Thoracoabdominal Aortic Aneurysm Repair
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Thoracoabdominal aortic aneurysms (TAAAs) are generally asymptomatic and are discovered incidentally on thoracic or abdominal imaging. When they are identified, management is often expectant, depending on the size of the aneurysm and its rate of growth. Surgery is indicated for larger aneurysms and those that expand rapidly so as to avoid the catastrophic rupture of the aneurysm. Here, we present the case of a 70-year-old female with a TAAA, whom we had been following with serial computed tomographic angiography scans. The decision to operate was made when the aneurysm began revealing growth in diameter. Her anatomy was not conducive to endovascular treatment; therefore, we repaired her aneurysm using a traditional open approach.
Cardiovascular diseases; vascular diseases; aneurysm; aortic aneurysm; thoracoabdominal.
Aortic aneurysms are focal dilatations of the aorta that can occur at any point along its length from the root, just above the aortic valve, down to the bifurcation in the pelvis. Classification is by anatomic location and divided into thoracic, abdominal, or thoracoabdominal aneurysms. Thoracic aneurysms are further divided into those that involve the root and ascending aorta, those that involve the aortic arch, and those that involve the descending thoracic aorta. Thoracoabdominal aortic aneurysms (TAAAs) are categorized using the Crawford classification: Extent I encompasses the majority of the descending thoracic aorta, spanning from the left subclavian artery to the suprarenal abdominal aorta. Extent II is the most extensive, involving the aorta from the left subclavian artery down to the aortoiliac bifurcation. Extent III includes the distal thoracic aorta and extends to the aortoiliac bifurcation. Extent IV is confined to the abdominal aorta below the diaphragm. Safi’s group introduced Extent V, which involves the distal thoracic aorta, including the origins of the celiac and superior mesenteric arteries but excluding the renal arteries (Figure 1).57
Figure 1. Crawford Classification of Thoracoabdominal Aortic Aneurysm, Modified by the Safi's Group. Legend: (R) SCA - Right Subclavian Artery, (R) CCA - Right Common Carotid Artery, (L) CCA - Left Common Carotid Artery, (L) SCA - Left Subclavian Artery, (L) GA - Left Gastric Artery, CHA - Common Hepatic Artery, SA - Splenic Artery, (R) RA - Right Renal Artery, (L) RA - Left Renal Artery, SMA - Superior Mesenteric Artery, IMA - Inferior Mesenteric Artery, (R) CIA - Right Common Iliac Artery, (L) CIA - Left Common Iliac Artery.
Etiology of dilation is typically multifactorial and the result of both hereditary and environmental factors whose final common pathway results in a degradation of collagen and elastin fibers and/or inhibition of their proper synthesis. These two extracellular matrix proteins of the aortic wall are principally responsible for its tensile strength and elasticity.1 In addition to collagen and elastin, other components of the aortic wall extracellular matrix (such as glycosaminoglycans) are found to be decreased in patients with aortic aneurysms, which is proposed to be due to aberrantly active matrix metalloproteinase activity.2 Other factors such as angiotensin II, mineralocorticoids, reactive oxygen species, and cells classically found in the systemic inflammatory response have also been implicated in the formation of aortic aneurysms.3,4,5 Secondary causes of aneurysm formation are trauma and infection, the latter classified as mycotic aneurysms. Finally, inherited and spontaneous genetic mutations coding for the aortic well components mentioned above may result in aneurysm formation in association with specific syndromes such as Ehlers-Danlos type IV and Marfan syndrome.6
Risk factors traditionally associated with the pathogenesis of aortic aneurysmal degeneration include male sex, family history, and cigarette smoking. Sex differences in aortic aneurysm prevalence are significant, with a 5:1 male to female ratio of affected patients, though a single unifying mechanism for these sex differences has not yet been elucidated.7,8 The exact pathogenesis of cigarette smoking on aneurysm formation is complex given the heterogeneous constituents of tobacco smoke, though the association with increased matrix metalloproteinase expression is well supported in the literature.9,10
Aortic aneurysm repair is undertaken to avoid rupture, which in most cases is fatal if not treated urgently or emergently.11
As noted above, aortic aneurysms are commonly insidious in nature and present asymptomatically, with the diagnosis often made incidentally on computed tomography (CT) for another indication. Aneurysms that have grown to become large may cause back or chest pain, or symptoms secondary to compression of surrounding structures. Some patients may also endorse the sensation of a “pulsating mass”, at the level of the aneurysm. Embolic stigmata from mural thrombus separating from the aneurysm wall can manifest as infarctions within abdominal organs or purpuric lesions in the lower extremities, the so-called “trash-toe” or “blue-toe” syndrome. As discussed, aneurysm patients may have elements of their history that elevate their risk for aneurysm development, such as smoking history, history of uncontrolled hypertension, or history of atherosclerotic cardiovascular disease. If there are secondary complications of the aneurysm, such as infection, the patient may present with subjective fever and other systemic symptoms.
