Open thoracoabdominal aortic aneurysm surgery technique: how we do it.

BACKGROUND More than four decades have passed since Dr. E. Stanley Crawford and colleagues established the modern principals to treat thoracoabdominal aortic aneurysm (TAAA). The historical challenges in repair of TAAA have been-and continue to be-multiorgan protection. Among all organs, the spinal cord remains one of the most vital and vulnerable. METHODS We describe our current techniques of open extent II TAAA repair, including the following topics: anesthesia, intraoperative monitoring, skin incision, exposure of the TAAA, left heart bypass, graft replacement technique, intercostal artery retattachment, visceral/renal artery reconstructions, and postoperative care. We use cerebrospinal fluid drainage, distal aortic perfusion, mild passive hypothermia, sequential clamping, and visceral and renal perfusion using roller pump in all the cases for multiorgan protection. We use both motor-evoked potentials and somatosensory-evoked potentials to guide the conduct of intercostal artery reattachment. RESULTS Our group demonstrated that the use of adjuncts has reduced the overall spinal cord ischemia rate after Extent I TAAA from 15% to less than 2% and after Extent II TAAA from 33% (50% with clamp time exceeding 40 minutes in "clamp and go" era) to less than 4%. CONCLUSIONS The current standard practice of TAAA repair with adjuncts has improved outcomes, especially with regard to spinal cord ischemia.