 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-bird? And you're going to keep tension on this so I can come against you and to push in here okay. And then let's have a suction up please. And a schnitz is next is. Okay hold your breathing please. Schnitz. Schnitz. Cannulas. Stop for a second. Give this to me. Hold it down here, Sean, with your left hand.

I guess you give me the line clamp. Tension up on the. 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. Someone have a scissors, ready. Yep that's not for you. I'll take a sins.

Okay Sean You Can Let Go Now switch hands. Switch hands so that this here holds this here and this holds this here. Take an a septo next and then three snaps. Scissor first. 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 taught don't pull it out. Walk this off over wire. I got wire. Let it go, pull it off. Let's go. Let's have the next dilator. Hold it down a little bit. Push wiring to 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 the right there for 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 I'll please as you're grabbing it with the okay. Now you going to take the white dilator out.

Does this pop out or is it's going to go? You got to come out a little faster guys like. Let go. Okay let’s have an a septo please. Help me out here. Let go. 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? Take it off. Let's have a little bit of saline drip drip here. Okay your lines open start to run at 500 an hour. Let's have a heparin antibiotic soap sponges, 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.

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 or go ahead and a stitch. Let that fall please. Help me out with your other hand. 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. Line clamp is back to you, Bruce. Let's see my clamp. Can you load up that my can you look on the my CT scan and let me know where her thrombus ends? I think it's all in this bubble right.

Relax here one second cause I want to be a little higher up. How you doing as far as flows there, Ralph. You ready for a clamp? Okay give me a few minutes. I've been there I need a straight hydro and then 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? Pick up to me. This is PA leave it alone. Sucks. I'll take a pick up please, Bruce. Okay turn your flows down for a second. Okay backup. Can I have a clamp on the info in the mid descending proximal descending thoracic have the proximal here? Suck. Okay scissor. Mets 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 please. Pick up this aorata here for me please. Suck and toe in toward you so we can see what we're cutting make sure it's not goose right.

Let’s have a silk 2-0 stitch. Scissor clamp. Take this. That's good here. Let's have a mets. 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 your fingertips are on PA don't dig in just flat. Grab a forcep, Sean. You grab yours, yeah Jahan side of the graft. Thank you. Let have a shod please. Does this 3-0 come in a longer stitch than this? Forcep 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. Here, Bruce, put a snap on it please. Give me another DeBakey please. Hold this. Let's have a sharp hook. That’s enough there. Don’t pull any harder. Okay hold that on tension. Stop pulling it up this way cause we have to come around that way with the anastomosis. Jahan put the suction on. Give that to Shawn and you follow from your angle. Driver. Thanks for keeping the needle out of the PA. Pull up on tension. Let’s just let it go so I can orient properly. Otherwise we are going to create a big pucker right in there. Ok, Sean, driver . You keep that on tension. Come closer to me. Got that on tension.

Hang on I'll follow you. Get a forceps in your hand. Take a bite of that. Help. Bring it through. Now you're next one's going to go that way and you're going to Creech it over onto itself when you get a nice deep bite with that thing without grabbing the no creature toward yourself instead of up the aorta so if you can't do it then let it go in Creech back. 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 clap as possible.Deep. Rollback get in. That’s nice. Don’t raunch on the aorta. Now take it out. Grab it. Now orient so you come way out there. Don't stick this thing cause I want to leave it behind. Mhmm and then 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. Yes, I am and I 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 you left forcep 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 creech it back so that as it gets here it's going to be a little tight so learn to show some respect. Right next to the clamp here. You’ve got to creech. There you go that's all you need. You don't need it. Two more bites here. Drive it right across.

You can see the subclavian artery 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 got nice tension there Jahan and that's going in there right the right across right at 2. Okay come through tied up. Let's have an a septo. Watch the pulmonary artery. Cut. Squirt. Trigger trigger trigger. Good. Scissor. Now the A septo to me.

So this is a good way to test the nosis. 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. Tell a creeper Co-op. Take this. I need a pledget 4-0 stitch please. Let go. Choreography. 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 pick up. You have those from thrombeanies. Thrombeanies. Dry up in there I want to see what's bleeding. Nothing. Let’s have some more. Can 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 and buzz this 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. Let’s have a stitch next. You get a scissor in your hand Jahan. Move the forcep out of my way. It’s not helping me. You're 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. Pick up. Another stitch. Where's the goose here? Out there. 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. Yup. Baby. Pick up. Yeah I know so Jahan more this goes over 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? pickups and a new stitch. Suction. Show me where the next one is. She said that wrong.

So does the gold the nice thing about the sequential clamp technique is you minimize the blood loss and working a small segment here. Cut. Let’s have a... What's the distal perfusion? Here you go. Stitch. Pick up. Suck. Here you go. Cut. Suck suck suck. Find the next one. Pick up. Cut please, Bruce.

Okay turn your pump down for a second please. Yep. Go back up. No we're still uh we're just doing sequential's down. Check another motor please. Let’s have a bovie. Great grab here and pull out Griffith. Give me the give me a pick up. Can you take this off in a second to Jahan or one of you? Go ahead. They're good? Thank you.

Let’s get sucking in there please. Let’s have a pickup and a stitch. Yeah. Cut. Sitch. Show it to me. Keep it showing. Let’s warm the room up a little bit for her please. What is her Temp? 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. Give me a medium clip please. Let's have a scissors. You want to wedge here like that. Let’s have a cow crayford cork.

This is going to be the visceral ischemia time. Marking pen to me. Let’s have a Kelly. I'm sorry not a Kelly. A 2-0 silk stitch in a Kelly. Ralph what’s our BPs good? Distal perfusion’s good? Yeah I'm going to ligate the celiac artery here for you okay. Fine right angle.

CHAPTER 9

Let’s have a bulldog three bulldogs. Are you ready for visceral ischemia Time? Here it comes. Celiac is ligated Get a scissor in somebody's hand quickly. Celiac is clamped. Let’s have the straight bulldog. Cut. Let’s have that straight Hydro slip clamp now turn your flows down sucking here show me what I'm clamping and they go back up please this real segment is completely ischemic run another motor. Tell the red rubber stuff here like we did before and get your suction in your hand. Give that to him so he can do that. Get the forcep in your hand cause we need to open this and get this open; I'm going to need those two silk ties ready. Here we go. Scissors. Stitches sorry pick up and metz. Come on. Suck in here show me on this site so I can get this aorta divided. Jahan show me where the right renal artery is in here. There it is right there. Okay. Have the mets. Let’s have the heavy straight scissor. Pick ups to me. Yep. Four white towels up. Actually let's have it to me before we get that going. Cut. Yes. Another Stitch. I need a few more of these stitches, Bruce, okay and I will get the rest. Okay?

These are the critical intercoastals. The motors are okay from the distal aortic perfusion they go if you were worried about him 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 that suction on there hold it there under pressure tamponade it off. Cut. Let’s have the pruitt and a forcep. Rock it now you're worried about that intercoastal you could I'm not really but they will just leave it there for now. Didn't work okay look up a stitch you can see what happens if you're worried about the distal segment remind us if there's ever a shoes 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.