Case Report
A 53-year-old man was admitted to our hospital with thoracoabdominal fullness and discomfort after activity for about 2 years. He had no history of connective tissue disorder or aortic dissection. Computed tomography (CT) revealed a giant TAAA (Crawford extent â…˘) with the maximal diameter of 12.7 cm (Figure 1a, 1b). The laboratory data were within reference range.
The operation adopted sequential aortic clamp-and-sew technique under normothermia. After induction of anesthesia, CSFD was used. The repair was performed via a standard left thoracoabdominal incision, exposing the TAAA through the sixth intercostal space and retroperitoneal space under single-lung ventilation. Heparin was given systemically.
A 24-mm tetrafurcate Dacron graft (Vascutek, Terumo, Inchinnan, Scotland) and a 10mm Dacron graft (Hemashield platinum, Maquet, Wayne, New Jersy) were used. The 10-mm graft was anastomosed to the 24-mm graft to create a five-branched graft. The new branch was anastomosed to left common iliac artery in an end-to-side fashion. Another branch was connected to the roller pump through one branch of Y-shape arterial cannula, and the other branch of Y-shape arterial cannula was attached to two balloon catheters (6-Fr) through a Y-connector. The roller pump received the shed blood from surgical field through left ventricle vent and right heart vent (Figure 2a).
The normal descending thoracic aorta proximal to aneurysm was cross-clamped and then transected just 2cm distal to the clamp. The proximal end of 24-mm graft and the proximal descending thoracic aorta cuff was anastomosed. Once the proximal anastomosis was completed, the lower body, visceral organs, bilateral kidneys and spinal cord could be perfused through the bypass of descending thoracic aorta to 24-mm graft to10-mm graft to abdominal aorta (Figure 2b). After 10 minutes’ perfusion, aortic clamp was placed just proximal to the aortic-iliac bifurcation. The aorta is opened longitudinally from diseased segment down to the abdominal aorta. Two 6-Fr balloon catheters connected to Y-shape arterial cannula were introduced into the celiac axis and the SMA to provide SVP. Another two 6-Fr balloon catheters were introduced into bilateral renal arteries to provide cold renal perfusion with HTK fluid through a separate pump. The T10 intercostal arteries were anastomosed to the first branch of the graft with the island patch technique (Figure 2c).
Then the celiac and SMA were anastomosed to another two branches of 24-mm graft (Figure 2d). The aorta was transected just proximal to the bifurcation, leaving a cuff of abdominal aorta. The distal end of 24-mm graft and the abdominal aorta cuff was anastomosed (Figure 2e). The branch previously anastomosed to left iliac artery was re-anastomosed to right renal artery. The branch previously connected to the arterial cannula was re-anastomosed to left renal artery (Figure 2f). Thus, the reimplantation of bilateral renal arteries was completed (Figure 1c). Protamine was given to reverse the heparin after the hemostasis was completed. Then expeditious but meticulous closure was done.
The patient was extubated 22 hours after the operation. Acute kidney injury requiring dialysis and transient spinal cord injury was noted during the postoperative period. The kidney function improved gradually and the patient weaned dialysis on the 12nd postoperative day. Postoperative CT reexamination showed satisfactory results (Figure 1d). And the patient was discharged 21 days after the operation. Follow-up at 12 postoperative months showed good results.