Two distinct physical exam scenarios are relevant: incidental detection of a non-ruptured aneurysm and exam at the time of impending or active rupture. The former may present as a particularly prominent and pulsatile mass in the abdominal region above and slightly to the left of the umbilicus. Patient body habitus and aneurysm size will greatly affect the ability to appreciate this finding. Embolic stigmata in the lower extremities can occasionally be seen, particularly if lower extremity pulses are palpable through the pedal level. In cases of mycotic or inflammatory aneurysms, associated constitutional symptoms such as fevers and rigors may be present.
Unlike their asymptomatic counterparts, rupture or impending rupture most commonly presents with pain at any location along the distribution of the aneurysm. Contained rupture may result in compression of adjacent organs or structures such as the ureter resulting in hydronephrosis. Fistulization into luminal structures such as the bowel will result in GI bleeding, whereas rupture into surrounding structures such as the vena cava can result in acute onset of heart failure and a classic loud machinery bruit in the abdomen. Contained rupture into the retroperitoneum can manifest externally as Grey Turner (flank ecchymosis) or Cullen (peri-umbilical ecchymosis) signs.
Most aneurysms are discovered incidentally during other studies; however, in those who have never had such imaging, the United States Preventive Services Task Force (USPSTF) recommends a one-time abdominal ultrasound in men aged 65 to 75 who have any smoking history for abdominal aortic aneurysm (AAA) screening (B recommendation). These recommendations are not the same for women within the same age category and substance use history (I statement).12
Patients identified to have aortic aneurysms are followed up according to the size of the dilation. According to recommendations by the American Academy of Family Physicians, patients with AAA 3.0 to 3.9 cm in diameter should be monitored via ultrasonography of the abdomen every two to three years (C recommendation). Patients with AAAs 4.0 to 5.4 cm in diameter should be followed via ultrasonography or CT every six to twelve months (C recommendation).13, 14 Patients with aortic diameters exceeding 5.5 cm are referred for elective surgical repair. In thoracic aortic aneurysms (TAA), surveillance is typically repeat axial imaging six months after the initial detection and diagnosis to assess for growth or stability. Management and specific imaging modalities for continued surveillance of TAAs are dependent on extent, size, and rate of growth. Echocardiography and magnetic resonance imaging may also be options.15 Screening for TAA is appropriate in patients with a strong family history.16,17
Due to screening recommendations from the USPSTF, Society for Vascular Surgery, and American College of Radiology, abdominal aortic aneurysms are able to be detected and appropriately followed up with where they otherwise may have continued to grow. This allows for planned mitigation depending on the extent of the aneurysm’s size or rate of growth via risk factor management or surgical consultation.
