[HSF] Leaking thoraco-abdominal aneurysm.

Mon Jun 4 00:00:58 EDT 2007

Many thanks. I did her at our academic hospital
(Tygerberg) where I still have a part time post.
I have read the reports about one stage replacement,
but have had no experience with this, and the experts
in Houston also do not appear to favour this. My
concern with this route was possibly not being able to
deal with the intercostals due to poor exposure, but
favoring this is being able to protect the heart
better and being able to avoid the calcified area.

We replaced the descending down to the diaphragm. We
placed her on fem-fem bypass, and also placed a 24F
cannula in the left atrium via the pulmonary vein. We
placed an apex vent into the LV to decompress the
heart. Thoracotomy was in the 5th space, with sparing
of the diaphragm, but with combined retro-peritoneal
dissection to get good exposure of the abdominal
aorta. There was a massive calcified clot/false
aneurysm/?true aneurysm in the chest, with dense
adhesion to the lung. We managed to mobilise the lung
off it while cooling. The proximal 10 cm of the aorta
was rock hard, and the only clampable area was the
arch, between the brachiocephalic and left common
carotid. We cooled to 18 degrees, then arrested the
circulation. The heart had started to fibrillate only
at 24 degrees, but was still fibrillating. After
cracking open the aorta, we inserted a Foley catheter
into the ascending aorta, inflated the baloon, and
arrested the heart with cold blood cardioplegia (Maybe
Dr Salerno would have given continuous warm blood). We
managed to get in a 28mm graft with much effort, using
continuous, plus interrupted pledgetted sutures. The
circ arrest time was 40 minutes, the longest ever for
us, but the calcium did slow us down. After clamping
the graft, and cannulating it, we restarted the pump
and rewarmed. We could then clamp the abdominal aorta,
and restarted femoral perfusion. We did the distal
graft a bit higher than originally planned, as the
aorta here was veering to the right, and I was worried
about having to still attach intercostals in this
area. Here the aorta measured about 30mm. There were
luckily no significant intercostals higher up.

The heart spontaneously defibrillated with further
rewarming, and she weaned easily off bypass.

She has since been extubated, and is mobilising well,
and VERY grateful that her breathing feels better,
without the usual wheeze! She is neurologically intact
(we also used CSF drainage).

I think she may have Takayasu`s arteritis. The femoral
artery was characteristically thick, with adhesions
around it.

David Harris

--- Tdmartin2000 <tdmartin2000 at aol.com> wrote:

> Some how I missed this thread. If she is not a stent
> candidate and you say the aorta is not clampable due
> to calcification at the prox descending then
> replacement of the entire thoracic aorta is a
> option. We reported our technique of doing it all
> through a sternotomy several yrs ago and Nik
> Kouchoukos in St Louis also has reported on this. It
> is something that probably should be referred to a
> major aortic center if possible.
> 
> Tom Martin
> U of Florida
> Gainesville
> 
> 
> 
> In a message dated 06/02/07 11:56:14 Eastern
> Daylight Time, msfirst at gmail.com writes:
> It has been a few days now and I am surprise that no
> one has chimed in. 
> What did you do? 
> 
> >From the basics, sounds like the descending to the
> diaphragm needed acutely 
> replaced (with some type of bypass to prevent the
> heart from hating a cross 
> clamp and sew with all of that AI) then attack the
> rest of the chest. 
> 
> I guess another option, if you can get help (i.e.
> someone who has done it 
> before - at least once) is replace the entire
> thoracic aorta in one 
> operation - a real tour de force, but she is young. 
> 
> What did or are you doing? 
> 
> (I guess another option - the one that I would
> probably select - is put her 
> on a helicopter/airplane to a megacenter - I have
> Lars Svensson's number on 
> speed dial for just such emergencies) 
> 
> michael 
> 
> 
> On 5/31/07, David Harris <drdharris at yahoo.co.uk>
> wrote: 
> > 
> > I have been referred a 32 yr old female patient
> who 
> > was turned down for surgery a year ago. She needed
> a 
> > root, ascending, and arch replacement, with
> elephant 
> > trunk, followed by repair of the descending part
> which 
> > stretches to the diaphragm. She was turned down as
> the 
> > aorta was heavily calcified. 
> > 
> > She now presents with symptoms from the thoraco, 
> > namely dyspnea, chest pain and hemoptysis. The
> distal 
> > half of the descending aorta is surrounded by a
> large 
> > round thrombus / contained leak, measuring 12 cm
> in 
> > diameter. The lumen of the desc aorta measures 5
> cm, 
> > up to the diaphragm, where it is 3 cm, about 4cm
> above 
> > the celiac. 
> > 
> > Scan show ascending measuring 5cm, sinuses dilated
> 
> > (there is mild to moderate aortic regurg), arch 
> > measures 4cm, there is a neck of 3cm at the
> isthmus. 
> > The aorta is heavily calcified from halfway up the
> 
> > ascending, all the way to the T6 level. The ishmus
> is 
> > spared a bit and is POSSIBLY clampable. A stent
> would 
> > not be possible with peripheral access, as the
> left 
> > subclavian attaches to the aorta at an angle, and
> is a 
> > bit stenotic there, and the descending aorta makes
> a 
> > 90 degree turn at the level of the pulmonary
> ligament 
> > towards the right before bending back towards the 
> > left. The left external iliac artery is completely
> 
> > occluded. 
> > 
> > Any extra tips?(I think I have already made up my
> mind 
> > what to do, but some confirmation, and gleaming
> pearls 
> > would be greatly appreciated) 
> > 
> > Dave Harris 
> > 
> > Dr. David G. Harris, FCS, MMED, 
> > Cardiothoracic Surgeon 
> > Suite 207 
> > Kuils River Private Hospital, 
> > PO Box 1200, Kuils River, 7579, Cape Town, South
> Africa. 
> > Tel +27-21-9006411 
> > Fax +27-21-9006412      Mobile +27-83-3309587 
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Dr. David G. Harris, FCS, MMED,
Cardiothoracic Surgeon        
Suite 207                                
Kuils River Private Hospital,        
PO Box 1200, Kuils River, 7579, Cape Town, South Africa.            
Tel +27-21-9006411             
Fax +27-21-9006412      Mobile +27-83-3309587