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2.2 Crawford type IV thoracoabdominal aneurysms: Median laparatomy surgical approach
Monday, September 22. 1997
Co-Chairmen:L.H. Hottter, T. Yamada WestmtnsterSuite 2.1 Minimizing Visceral Ischemia in the Repair of Thoracoabdominal Aortic Aneurysm by Using an Internal Shunt R.C. DARLING III, P.B. KREIENBERG, B.B. CHANG, P.S.K. PATY, WE. LLOYD and D.M. SHAH, Albany, New .York, USA Despite numerous modifications in the surgical treatment of thoracoabdominal aortic aneurysms (TAAA) over the past three decades, the mortality and perioperative complications have remained relatively constant. The use of partial cardiac bypass, periperative axillo-femoral bypass and manipulation of spinal cord perfusion pressure and metabolism have shown some promise in limiting myocardial, visceral and neurological complications. In this report, we outline a technique of an internal bypass from descending thoracic aorta to celiac axis as a first step in minimizing the stress of thoracic aortic cross clamping, visceral warm ischemia time, and declamping hypotension. An end-to-side descending thoracic aorta to cehac axis or SMA bypass was performed using a 10 or 8 mm PTFE graft prior to cross clamping and anastomosis of the descending thoracic aorta was performed in nine patients. After completion of this bypass and repair of the TAAA, the internal bypass is detached from the celiac axis and is used for anastomosis to the intercostal vessels allowing direct intercostal revascularization and spinal cord perfusion. This technique may reduce coagulopathy secondary to minimizing visceral and renal warm ischemia time. There were no mortalities or neurological complications. No patients experienced perioperative coagulopathy, bleeding complications or renal impairment. We suggest that an internal bypass allows security and safety for unhurried repair of TAAA.
In the last year we have operated on four patients with a Crawford type IV thoracoabdominal aneurysm using a median laparatomy surgical approach instead of a thoracofrenic laparatomy. The patients’ mean age was 60 years; they were all men. Hypertension was present in two patients, one patient had a history of coronary artery disease. One patient had diabetes mellitus. All patients were studied preoperatively with aortography and thoracoabdominal computed tomography and an underwent elective surgical therapy. We performed a median laparatomy and through the incision of the left parieto-colic space the peritoneum was gently dissected; the peritoneum envelope was stripped laterally to medially uncover the third medium and the lower abdominal aorta. The peritoneum was then dissected and freed from the base of diaphragm; to expose the upper abdominal aorta and the lower thoracic aorta we incised the posterior diaphragm; to extend the aortic diaphragmatic hiatus; then the thoracic aorta was pulled downward in order to have a surgical exposure of the proximal end of the aneurysm and lower thoracic aorta. The mean aortic cross clamp time was 30min. All patients survived the surgical procedure; no patients had paraplegia, renal dysfunction, intraabdominal or thoracic bleeding and mesenteric ischaemia. In our experience, this surgical approach provides a good exposure of the Crawford IV type aneurysm proximal end and the proximal anastomosis between the lower thoracic aorta and the prosthesis can be easily performed. The surgical treatment of the Crawford IV type aneursym through the median laparatomy, avoiding a rhoracofrenic laparatomy approach, reduces the risk of postoperative pulmonary complications with an easier weaning from ventilatory support and an overall shorter hospital stay.
2.3 2.2 Crawford Type IV Thoracoabdominal Aneurysms: Median Laparatomy Surgical Approach P. BIGLIOLI, R. SPIRITO, M. PORQUEDDU, L. DAINESE, M. AGRIFOGLIO, E ALAMANNI and A. PAROLARI, Milan, Italy From January 1985 to November 1996, 45 patients with thoracoabdominal aortic aneurysms were treated surgically at Centro Cardiologico “Monzino Foundation”, Department of Cardiac surgery, University of Milan. Types I, II, III and IV Crawford classification aneurysms were operated on with a classical surgical approach: left diaphragm-splitting thoraccoabdominal incision and retroperitoneal route.