Patients who fall outside the risk categories for screening may still develop aortic aneurysms and may never have them visualized, where they may be asymptomatic to the point of rupture. Some studies have suggested that an estimated 70–80% of patients brought to the ER for ruptured aortic aneurysms had no known history or knowledge of a diagnosed aortic aneurysm.18,19
Asymptomatic aortic aneurysms that do not meet the appropriate diameter/expansion criteria for repair are managed via the reduction of cardiovascular risk factors. This is achieved through antihypertensive and statin therapy, in addition to smoking cessation. Other pharmacologic therapies such as doxycycline are being investigated for their anti-MMP properties, but as it stands there is no data that suggests any substantial benefits for aneurysm risk mitigation outside of those previously mentioned.20,21,22
Aortic aneurysms in which the risk for rupture exceeds the risk of surgery are referred for a surgical consultation to repair the aneurysm. Though considered prophylaxis, repair of a high-risk aortic aneurysm has a significantly better 5-year survival rate than repair of a ruptured aortic aneurysm.23 Surgical options for aneurysm repair include open, endovascular, or a hybrid of the two. The choice between the procedural modalities is dependent on the specifics of the patient’s case, such as the location along the aorta or other anatomical considerations, in addition to the extent of the aneurysm. Other more nuanced considerations, such as the exact etiology of the aneurysm (degenerative vs. part of a genetic syndrome) also factor into the decision, as patients who otherwise would be good candidates for endovascular therapy are instead treated surgically if the etiology of the aneurysm is thought to be genetic in nature.
Of course, the patient’s medical comorbidities that would impact their surgical candidacy are taken into consideration as well.
Endovascular repair involves placing a collapsed fabric tube woven to a stent, a stent graft, into the aorta from one or both femoral arteries. The stent graft is brought into position across the aneurysm under fluoroscopy and then deployed so that it can expand and bridge from the normal aorta proximally to the normal aorta or iliac arteries distally. The aneurysm is effectively “sealed” off from the systemic blood pressure and flow is maintained through the aorta. Aneurysms involving the thoracoabdominal aorta, however, are much more challenging because major blood vessels supplying the abdominal organs arise from the aneurysm itself. Traditionally stent graft deployment through the area would result in disrupting blood flow to these organs. While advanced and very elegant endovascular techniques exist to address and maintain blood flow to these vessels while simultaneously sealing the aneurysm, details are beyond the scope of this chapter. Rather, the focus here is on the open surgical repair of TAAA. The operation entails exposing the aorta by accessing both the chest and abdominal cavities, mobilizing the adjacent organs and tissues off the aorta, controlling the aorta above and below the aneurysm, controlling all branch vessels arising from the aneurysm, arresting blood flow through the aneurysmal segment and then replacing all of the aneurysmal aorta with a fabric graft and restoring flow to the branch arteries. Adjuncts such as atrial-femoral bypass are used to help minimize and mitigate the effects of organ ischemia during repair.
Endovascular therapy has been shown in observational and prospective studies to confer a perioperative mortality benefit, though the superiority of endovascular therapy versus surgical therapy remains contested when considering short-term mortality, especially regarding repair of the thoracic aorta.24-31 Conclusions from the DREAM, EVAR-1, OVER, and ACE trials, evaluating infrarenal AAA management, appear to corroborate with prior studies identifying a short-term mortality benefit versus open surgery, though these trials show no significant difference in long-term outcomes up to 10 years.32-42 These data have helped providers identify the most appropriate procedural course for patients that fit into these categories. Older patients who are at perioperative risk are more appropriate candidates for endovascular therapy, though the risk for younger, otherwise healthy patients with lower perioperative risk is less clear and warrants further investigation.43-47
The patient in this case was diagnosed with a type I TAAA, meaning aortic involvement extended from the descending aorta to the suprarenal abdominal aorta. In this patient’s specific case, their aneurysm begins just beyond the origin of the left subclavian artery and extends through the thoracic aorta ending at their visceral segment. The plan for this patient’s surgery involves exposure of the thoracic, abdominal, and proximal infrarenal aorta, control of visceral vessels, placement of the patient in left atrial femoral bypass, graft placement, and abdominal closure.
The patient is placed in a right lateral decubitus position (as is customary in type I–III TAAA repair) to allow for ease of access to both the chest and abdomen. Spinal drains and motor evoked potential leads are also placed for assessment of the spinal cord throughout the procedure. The primary incision is made along the base of the neck between the spinal column and scapula at an oblique angle, passing under the tip of the scapula and following parallel to the ribs, terminating at a space between the patient’s umbilicus and symphysis pubis.
