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Ann Thorac Surg 2000;69:623-625
© 2000 The Society of Thoracic Surgeons

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Case Reports

Thoracoabdominal aortic aneurysm combined with aortic occlusion

^a First Department of Surgery, Kumamoto University School of Medicine, Kumamoto, Japan

Address reprint requests to Dr Kunitomo, First Department of Surgery, Kumamoto University School of Medicine, 1-1-1 Honjo, Kumamoto 860-8556, Japan
e-mail: ryuji{at}kaiju.medic.kumamoto-u-ac.jp

	Abstract

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The case of a 73-year-old woman with aneurysms of the thoracoabdominal aorta and distal arch, combined with aortic occlusion, is reported. Cannulation from the femoral artery was not possible because of the aortic occlusion. Blood supply to the abdominal viscera and lower extremities was achieved only by selective perfusion from the celiac artery, superior mesenteric artery, and bilateral renal arteries. A unique choice of selective perfusion for distal circulatory support is described.

	Introduction

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Cardiopulmonary bypass (CPB) is a safe and established technique to use for distal perfusion support during operations for thoracic or thoracoabdominal aortic aneurysms (TAAA) [1]. However, femoral cannulation is contraindicated in those patients with atherosclerotic occlusive disease or obstruction of the distal aorta [2]. We describe a patient who developed a TAAA combined with aortic occlusion in whom only selective perfusion using CPB from the celiac artery (CA), superior mesenteric artery (SMA), and bilateral renal arteries (RAs) was used during repair.

Chest roentgenograms and computed tomographic scans revealed aneurysms of the distal arch and thoracoabdominal aorta in a 73-year-old woman. Her only complaint was intermittent claudication (approximately 200 m). Preoperative studies, including computed tomographic scans of the chest and abdomen, aortography, and digital subtraction angiography, demonstrated that the patient had a 5 cm distal arch aneurysm, a 7 cm Crawford-type III TAAA, obstruction of the distal aorta, severely calcified distal aortic walls, and patent common femoral arteries which were stained by collateral flow from the SMA.

An epidural tube was inserted into the subarachnoidal space, and the cerebrospinal fluid pressure was maintained at less than 10 mm Hg during the operation. The thoracic and abdominal parts of the aorta were exposed by a sixth intercostal thoracotomy and a retroperitoneal approach using a spiral incision. A 7.0 cm TAAA involving the visceral arteries was found from 10 cm above the hiatus. The patient was heparinized, and a venous cannula was inserted from the right femoral vein. An aortic cannula was placed in the descending aorta for use in the event of an emergency such as rupture of the distal arch aneurysm. After aortic cross-clamping, the aneurysm was opened longitudinally and the mural thrombus occupying the lumen was removed. Selective perfusion of the viscera was started using CPB at a flow rate of 1.5 L/min. The descending aorta was resected to leave the ostia of the backflowing intercostal arteries at their native sites and was replaced with a 26 mm collagen-sealed Dacron (C.R. Bard, Haverhill, MA) tube graft. The ischemia time of the spinal cord was 29 minutes. An aortic flap, including the ostia of the CA, SMA, and RAs, was constructed from the aneurysm and sewn onto the distal end of the 26 mm graft. The aortic cross-clamping time and selective perfusion time were 65 and 58 minutes, respectively. After the removal of the aortic cannula, two 8 mm ringed, gelatin-sealed Dacron grafts were sewn onto the side of the 26 mm graft. The other sides of the two 8 mm grafts were sewn onto the sides of the common femoral arteries.

