What are surgical options for the treatment of thoracoabdominal aortic aneurysms (TAAA)?

Answer

Thoracoabdominal aortic aneurysms (TAAAs), accounting for approximately 10% of thoracic aneurysms, may be repaired with the use of a partial bypass of the left atrium to the femoral artery.

Crawford type I TAAAs involve Dacron graft replacement of the aorta from the left subclavian artery to the visceral and renal arteries as a beveled distal anastomosis, using sequential cross-clamping of the aorta. Crawford type II TAAAA repair requires a Dacron graft from the left subclavian to the aortic bifurcation with reattachment of the intercostal arteries, visceral arteries, and renal arteries. Crawford type III or IV thoracoabdominal aneurysm repairs, which begin lower along the thoracic aorta or upper abdominal aorta, may use either the partial bypass of the left atrial artery to the femoral artery or a modified atriovisceral and/or renal bypass.

Prevention of paraplegia is one of the principal concerns in the repair of descending and thoracoabdominal aneurysms.

Previous investigational trials by Chuter at the University of California at San Francisco Medical Center and Greenberg at the Cleveland Clinic treated TAAAs with custom-built fenestrated and branched stent grafts. Such devices required precise anatomic tailoring of the grafts to the specific patient's anatomy for placement of the scallops (for visceral flow) or branches (for direct stenting into the visceral vessels) and resulted in prolonged operative delays.

Subsequent data and improvement in devices demonstrated that standardized multibranched endografts were applicable to approximately 90% of the patient population, thereby eliminating manufacturing delays and expanding the applicability of these devices in TAAAs.^[57]

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Media Gallery

Chest radiograph showing widening of superior mediastinum.
Computed tomography (CT) scan depicting descending thoracic aortic aneurysm with mural thrombus at level of left atrium.
Ascending aortogram showing ascending aortic aneurysm. Patient also underwent computed tomography (CT).
Endovascular repair of thoracoabdominal aortic aneurysm (TAAA). Procedure performed by Inkyong Kim, MD, and Rajeev Dayal, MD, ColumbiaDoctors, New York, NY. Video courtesy of ColumbiaDoctors (https://www.columbiadoctors.org).

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