Careful attention is taken during the primary incision to not penetrate the fascia before it is fully exposed along the entire incision. Small bleeding vessels are identified and electrocauterized to prevent bleeding when heparin is given later in the procedure. After exposure of the fascia, division of the overlaying musculature, including the latissimus dorsi, trapezius, serratus anterior, and rhomboids occurs separately, with the creation of flaps occurring to allow for easier reconstruction at the end of the procedure. Marking sutures are also placed to assist with identifying anatomical borders for the reconstruction of muscle. The sixth rib is identified and marked, as this will be the entry point into the thoracic cavity. Entry begins with the division of the intercostal muscles, freeing of the posterior rib from the diaphragm, and osteotomy of the sixth rib. Marking stitches are placed throughout for anatomical reference.
Once the diaphragm is exposed, a GIA stapler is used to divide the diaphragm. Lung adhesions to the thoracic aneurysm are then lysed. The left kidney was then identified and mobilized. The diaphragm is further divided, and the pericardium is exposed. The left renal artery and vein and superior mesenteric artery are identified in preparation for dissection from the aorta. Branches from the celiac trunk are then ligated and divided. The aorta is followed upwards, continuing to expose it and its branches for dissection and ligation prior to cannulation at the proximal anastomosis for atrio-femoral bypass.
Clamp sites for the proximal anastomosis are identified at the descending thoracic aorta, and the left inferior pulmonary vein and ligament are mobilized before a purse-string suture is placed for the left inferior pulmonary vein prior to proximal cannulation. An incision is made in the lower extremity to dissect and place a purse string for the femoral artery, the distal anastomotic bypass site. Placement of a cannula from the left inferior pulmonary vein to the femoral artery allows for perfusion of the lower extremities while the aorta is repaired. Once proper exposure is achieved, the left femoral artery is dilated, and both the left inferior pulmonary vein and left femoral artery are cannulated.
Aortic repair after cannulation begins with clamping the proximal aorta before the anastomosis of the graft. During this phase, we manage pump flow at 500 mL/hr to ensure adequate perfusion. The graft is then sutured to the clamped proximal end of the aorta, and after the proximal anastomosis is completed, it is assessed for leaks at the suture site. Once the proximal anastomosis is secure, a second clamp is placed at the mid descending thoracic aorta, and the aorta is divided longitudinally, with ligation of any bleeding luminal vessels. Throughout the procedure, we maintain mean distal pressure at 70 mmHg to ensure proper organ perfusion, adjusting as necessary based on intraoperative monitoring. This technique is continued as the clamp is moved sequentially downward toward the distal segment of the aortic aneurysm, with continued longitudinal incision and ligation of bleeding intraluminal vessels. The graft is then measured to the appropriate length in preparation for the distal anastomosis.
The next part of the surgery involves visceral ischemia time, a time-sensitive portion of the procedure in which the visceral segment is ischemic due to ligation of the celiac artery. Similar to prior steps, the aorta is divided longitudinally and transected below the right renal artery, and intraluminal bleeding vessels are ligated. The aorta is then transected at the site of implantation, and the graft is anastomosed to the distal segment, with pledgets sutured at the site of the anastomosis to minimize the risk of leakage after the graft is fully sutured and assessed. Once assessed, the distal clamps are sequentially removed, allowing for perfusion of the lower extremities and viscera. The total clamp time for this surgery was 21 minutes.
After the graft is anastomosed both proximally and distally, the patient is decannulated at the site of the left inferior pulmonary vein with the closure of the purse-string suture on the left inferior pulmonary vein, followed by decannulation of the left femoral artery and closure of the incision at the femoral artery. As the incision for femoral artery access is closed, the aortic graft is clamped longitudinally and incised to facilitate anastomosis of a side-arm exit point. The side-arm anastomosis is assessed for leaks once it is fully sutured. The celiac artery is then anastomosed end-to-end to the distal segment of the side-arm graft, and assessed for leaks.
At this point, all transiently devascularized structures are revascularized, and the aneurysm sac is sewn back together with the patent graft carrying aortic blood inside. From there, the left hemidiaphragm and thoracotomy are repaired and thoracic drains are placed. The skin is closed, thus concluding the procedure.
