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Hybrid Thoracoabdominal Aneurysm Repair With Antegrade Visceral Debranching From the Ascending Aorta: Concomitant Cardiac Surgery and Stent-Grafting

2011; Elsevier BV; Volume: 92; Issue: 6 Linguagem: Inglês

10.1016/j.athoracsur.2011.06.018

1552-6259

Alessandro Vivacqua, Turki B. Albacker, Eric E. Roselli,

Cardiac, Anesthesia and Surgical Outcomes

Patients with thoracoabdominal aneurysm that require concomitant cardiac surgery present a complex surgical challenge. A staged hybrid technique including combined cardiac surgery and visceral revascularization from the ascending aorta, followed by endovascular aneurysmal exclusion is reported in four patients. No perioperative death and no neurological complications were observed. The surgical technique is described. Patients with thoracoabdominal aneurysm that require concomitant cardiac surgery present a complex surgical challenge. A staged hybrid technique including combined cardiac surgery and visceral revascularization from the ascending aorta, followed by endovascular aneurysmal exclusion is reported in four patients. No perioperative death and no neurological complications were observed. The surgical technique is described. Dr Roselli discloses that he has a financial relationship with Vascutek.Patients with thoracoabdominal aortic aneurysms (TAAAs) often have multiple comorbidities that increase the morbidity associated with open repair [1Coselli J.S. Bozinovski J. LeMaire S.A. Open surgical repair of 2286 thoracoabdominal aortic aneurysms.Ann Thorac Surg. 2007; 83: S862-S864Abstract Full Text Full Text PDF PubMed Scopus (397) Google Scholar, 2Svensson L.G. Crawford E.S. Hess K.R. Coselli J.S. Safi H.J. Experience with 1509 patients undergoing thoracoabdominal aortic operations.J Vasc Surg. 1993; 17: 357-368Abstract Full Text Full Text PDF PubMed Scopus (1091) Google Scholar, 3Schepens M.A. Heijmen R.H. Ranschaert W. Sonker U. Morshuis W.J. Thoracoabdominal aortic aneurysm repair: Results of conventional open surgery.Eur J Vasc Endovasc Surg. 2009; 37: 640-645Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar]. This is especially noteworthy in those with associated cardiac disease who are at increased risk for mortality. Hybrid repair with retrograde visceral bypass from the iliac artery and subsequent endovascular exclusion of the aneurysm has been proposed as an alternative to conventional open repair [4Black S.A. Wolfe J.H. Clark M. Hamadi M. Cheshire N.J. Jenkins M.P. Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization.J Vasc Surg. 2006; 43: 1081-1089Abstract Full Text Full Text PDF PubMed Scopus (259) Google Scholar, 5Resch T.A. Greenberg R.K. Lyden S.P. et al.Combined staged procedures for the treatment of thoracoabdominal aneurysms.J Endovasc Ther. 2006; 13: 481-489Crossref PubMed Scopus (123) Google Scholar]. This approach, however, is still associated with a high rate of complications and mortality in high-risk patients. Totally endovascular repair with branched-graft devices is rapidly evolving, but can be associated with serious cardiovascular complications, and it is not readily applicable to all patients [6Roselli E.E. Greenberg R.K. Pfaff K. Francis C. Svensson L.G. Lytle B.W. Endovascular treatment of thoracoabdominal aortic aneurysms.J Thorac Cardiovasc Surg. 2007; 133: 1474-1482Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar, 7Greenberg R.K. Lytle B. Endovascular repair of thoracoabdominal aneurysms.Circulation. 2008; 117: 2288-2296Crossref PubMed Scopus (131) Google Scholar]. A novel approach combining visceral revascularization from the ascending aorta with other cardiac procedures, and later endovascular aneurysm exclusion is presented.TechniqueMedian sternotomy extending to an upper midline laparotomy is performed to the level of the umbilicus. Before systemic heparinization, exposure of the visceral arteries is obtained through the lesser sac for the celiac artery, by mobilizing the ligament of Treitz for the superior mesenteric artery, and by medial visceral rotation for the renal arteries. After institution of cardiopulmonary bypass and completion of the cardiac procedure, a multi-branched graft (Maquet, Wayne, NJ, or Vascutek, Renfrewshire, Scotland, UK) is anastomosed end to side to the ascending aorta. The graft is positioned within the right side of the mediastinum along the right atrium and anterior to the inferior vena cava. It is then tunneled through the diaphragm into the peritoneum via an incision near the central tendon. Intraabdominal revascularization then proceeds in a