"How I Do It" Thoracoabdominal Aneurysm Repair


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A discussion about vascular surgery techniques to repair a thoracoabdominal aneurysm.

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"How I Do It" Thoracoabdominal Aneurysm Repair

  1. 1. Mark Wright, MD October 12, 2010
  2. 3. <ul><li>Review CT and have in OR </li></ul><ul><ul><li>Preoperative localization of artery of Adamkiewicz (Arteria Radicularis Magna) </li></ul></ul><ul><li>Blood products on hold and cell saver </li></ul><ul><li>Pulse exam </li></ul><ul><li>Renal function </li></ul><ul><li>Discuss major complications with the pt </li></ul><ul><ul><li>MI, Stroke, Renal Failure, Paralysis, Ischemia, Resipiratory Failure, Death </li></ul></ul>
  3. 4. <ul><li>A-line in right radial </li></ul><ul><li>Foley </li></ul><ul><li>Double lumen ET tube </li></ul><ul><li>Adequate vascular access </li></ul><ul><li>Consider lumbar drain </li></ul><ul><li>Position: right lateral decubitus with hips supine to access both groins </li></ul><ul><li>Preoperative antibiotics </li></ul><ul><li>Prep and drape </li></ul>
  4. 6. <ul><li>Tip of scapula over 6 th intercostal space across costal cartilage, down to below the umbilicus </li></ul><ul><li>Resect 6 th rib for more exposure </li></ul><ul><li>Divide muscular portion of the diaphragm (not tendinous portion) to preserve phrenic nerve function </li></ul>
  5. 7. <ul><li>Identify the ligamentum arteriosum and divide it </li></ul><ul><li>Identify the recurrent laryneal nerve and protect it and get circumferential control of the aorta distal to the left subclavian artery </li></ul>
  6. 8. <ul><li>Get retroperitoneal exposure in the abdomen and mobilize the spleen, pancreas, colon and left colon medially </li></ul><ul><li>Identify the ascending lumbar vein coming from the left renal vain and divide it </li></ul><ul><li>Expose the distal aortal and both common iliac and get control </li></ul>
  7. 9. <ul><li>Heparinize with 100u/kg of heparin </li></ul><ul><li>Sew side arm of graft to the left common iliac artery for retrograde perfusion </li></ul><ul><li>Clamp aorta distal to the left subclavian and above the T8 level and transect it proximally and mobilize the aorta off of the esophagus </li></ul><ul><li>Perform proximal anastamosis in a running fashion </li></ul>
  8. 12. <ul><li>Move aortic clamp to graft and sidearm and distal clamp to above the celiac axis, open aorta down to distal clamp </li></ul><ul><li>T8-T12 sewn on to sidearm as a patch (artery of Adamkiewicz) Restore flow to the spinal cord </li></ul><ul><li>Tunnel graft through the aortic hiatus </li></ul>
  9. 14. <ul><li>Move distal clamp to infrarenal position </li></ul><ul><li>Revascularize the celiac, sma, right renal as a patch and reimplant left renal directly onto graft </li></ul>
  10. 15. <ul><li>Move distal clamp to the common iliacs and perform distal anastamosis in a running fashion </li></ul><ul><li>Reverse heparin with protamine </li></ul><ul><li>Check pulses </li></ul>
  11. 17. <ul><li>Cover graft with native aorta </li></ul><ul><li>Reapproximate the muscular portion of the diaphragm with running #1 polypropylene </li></ul><ul><li>Place 2 36 F chest tubes in the left pleural space </li></ul><ul><li>Close chest and abdomen </li></ul>
  12. 18. <ul><li>Switch double lumen tube to a single lumen tube </li></ul><ul><li>Recheck pulses </li></ul><ul><li>Check neurologic status when pt wakes up </li></ul><ul><li>Transfer to SICU intubated </li></ul>