Thoracoabdominal Aortic Aneurysm Repair

1. Introduction

2. Positioning

3. Posterolateral Thoracotomy

1. Skin Marking
2. Skin Incision
3. Divide Overlying Musculature
4. Mark 5th Rib
5. Divide Costal Margin
6. 6th Rib Osteotomy
7. Divide Diaphragm with GIA Stapler

4. Left Medial Visceral Rotation

1. Mobilize Left Kidney
2. Further Division of Diaphragm
3. Shingle Rib
4. Expose Left Renal Artery and Vein

5. Mobilization of Infrarenal Aorta

1. Dissect Superior Mesenteric, Celiac, and Left Renal Arteries
2. Ligate and Divide Branches of Celiac

6. Atrio-Femoral Bypass

1. Identify Sequential Clamp Sites
2. Mobilize Left Pulmonary Vein and Ligament
3. Left Inferior Pulmonary Vein Purse String
4. Dissect Left Femoral Artery
5. Left Femoral Artery Purse String
6. Cannulate Left Inferior Pulmonary Vein
7. Dilate and Cannulate Left Femoral Artery

7. Proximal Descending Aortic Anastomosis

1. Clamp Proximal Aorta
2. Open Aorta
3. Anastomose Graft
4. Check Anastomosis for Leaks
5. Revise as Needed

8. Aortic Exposure

1. Clamp Middle Descending Aorta
2. Divide Aorta Longitudinally
3. Ligate Bleeding Vessels in Lumen
4. Continue Sequential Clamping Distally
5. Measure Graft Length

9. Visceral Ischemia Time

1. Ligate Celiac Artery
2. Clamp Infrarenal Aorta
3. Quickly Divide Aorta
4. Transect Aorta Below Right Renal Artery
5. Control Bleeding Vessels

10. Distal Descending Aorta Anastomosis

1. Anastomose Graft (Distal)
2. Check Anastomosis for Leaks
3. Sequentially Open Distal Clamps (Clamp Time: 21 Min)

11. Atrio-Femoral Bypass Removal

1. Decannulate Left Inferior Pulmonary Vein
2. Close Purse String Suture of Left Inferior Pulmonary Vein
   
3. Decannulate Left Femoral Artery

12. Celiac Artery Reconstruction

1. Create Side-Arm Exit Point in the Aortic Graft
2. Anastomose Side-Arm Graft to Aortic Graft
   
3. Check Anastomosis for Leaks
4. End-to-End Anastomosis of Celiac Artery to Side-Arm Graft
5. Check Anastomosis for Leaks

13. Closure

1. Close Aneurysm Sac over Aortic Graft
2. Repair Left Hemi-Diaphragm
3. Insert Thoracic Drains
4. Repair Thoracotomy