sequential fashion. Usually the visceral arteries are clamped distally, oversewn proximally, divided, and grafted in an end-to-end fashion. Occasionally the target vessel must be grafted in an end-to-side fashion because of a hostile environment around the aorta (i.e., dense adhesions because of previous aortic surgery) precluding access to the origin of the vessels. In such situations, the origin of the native vessel is embolized with coils during the endovascular stage of the repair. After weaning off cardiopulmonary bypass, a selective angiography is performed to demonstrate patency of the visceral and renal bypasses. In patients without adequate iliofemoral access, an additional bypass from the ascending aorta to the axillary artery can be created with one of the 10-mm limbs of the multibranched graft passed transpleurally to provide an access conduit for the subsequent endovascular repair. After the initial recovery phase, endovascular stent grafting is performed to exclude the aneurysm. Both stages are performed in a hybrid operating room and can be performed at the same time if it is warranted.Four patients were treated with this strategy. Three presented with degenerative TAAA and one with an enlarging aneurysm in the setting of chronic distal dissection.All patients required an associated cardiac procedure (two required coronary artery bypass grafting, one Bentall procedure with coronary artery bypass grafting, and one aortic arch repair). In one patient, the celiac artery, the superior mesenteric artery (SMA), and the right renal artery were bypassed. In two patients the celiac and SMA were bypassed, and in one patient the celiac artery alone was bypassed in combination with the arch vessels (Fig 1).The endovascular portion of the repair was completed after 2 to 4 weeks in all patients as aortic stent grafting with or without embolization of the branch vessels (Fig 2, Fig 3). One patient required repeated operation for occlusion of the aorta to renal artery bypass. No neurologic complications, respiratory failure requiring tracheostomy, nor renal failure requiring dialysis were observed. There was no 30-day mortality.Fig 2Preoperative computed tomographic scan with three-dimensional reconstruction showing the root and thoracoabdominal aneurysms (TAAAn) in the setting of prior descending and infrarenal repairs.View Large Image Figure ViewerDownload (PPT)Fig 3Postoperative computed tomographic scan with three-dimensional reconstruction of the same patient as Figure 2 showing the Bentall procedure, ascending to visceral and renal artery bypasses, and the stent graft in the thoracoabdominal aorta. (Asc = ascending; Desc = descending.)View Large Image Figure ViewerDownload (PPT)CommentConventional open surgical repair, hybrid repair with retrograde debranching, and totally endovascular branch grafting of TAAA are all associated with considerable morbidity and mortality, especially in patients with concomitant cardiac disease [1Coselli J.S. Bozinovski J. LeMaire S.A. Open surgical repair of 2286 thoracoabdominal aortic aneurysms.Ann Thorac Surg. 2007; 83: S862-S864Abstract Full Text Full Text PDF PubMed Scopus (397) Google Scholar, 2Svensson L.G. Crawford E.S. Hess K.R. Coselli J.S. Safi H.J. Experience with 1509 patients undergoing thoracoabdominal aortic operations.J Vasc Surg. 1993; 17: 357-368Abstract Full Text Full Text PDF PubMed Scopus (1091) Google Scholar, 3Schepens M.A. Heijmen R.H. Ranschaert W. Sonker U. Morshuis W.J. Thoracoabdominal aortic aneurysm repair: Results of conventional open surgery.Eur J Vasc Endovasc Surg. 2009; 37: 640-645Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar, 4Black S.A. Wolfe J.H. Clark M. Hamadi M. Cheshire N.J. Jenkins M.P. Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization.J Vasc Surg. 2006; 43: 1081-1089Abstract Full Text Full Text PDF PubMed Scopus (259) Google Scholar, 5Resch T.A. Greenberg R.K. Lyden S.P. et al.Combined staged procedures for the treatment of thoracoabdominal aneurysms.J Endovasc Ther. 2006; 13: 481-489Crossref PubMed Scopus (123) Google Scholar, 6Roselli E.E. Greenberg R.K. Pfaff K. Francis C. Svensson L.G. Lytle B.W. Endovascular treatment of thoracoabdominal aortic aneurysms.J Thorac Cardiovasc Surg. 2007; 133: 1474-1482Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar, 7Greenberg R.K. Lytle B. Endovascular repair of thoracoabdominal aneurysms.Circulation. 