A HYBRID SOLUTION TO MANAGE A THORACOABDOMINAL AORTIC ANEURYSM: THE “SIMPLIFIED TECHNIQUE” ASSOCIATED TO ENDOGRAFTING OF THE PROXIMAL AORTIC ANASTOMOSIS

  • Tony Soares Department of Vascular Surgery, Hospital Santa Maria (CHULN), Lisbon, Portugal; Lisbon Academic Medical Centre, Lisbon, Portugal
  • Pedro Amorim Department of Vascular Surgery, Hospital Santa Maria (CHULN), Lisbon, Portugal; Lisbon Academic Medical Centre, Lisbon, Portugal; University of Lisbon, Lisbon, Portugal
  • Carlos Martins Department of Vascular Surgery, Hospital Santa Maria (CHULN), Lisbon, Portugal; Lisbon Academic Medical Centre, Lisbon, Portugal
  • Vivivana Manuel Department of Vascular Surgery, Hospital Santa Maria (CHULN), Lisbon, Portugal; Lisbon Academic Medical Centre, Lisbon, Portugal
  • Emanuel Silva Department of Vascular Surgery, Hospital Santa Maria (CHULN), Lisbon, Portugal; Lisbon Academic Medical Centre, Lisbon, Portugal
  • Mariana Moutinho Department of Vascular Surgery, Hospital Santa Maria (CHULN), Lisbon, Portugal; Lisbon Academic Medical Centre, Lisbon, Portugal
  • João Rato Department of Vascular Surgery, Hospital Santa Maria (CHULN), Lisbon, Portugal; Lisbon Academic Medical Centre, Lisbon, Portugal
  • Luís Silvestre Department of Vascular Surgery, Hospital Santa Maria (CHULN), Lisbon, Portugal; Lisbon Academic Medical Centre, Lisbon, Portugal; University of Lisbon, Lisbon, Portugal
  • Luís Mendes Pedro Department of Vascular Surgery, Hospital Santa Maria (CHULN), Lisbon, Portugal; Lisbon Academic Medical Centre, Lisbon, Portugal; University of Lisbon, Lisbon, Portugal
Keywords: Thoracoabdominal aortic aneurysms, endograft, open surgery, simplified technique

Abstract

Introduction: Thoracoabdominal aortic aneurysms (TAAA) remain a therapeutic challenge for vascular surgeons. We report a Crawford extent type III TAAA managed with the “simplified technique”1 to approach TAAA associated to endograft implantation in the proximal aortic anastomosis to minimize the risk of blowout of the aortic stump.

Case Report: A 43-year-old female patient was evacuated from Mozambique with a history of TAAA and admitted in our emergency department with recent chest and abdominal pain. She had history of HIV infection and pulmonary tuberculosis. The physical examination revealed a painful, pulsatile abdominal mass and the computed tomographic angiography (CTA) an 8cm type III TAAA without signs of rupture.

The aneurysm morphology was not adequate for endovascular treatment and, due to the immediate unavailability of the usual adjuncts for Crawford technique (ECC and selective visceral perfusion), this symptomatic patient was submitted to a thoraco-phreno-laparotomy with left medial visceral rotation. A bifurcated Dacron 18x9mm graft was distally anastomosed in an end-to-side fashion to both external iliac arteries and proximally to a 22mm polyester four branched graft (Jotec®). This later graft was proximally anastomosed to the descending thoracic aorta (end-to-side) with no visceral or renal ischemia. The aorta distal to the anastomosis was then cross-clamped as well as the infra-renal segment, the aneurysm opened, and no patent intercostal arteries were visible. The lower limb perfusion was maintained by the lateral shunt. Both kidneys were cooled with lactated Ringer’s solution through Pruitt catheters and the visceral arteries were temporarily occluded with Fogarty catheters. The four anastomoses were sequentially performed to the right renal artery, superior mesenteric artery, celiac trunk and left renal artery. After completing all the reconstructions, a Zenith Alpha® 32x155mm endograft was implanted from the descending thoracic aorta to the pre-branch segment of the lateral shunt. The operation was uneventful, and the patient remained hemodynamically stable. The postoperative period was complicated by pulmonary infection and the postoperative CTA revealed the occlusion of the left renal artery graft (without clinical or laboratory repercussion). The patient was discharged 50 days after the operation due to social reasons.

Conclusion: The adjunct of an endograft to the “simplified technique” was previously described2 and allows to overcome the risk of aortic stump blowout which is one of the major limitations of this technique. This strategy was a successful alternative to manage a TAAA since organ-protection adjuncts to the Crawford technique were not available.

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Published
2019-10-16
Section
Clinical Case