Abstract
Background: In the surgery of the thoracoabdominal aortic aneurysm, retrograde perfusion from the femoral artery has risks of proximal embolization of peripheral atheroma and thrombus, or of malperfusion to the abdominal organs and segmental arteries of the spinal cord in patients with dissection. To avoid these risks, we performed a “segmental retrograde replacement of the thoracoabdominal aneurysm without the retrograde perfusion from the femoral artery”. Methods: Between July 2005 and February 2007, consecutive 7 patients were enrolled in this retrospective study. The average age was 62 years (4 men, 3 women). The aneurysms were true in 1, chronic dissection in 5, and infective pseudoaneurysm with sepsis in 1 patient. Crawford classification type I was seen in 1, type II in 4 and type III in 2 patients. Adamkiewicz arteries were preoperatively confirmed on multidetector row CT in all patients. Procedure: The infrarenal abdominal aorta was cross clamped and a composite tube graft with multiple side branches was anastomosed to the distal abdominal aorta or the iliac arteries without cardiopulmonary bypass. When the ischemic duration of the lower body reached 60 to 90 minutes, partial cardiopulmonary bypass to the lower body (main pump) was initiated through a side branch of the main graft (venous drainage from the right atrium with a long cannula inserted from the femoral vein). Then, the descending aorta was clamped above the celiac artery and the upper abdominal aneurysm was opened. The abdominal organs (8F cannulae) and the opened lumbar (L1, 2) arteries (2–2.5 mm cannulae) were selectively perfused with a second pump (450–600 ml/min). The selectively perfused abdominal branches and lumbar arteries were interposed with side branches of the main graft, and the perfusion was changed from a main graft in order. The proximal aorta was then clamped, and the descending thoracic aorta was opened. The intercostal arteries (T8–T12) were selectively perfused (10–20 ml/min/1 artery). The proximal anastomosis of the main graft was accomplished with discontinuation of the cardiopulmonary bypass. The graft interposition to the intercostals arteries, including the Adamkiewicz artery, were completed while continuing the selective perfusion. Results: There was 1 hospital death caused by respiratory failure in a patient with infective pseudoaneurysm with sepsis (postoperative 45th days). No patient showed spinal cord dysfunction, nor organ dysfunction caused by embolism of atheroma, thrombus or bacterial mass, or by malperfusion in patients with dissection. Conclusion: This surgical procedure provides an excellent protection of the abdominal organs and spinal cord, and will contribute to the improvement of the results of thoracoabdominal aortic surgery.