2008; 117: 2288-2296Crossref PubMed Scopus (131) Google Scholar]. In addition, an individual patient may have anatomic limitations to one or more of these approaches because of considerations such as a history of previous operations resulting in a hostile operative field, aortoiliac occlusive disease, or the presence of a chronic dissection with branch artery flow dependent on the patent false lumen [6Roselli E.E. Greenberg R.K. Pfaff K. Francis C. Svensson L.G. Lytle B.W. Endovascular treatment of thoracoabdominal aortic aneurysms.J Thorac Cardiovasc Surg. 2007; 133: 1474-1482Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar, 7Greenberg R.K. Lytle B. Endovascular repair of thoracoabdominal aneurysms.Circulation. 2008; 117: 2288-2296Crossref PubMed Scopus (131) Google Scholar].The technique described in this manuscript offers a feasible alternative for repair of TAAA in select patients who are not good candidates for the other repair options or who require another cardiac procedure. Despite the need to extend the incision into the upper abdomen, this approach obviates the need for a second open chest procedure and limits the diaphragmatic incision.Like other thoracic aortic operations, careful imaging-based preoperative planning is required for success. It is critical to recognize details such as the presence of a replaced right hepatic artery or a multibranched renal arterial system so that organ preservation is optimized during the reconstruction. A plan for addressing potential type 2 endoleaks from retrograde filling of bypassed visceral vessels must be in place before completing the first stage so that the bypassed vessel can be ligated if it is not amenable to endovascular occlusion.During the second stage of the procedure, cardiac and visceral protection is no longer a problem, but protecting the spinal cord from ischemia becomes a major issue. Most of these patients require extensive aortic coverage, which has been shown to be the most important predictor of spinal cord injury regardless of approach [8Greenberg R.K. Lu Q. Roselli E.E. et al.Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques.Circulation. 2008; 118: 808-817Crossref PubMed Scopus (427) Google Scholar]. Spinal drainage catheters were used for the first 48 to 72 postoperative hours in all patients, and the mean arterial pressure was maintained above 90 mm Hg during the intensive care unit stay. Although endovascular exclusion of the aneurysm during the initial procedure is feasible to make this a single-stage repair, we have preferred to complete the repair in two separate stages. For these select patients, the extent of the first operation puts them at risk for bleeding, hemodynamic fluctuations, and diffuse edema that all may increase the risk of spinal cord injury. A staged approach offers the potential advantages of decreased operating time and exposure to radiation and intravenous contrast, as well as decreasing the inflammatory response and surgical trauma to the patient. On the contrary, the risk of rapid aneurysmal growth, dissection, and rupture between the two stages must be considered. Given the minimally invasive nature of the endovascular approach, the second stage can be performed relatively safely within several days of the initial operation to mitigate this risk.In conclusion, complex patients with thoracoabdominal aneurysms and cardiac disease, or another contraindication to conventional or branched endovascular repair, may be treated by antegrade visceral debranching from the ascending aorta followed by stent grafting of the aneurysm as a feasible alternative. Dr Roselli discloses that he has a financial relationship with Vascutek. Dr Roselli discloses that he has a financial relationship with Vascutek. Dr Roselli discloses that he has a financial relationship with Vascutek. Patients with thoracoabdominal aortic aneurysms (TAAAs) often have multiple comorbidities that increase the morbidity associated with open repair [1Coselli J.S. Bozinovski J. LeMaire S.A. Open surgical repair of 2286 thoracoabdominal aortic aneurysms.Ann Thorac Surg. 2007; 83: S862-S864Abstract Full Text Full Text PDF PubMed Scopus (397) Google Scholar, 2Svensson L.G. Crawford E.S. Hess K.R. Coselli J.S. Safi H.J. Experience with 1509 patients undergoing thoracoabdominal aortic operations.J Vasc Surg. 1993; 17: 357-368Abstract Full Text Full Text PDF PubMed Scopus (1091) Google Scholar, 3Schepens M.A. Heijmen R.H. Ranschaert W. Sonker U. Morshuis W.J. Thoracoabdominal aortic aneurysm repair: Results of conventional open surgery.Eur J Vasc Endovasc Surg. 2009; 37: 640-645Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar]. This is especially noteworthy in those with associated cardiac disease who are at increased risk for mortality. Hybrid repair with retrograde visceral bypass from the iliac artery and subsequent endovascular exclusion of the aneurysm has been proposed as an alternative to conventional open repair [4Black S.A. Wolfe J.H. Clark M. Hamadi M. Cheshire N.J. Jenkins M.P. Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization.J Vasc Surg. 2006; 43: 1081-1089Abstract Full Text Full Text PDF PubMed Scopus (259) Google Scholar, 5Resch T.A. Greenberg R.K. Lyden S.P. et al.Combined staged procedures for the treatment of thoracoabdominal aneurysms.J Endovasc Ther. 2006; 13: 481-489Crossref PubMed Scopus (123) Google Scholar]. This approach, however, is still associated with a high rate of complications and mortality in high-risk patients. Totally endovascular repair with branched-graft devices is rapidly evolving, but can be associated with serious cardiovascular complications, and it is not readily applicable to all patients [6Roselli E.E. Greenberg R.K. Pfaff K. Francis C. Svensson L.G. Lytle B.W. Endovascular treatment of thoracoabdominal aortic aneurysms.J Thorac Cardiovasc Surg. 2007; 133: 1474-1482Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar, 7Greenberg R.K. Lytle B. Endovascular repair of thoracoabdominal aneurysms.Circulation. 2008; 117: 2288-2296Crossref PubMed Scopus (131) Google Scholar]. A novel approach combining visceral revascularization from the ascending aorta with other cardiac procedures, and later endovascular aneurysm exclusion is presented. TechniqueMedian sternotomy extending to an upper midline laparotomy is performed to the level of the umbilicus. Before systemic heparinization, exposure of the visceral arteries is obtained through the lesser sac for the celiac artery, by mobilizing the ligament of Treitz for the superior mesenteric artery, and by medial visceral rotation for the renal arteries. After institution of cardiopulmonary bypass and completion of the cardiac procedure, a multi-branched graft (Maquet, Wayne, NJ, or Vascutek, Renfrewshire, Scotland, UK) is anastomosed end to side to the ascending aorta. The graft is positioned within the right side of the mediastinum along the right atrium and anterior to the inferior vena cava. It is then tunneled through the diaphragm into the peritoneum via an incision near the central tendon. Intraabdominal revascularization then proceeds in a sequential fashion. Usually the visceral arteries are clamped distally, oversewn proximally, divided, and grafted in an end-to-end fashion. Occasionally the target vessel must be grafted in an end-to-side fashion because of a hostile environment around the aorta (i.e., dense adhesions because of previous aortic surgery) precluding access to the origin of the vessels. In such situations, the origin of the native vessel is embolized with coils during the endovascular stage of the repair. After weaning off cardiopulmonary bypass, a selective angiography is performed to demonstrate patency of the visceral and renal bypasses. In patients without adequate iliofemoral access, an additional bypass from the ascending aorta to the axillary artery can be created with one of the 10-mm limbs of the multibranched graft passed transpleurally to provide an access conduit for the subsequent endovascular repair. After the initial recovery phase, endovascular stent grafting is performed to exclude the aneurysm. Both stages are performed in a hybrid operating room and can be performed at the same time if it is warranted.Four patients were treated with this strategy. Three presented with degenerative TAAA and one with an enlarging aneurysm in the setting of chronic distal dissection.All patients required an associated cardiac procedure (two required coronary artery bypass grafting, one Bentall procedure with coronary artery bypass grafting, and one aortic arch repair). In one patient, the celiac artery, the superior mesenteric artery (SMA), and the right renal artery were bypassed. In two patients the celiac and SMA were bypassed, and in one patient the celiac artery alone was bypassed in combination with the arch vessels (Fig 1).The endovascular portion of the repair was completed after 2 to 4 weeks in all patients as aortic stent grafting with or without embolization of the branch vessels (Fig 2, Fig 3). One patient required repeated operation for occlusion of the aorta to renal artery bypass. No neurologic complications, respiratory failure requiring tracheostomy, nor renal failure requiring dialysis were observed. There was no 30-day mortality.Fig 3Postoperative computed tomographic scan with three-dimensional reconstruction of the same patient as Figure 2 showing the