CARDIOVASCULAR SURGERY SEPTEMBER 1997
Traumatic Rupture of the Descend&g Asrta E. KOVACS, Cs. DZSINNICH, T. GYONGY, E. MORAVCSIK, Z. SZABOLCS and E. BODOR, Budapest, Hungary During a IO-year period, 16 patients with aortic rupture and false aneurysm secondary to blunt trauma were seen. One patient underwent an acute operation, four patients had operative therapy electively delayed and 1 I patients were operated on for chronic traumatic false aneurysm. Operative delay was carried out in case of simultaneous multisystem injury (e.g. shock caused by abdominal injuries, cerebral contusion or pulmonary contusion on the right-hand side). The shunt bypass method of repair was used in the case of
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Co-Chairmen:L.H. Hottter, T. Yamada WestmtnsterSuite 2.1 Minimizing Visceral Ischemia in the Repair of Thoracoabdominal Aortic Aneurysm by Using an Internal Shunt R.C. DARLING III, P.B. KREIENBERG, B.B. CHANG, P.S.K. PATY, WE. LLOYD and D.M. SHAH, Albany, New .York, USA Despite numerous modifications in the surgical treatment of thoracoabdominal aortic aneurysms (TAAA) over the past three decades, the mortality and perioperative complications have remained relatively constant. The use of partial cardiac bypass, periperative axillo-femoral bypass and manipulation of spinal cord perfusion pressure and metabolism have shown some promise in limiting myocardial, visceral and neurological complications. In this report, we outline a technique of an internal bypass from descending thoracic aorta to celiac axis as a first step in minimizing the stress of thoracic aortic cross clamping, visceral warm ischemia time, and declamping hypotension. An end-to-side descending thoracic aorta to cehac axis or SMA bypass was performed using a 10 or 8 mm PTFE graft prior to cross clamping and anastomosis of the descending thoracic aorta was performed in nine patients. After completion of this bypass and repair of the TAAA, the internal bypass is detached from the celiac axis and is used for anastomosis to the intercostal vessels allowing direct intercostal revascularization and spinal cord perfusion. This technique may reduce coagulopathy secondary to minimizing visceral and renal warm ischemia time. There were no mortalities or neurological complications. No patients experienced perioperative coagulopathy, bleeding complications or renal impairment. We suggest that an internal bypass allows security and safety for unhurried repair of TAAA.
In the last year we have operated on four patients with a Crawford type IV thoracoabdominal aneurysm using a median laparatomy surgical approach instead of a thoracofrenic laparatomy. The patients’ mean age was 60 years; they were all men. Hypertension was present in two patients, one patient had a history of coronary artery disease. One patient had diabetes mellitus. All patients were studied preoperatively with aortography and thoracoabdominal computed tomography and an underwent elective surgical therapy. We performed a median laparatomy and through the incision of the left parieto-colic space the peritoneum was gently dissected; the peritoneum envelope was stripped laterally to medially uncover the third medium and the lower abdominal aorta. The peritoneum was then dissected and freed from the base of diaphragm; to expose the upper abdominal aorta and the lower thoracic aorta we incised the posterior diaphragm; to extend the aortic diaphragmatic hiatus; then the thoracic aorta was pulled downward in order to have a surgical exposure of the proximal end of the aneurysm and lower thoracic aorta. The mean aortic cross clamp time was 30min. All patients survived the surgical procedure; no patients had paraplegia, renal dysfunction, intraabdominal or thoracic bleeding and mesenteric ischaemia. In our experience, this surgical approach provides a good exposure of the Crawford IV type aneurysm proximal end and the proximal anastomosis between the lower thoracic aorta and the prosthesis can be easily performed. The surgical treatment of the Crawford IV type aneursym through the median laparatomy, avoiding a rhoracofrenic laparatomy approach, reduces the risk of postoperative pulmonary complications with an easier weaning from ventilatory support and an overall shorter hospital stay.
2.3 2.2 Crawford Type IV Thoracoabdominal Aneurysms: Median Laparatomy Surgical Approach P. BIGLIOLI, R. SPIRITO, M. PORQUEDDU, L. DAINESE, M. AGRIFOGLIO, E ALAMANNI and A. PAROLARI, Milan, Italy From January 1985 to November 1996, 45 patients with thoracoabdominal aortic aneurysms were treated surgically at Centro Cardiologico “Monzino Foundation”, Department of Cardiac surgery, University of Milan. Types I, II, III and IV Crawford classification aneurysms were operated on with a classical surgical approach: left diaphragm-splitting thoraccoabdominal incision and retroperitoneal route.
CARDIOVASCULAR SURGERY SEPTEMBER 1997
Traumatic Rupture of the Descend&g Asrta E. KOVACS, Cs. DZSINNICH, T. GYONGY, E. MORAVCSIK, Z. SZABOLCS and E. BODOR, Budapest, Hungary During a IO-year period, 16 patients with aortic rupture and false aneurysm secondary to blunt trauma were seen. One patient underwent an acute operation, four patients had operative therapy electively delayed and 1 I patients were operated on for chronic traumatic false aneurysm. Operative delay was carried out in case of simultaneous multisystem injury (e.g. shock caused by abdominal injuries, cerebral contusion or pulmonary contusion on the right-hand side). The shunt bypass method of repair was used in the case of
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