	Comment

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What was the best type of perfusion support and where was the best cannulation site under the complicated circumstances encountered in our case? Simple aortic cross-clamping and rapid reconstruction might be one surgical technique of choice [3, 4]; however, limitation of the ischemia time was a concern in this case because we thought that distal anastomosis might be time-consuming due to the severely calcified infrarenal aortic wall. In addition, proximal unloading and pressure control during aortic cross-clamping seemed important because of the distal arch aneurysm. For safety, we chose to use CPB for circulatory support, and the cannulation site became a major problem. We considered two possible options for the cannulation site without selective perfusion, ie, direct infrarenal cannulation or application of the Coselli and Crawford technique. Coselli and Crawford [5] demonstrated a new arterial access technique for CPB using a bifurcation graft in a patient with dissection-induced distal aortic and proximal iliac artery obstruction. Neither of these options was possible because of the extent of the aortic occlusion and the severely calcified aortic wall. Deep hypothermia and circulatory arrest might have been useful for perfusion support in our case. Deep hypothermia provides effective protection of the spinal cord, kidneys, and abdominal viscera, and circulatory arrest provides a bloodless field and eliminates the need for aortic isolation and proximal aortic clamping in thoracoabdominal aortic surgery [6, 7]. However, we hesitated to apply this technique for a Crawford-type III TAAA due to concerns regarding the risk of serious pulmonary complications [8] or the need for myocardial protection, including left heart venting, during the procedure [6]. Selective perfusion of the viscera using CPB seemed to be the simplest and best type of perfusion support with reduced operative risk.

With regard to graft choice, we chose to anastomose two 8 mm ringed distal grafts to the 26 mm thoracoabdominal graft instead of extending the thoracoabdominal prosthesis with a conventional Y graft. This is because the Y graft tended to kink at the body due to the remnant distal aorta and the 8 mm grafts seemed to fit the small femoral arteries. However, we realized that careful follow-up observation would be required due to the risk of thrombus formation in the blind sac.

We conclude that selective perfusion of the viscera using CPB is a useful circulatory support system for thoracoabdominal aortic repair in patients with distal aortic occlusive disease (Figures 1, 2, 3).

View larger version (14K): [in this window] [in a new window]   Fig 1. The aorta and iliac arteries.

View larger version (27K): [in this window] [in a new window]   Fig 2. The selective perfusion of the viscera.

View larger version (95K): [in this window] [in a new window]   Fig 3. Postoperative digital subtraction angiogram showing good patency of the visceral branches and the grafts to the lower limbs.

	References

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1. Von Segesser L.K., Killer I., Jenni R., Lutz U., Turina M.I. Improved distal circulatory support for repair of descending thoracic aortic aneurysms. Ann Thorac Surg 1993;56:1373-1380.[Abstract]
2. Martin T.D., Accola K.D. Megaaorta and aortoiliac obstruction. Ann Thorac Surg 1992;53:889-891.[Abstract]
3. Schepens M.A., Defauw J.J., Hamerlijnck R.P., De Geest R., Vermeulen F.E. Surgical treatment of thoracoabdominal aortic aneurysms by simple crossclamping. J Thorac Cardiovasc Surg 1994;107:134-142.[Abstract/Free Full Text]
4. Crawford E.S., Walker H.S., III, Saleh S.A., Normann N.A. Graft replacement of aneurysm in descending thoracic aorta. Surgery 1981;89:73-85.[Medline]
5. Coselli J.S., Crawford E.S. Femoral artery perfusion for cardiopulmonary bypass in patients with aortoiliac artery obstruction. Ann Thorac Surg 1987;43:437-439.[Abstract]
6. Kouchoukos N.T., Wareing T.H., Izumoto H., Klausing W., Abboud N. Elective hypothermic cardiopulmonary bypass and circulatory arrest for spinal cord protection during operations on the thoracoabdominal aorta. J Thorac Cardiovasc Surg 1990;99:659-664.[Abstract]
7. Kouchoukos N.T., Daily B.B., Rokkas C.K., Murphy S.F., Bauer S., Abboud N. Hypothermic bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg 1995;60:67-77.[Abstract/Free Full Text]
8. Crawford E.S., Coselli J.S., Safi H.J. Partial cardiopulmonary bypass, hypothermic circulatory arrest, and posterolateral exposure for thoracic aortic aneurysm operation. J Thorac Cardiovasc Surg 1987;94:824-827.[Abstract]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hiraaki Goto Nobuo Kitamura Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kunitomo, R. Articles by Kitamura, N. Search for Related Content PubMed PubMed Citation Articles by Kunitomo, R. Articles by Kitamura, N.