Bentall procedure, ascending to visceral and renal artery bypasses, and the stent graft in the thoracoabdominal aorta. (Asc = ascending; Desc = descending.)View Large Image Figure ViewerDownload (PPT) Median sternotomy extending to an upper midline laparotomy is performed to the level of the umbilicus. Before systemic heparinization, exposure of the visceral arteries is obtained through the lesser sac for the celiac artery, by mobilizing the ligament of Treitz for the superior mesenteric artery, and by medial visceral rotation for the renal arteries. After institution of cardiopulmonary bypass and completion of the cardiac procedure, a multi-branched graft (Maquet, Wayne, NJ, or Vascutek, Renfrewshire, Scotland, UK) is anastomosed end to side to the ascending aorta. The graft is positioned within the right side of the mediastinum along the right atrium and anterior to the inferior vena cava. It is then tunneled through the diaphragm into the peritoneum via an incision near the central tendon. Intraabdominal revascularization then proceeds in a sequential fashion. Usually the visceral arteries are clamped distally, oversewn proximally, divided, and grafted in an end-to-end fashion. Occasionally the target vessel must be grafted in an end-to-side fashion because of a hostile environment around the aorta (i.e., dense adhesions because of previous aortic surgery) precluding access to the origin of the vessels. In such situations, the origin of the native vessel is embolized with coils during the endovascular stage of the repair. After weaning off cardiopulmonary bypass, a selective angiography is performed to demonstrate patency of the visceral and renal bypasses. In patients without adequate iliofemoral access, an additional bypass from the ascending aorta to the axillary artery can be created with one of the 10-mm limbs of the multibranched graft passed transpleurally to provide an access conduit for the subsequent endovascular repair. After the initial recovery phase, endovascular stent grafting is performed to exclude the aneurysm. Both stages are performed in a hybrid operating room and can be performed at the same time if it is warranted. Four patients were treated with this strategy. Three presented with degenerative TAAA and one with an enlarging aneurysm in the setting of chronic distal dissection. All patients required an associated cardiac procedure (two required coronary artery bypass grafting, one Bentall procedure with coronary artery bypass grafting, and one aortic arch repair). In one patient, the celiac artery, the superior mesenteric artery (SMA), and the right renal artery were bypassed. In two patients the celiac and SMA were bypassed, and in one patient the celiac artery alone was bypassed in combination with the arch vessels (Fig 1). The endovascular portion of the repair was completed after 2 to 4 weeks in all patients as aortic stent grafting with or without embolization of the branch vessels (Fig 2, Fig 3). One patient required repeated operation for occlusion of the aorta to renal artery bypass. No neurologic complications, respiratory failure requiring tracheostomy, nor renal failure requiring dialysis were observed. There was no 30-day mortality. CommentConventional open surgical repair, hybrid repair with retrograde debranching, and totally endovascular branch grafting of TAAA are all associated with considerable morbidity and mortality, especially in patients with concomitant cardiac disease [1Coselli J.S. Bozinovski J. LeMaire S.A. Open surgical repair of 2286 thoracoabdominal aortic aneurysms.Ann Thorac Surg. 2007; 83: S862-S864Abstract Full Text Full Text PDF PubMed Scopus (397) Google Scholar, 2Svensson L.G. Crawford E.S. Hess K.R. Coselli J.S. Safi H.J. Experience with 1509 patients undergoing thoracoabdominal aortic operations.J Vasc Surg. 1993; 17: 357-368Abstract Full Text Full Text PDF PubMed Scopus (1091) Google Scholar, 3Schepens M.A. Heijmen R.H. Ranschaert W. Sonker U. Morshuis W.J. Thoracoabdominal aortic aneurysm repair: Results of conventional open surgery.Eur J Vasc Endovasc Surg. 2009; 37: 640-645Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar, 4Black S.A. Wolfe J.H. Clark M. Hamadi M. Cheshire N.J. Jenkins M.P. Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization.J Vasc Surg. 2006; 43: 1081-1089Abstract Full Text Full Text PDF PubMed Scopus (259) Google Scholar, 5Resch T.A. Greenberg R.K. Lyden S.P. et al.Combined staged procedures for the treatment of thoracoabdominal aneurysms.J Endovasc Ther. 2006; 13: 481-489Crossref PubMed Scopus (123) Google Scholar, 6Roselli E.E. Greenberg R.K. Pfaff K. Francis C. Svensson L.G. Lytle B.W. Endovascular treatment of thoracoabdominal aortic aneurysms.J Thorac Cardiovasc Surg. 2007; 133: 1474-1482Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar, 7Greenberg R.K. Lytle B. Endovascular repair of thoracoabdominal aneurysms.Circulation. 2008; 117: 2288-2296Crossref PubMed Scopus (131) Google Scholar]. In addition, an individual patient may have anatomic limitations to one or more of these approaches because of considerations such as a history of previous operations resulting in a hostile operative field, aortoiliac occlusive disease, or the presence of a chronic dissection with branch artery flow dependent on the patent false lumen [6Roselli E.E. Greenberg R.K. Pfaff K. Francis C. Svensson L.G. Lytle B.W. Endovascular treatment of thoracoabdominal aortic aneurysms.J Thorac Cardiovasc Surg. 2007; 133: 1474-1482Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar, 7Greenberg R.K. Lytle B. Endovascular repair of thoracoabdominal aneurysms.Circulation. 2008; 117: 2288-2296Crossref PubMed Scopus (131) Google Scholar].The technique described in this manuscript offers a feasible alternative for repair of TAAA in select patients who are not good candidates for the other repair options or who require another cardiac procedure. Despite the need to extend the incision into the upper abdomen, this approach obviates the need for a second open chest procedure and limits the diaphragmatic incision.Like other thoracic aortic operations, careful imaging-based preoperative planning is required for success. It is critical to recognize details such as the presence of a replaced right hepatic artery or a multibranched renal arterial system so that organ preservation is optimized during the reconstruction. A plan for addressing potential type 2 endoleaks from retrograde filling of bypassed visceral vessels must be in place before completing the first stage so that the bypassed vessel can be ligated if it is not amenable to endovascular occlusion.During the second stage of the procedure, cardiac and visceral protection is no longer a problem, but protecting the spinal cord from ischemia becomes a major issue. Most of these patients require extensive aortic coverage, which has been shown to be the most important predictor of spinal cord injury regardless of approach [8Greenberg R.K. Lu Q. Roselli E.E. et al.Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques.Circulation. 2008; 118: 808-817Crossref PubMed Scopus (427) Google Scholar]. Spinal drainage catheters were used for the first 48 to 72 postoperative hours in all patients, and the mean arterial pressure was maintained above 90 mm Hg during the intensive care unit stay. Although endovascular exclusion of the aneurysm during the initial procedure is feasible to make this a single-stage repair, we have preferred to complete the repair in two separate stages. For these select patients, the extent of the first operation puts them at risk for bleeding, hemodynamic fluctuations, and diffuse edema that all may increase the risk of spinal cord injury. A staged approach offers the potential advantages of decreased operating time and exposure to radiation and intravenous contrast, as well as decreasing the inflammatory response and surgical trauma to the patient. On the contrary, the risk of rapid aneurysmal growth, dissection, and rupture between the two stages must be considered. Given the minimally invasive nature of the endovascular approach, the second stage can be performed relatively safely within several days of the initial operation to mitigate this risk.In conclusion, complex patients with thoracoabdominal aneurysms and cardiac disease, or another contraindication to conventional or branched endovascular repair, may be treated by antegrade visceral debranching from the ascending aorta followed by stent grafting of the aneurysm as a feasible alternative. Conventional open surgical repair, hybrid repair with retrograde debranching, and totally endovascular branch grafting of TAAA are all associated with considerable morbidity and mortality, especially in patients with concomitant cardiac disease [1Coselli J.S. Bozinovski J. LeMaire S.A. Open surgical repair of 2286 thoracoabdominal aortic aneurysms.Ann Thorac Surg. 2007; 83: S862-S864Abstract Full Text Full Text PDF PubMed Scopus (397) Google Scholar, 2Svensson L.G. Crawford E.S. Hess K.R. Coselli J.S. Safi H.J. Experience with 1509 patients undergoing thoracoabdominal aortic operations.J Vasc Surg. 1993; 17: 357-368Abstract Full Text Full Text PDF PubMed Scopus (1091) Google Scholar, 3Schepens M.A. Heijmen R.H. Ranschaert W. Sonker U. Morshuis W.J. Thoracoabdominal aortic aneurysm repair: Results of conventional open surgery.Eur J Vasc Endovasc Surg. 2009; 37: 640-645Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar, 4Black S.A. Wolfe J.H. Clark M. Hamadi M. Cheshire N.J. Jenkins M.P. Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization.J Vasc Surg. 2006; 43: 1081-1089Abstract Full Text Full Text PDF PubMed Scopus (259) Google Scholar, 5Resch T.A. Greenberg R.K. Lyden S.P. et al.Combined staged procedures for the treatment of thoracoabdominal aneurysms.J Endovasc Ther. 2006; 13: 481-489Crossref PubMed Scopus (123) Google Scholar, 6Roselli E.E. Greenberg R.K. Pfaff K. Francis C. Svensson L.G. Lytle B.W. Endovascular treatment of thoracoabdominal aortic aneurysms.J Thorac Cardiovasc Surg. 2007; 133: 1474-1482Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar, 7Greenberg R.K. Lytle B. Endovascular repair of thoracoabdominal aneurysms.Circulation. 2008; 117: 2288-2296Crossref PubMed Scopus (131) Google Scholar]. In addition, an individual patient may have anatomic limitations to one or more of these approaches because of considerations such as a history of previous operations resulting in a hostile operative field, aortoiliac occlusive disease, or the presence of a chronic dissection with branch artery flow dependent on the patent false lumen [6Roselli E.E. Greenberg R.K. Pfaff K. Francis C. Svensson L.G. Lytle B.W. Endovascular treatment of thoracoabdominal aortic aneurysms.J Thorac Cardiovasc Surg. 2007; 133: 1474-1482Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar, 7Greenberg R.K. Lytle B. Endovascular repair of thoracoabdominal aneurysms.Circulation. 2008; 117: 2288-2296Crossref PubMed Scopus (131) Google Scholar]. The technique described in this manuscript offers a feasible alternative for repair of TAAA in select patients who are not good candidates for the other repair options or who require another cardiac procedure. Despite the need to extend the incision into the upper abdomen, this approach obviates the need for a second open chest procedure and limits the diaphragmatic incision. Like other thoracic aortic operations, careful imaging-based preoperative planning is required for success. It is critical to recognize details such as the presence of a replaced right hepatic artery or a multibranched renal arterial system so that organ preservation is optimized during the reconstruction. A plan for addressing potential type 2 endoleaks from retrograde filling of bypassed visceral vessels must be in place before completing the first stage so that the bypassed vessel can be ligated if it is not amenable to endovascular occlusion. During the second stage of the procedure, cardiac and visceral protection is no longer a problem, but protecting the spinal cord from ischemia becomes a major issue. Most of these patients require extensive aortic coverage, which has been shown to be the most important predictor of spinal cord injury regardless of approach [8Greenberg R.K. Lu Q. Roselli E.E. et al.Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques.Circulation. 2008; 118: 808-817Crossref PubMed Scopus (427) Google Scholar]. Spinal drainage catheters were used for the first 48 to 72 postoperative hours in all patients, and the mean arterial pressure was maintained above 90 mm Hg during the intensive care unit stay. Although endovascular exclusion of the aneurysm during the initial procedure is feasible to make this a single-stage repair, we have preferred to complete the repair in two separate stages. For these select patients, the extent of the first operation puts them at risk for bleeding, hemodynamic fluctuations, and diffuse edema that all may increase the risk of spinal cord injury. A staged approach offers the potential advantages of decreased operating time and exposure to radiation and intravenous contrast, as well as decreasing the inflammatory response and surgical trauma to the patient. On the contrary, the risk of rapid aneurysmal growth, dissection, and rupture between the two stages must be considered. Given the minimally invasive nature of the endovascular approach, the second stage can be performed relatively safely within several days of the initial operation to mitigate this risk. In conclusion, complex patients with thoracoabdominal aneurysms and cardiac disease, or another contraindication to conventional or branched endovascular repair, may be treated by antegrade visceral debranching from the ascending aorta followed by stent grafting of the aneurysm as a feasible alternative.