To briefly touch on postoperative care of these patients, patients are kept intubated for 24 hours until they reach euthermia and are adequately resuscitated. After this period, extremely careful attention is paid to the patient’s neurologic assessment (hip flexion/leg extension), vitals (blood pressure), and complete blood counts (Hgb), as the risk of intraoperative spinal cord injury is assessed with meticulous detail. Additionally, the CSF drain in place must be managed with care to ensure an adequate arterial perfusion pressure to the spinal cord, which normally corresponds with a low CSF pressure. The CSF drain is normally kept in place for the first two postoperative days, followed by a clamping trial on the second or third postoperative day, and (assuming a successful clamping trial) the drain is removed on the third or fourth postoperative day.
Other than death, paraplegia secondary to poor spinal cord perfusion is a significant adverse event that may occur following this type of aortic aneurysmal repair. Crawford and colleagues demonstrated that cross-clamp time and aneurysmal extent are directly associated with this risk, and full, permanent spinal cord injury confers near 100% mortality at five years postoperation48 Due to this potential morbidity, significant investigation and research has been done to optimize strategy and protect perfusion. Though much attention had been given to the anterior spinal artery (of Adamkiewicz) as the principal determinant of spinal cord perfusion, the paradigm has shifted to a “collateral network concept” as described by Backes, Jacobs, Griepp, Wynn and Acher.49-52 These collateral networks include anastomoses from the subclavians, segmental (intercostal and lumbar), and internal iliac arteries. In this model, as long as adequate perfusion is maintained from two of these arteries, the disruption of one will minimally affect risk for permanent ischemic damage.53 Paraplegia rates differ between open and endovascular TAAA repair, with reported incidences of approximately 8.5% for open repair and 1.7% for endovascular techniques in some studies. Further research is encouraged to confirm outcomes across populations, as approach depends on anatomy, circumstances, and expertise.55,56
The rise of endovascular techniques for TAAA repair has reduced training opportunities for open surgical repair. With fewer open cases performed, trainees have limited exposure to the complex skills required for aortic dissection and graft placement. This trend risks a shortage of surgeons proficient in open repair, particularly for patients unsuitable for endovascular approaches. Addressing this issue requires alternative training strategies, such as high-fidelity simulation and centralized programs in high-volume centers.
Historically, repair of aortic aneurysms evolved from Rudolph Matas performing an endoaneurysmorraphy for arterial lesions in 1888, to 1951 with DeBakey and colleagues attempting excision and aortorrhaphy on patients with aneurysms, to the establishment of active aortic surgery programs at medical centers across the country. Medical innovation in the aortic aneurysm realm has recently exploded, with individual advancements in imaging modalities, grafts, anticoagulant medications, and cardiopulmonary bypass all contributing to better approaches to solving a medical problem with a near-fatal consequence if ruptured. Additionally, endovascular approaches have entered the foreground for principal considerations when planning aortic aneurysm repairs with no contraindications.54 As our imaging, medications, surgical instruments, and other players in aortic surgery continue to evolve, so too will our ability to perform these procedures safely and effectively for our patients.
GIA stapler; prosthetic graft.
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
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Cite this article
Del Re A, Mohebali J, Patel VI. Thoracoabdominal aortic aneurysm repair. J Med Insight. 2024;2024(109). doi:10.24296/jomi/109.
Procedure Outline
Table of Contents
- 1. Introduction
- 2. Positioning
- 3. Posterolateral Thoracotomy
- 4. Left Medial Visceral Rotation
- 5. Mobilization of Infrarenal Aorta
- 6. Atrio-Femoral Bypass
- 7. Proximal Descending Aortic Anastomosis
- 8. Aortic Exposure
- 9. Visceral Ischemia Time
- 10. Distal Descending Aorta Anastomosis
- 11. Atrio-Femoral Bypass Removal
- 12. Celiac Artery Reconstruction
- 13. Closure
- Skin Marking
- Skin Incision
- Divide Overlying Musculature
- Mark 5th Rib
- Divide Costal Margin
- 6th Rib Osteotomy
- Divide Diaphragm with GIA Stapler
- Mobilize Left Kidney
- Further Division of Diaphragm
- Shingle Rib
- Expose Left Renal Artery and Vein
- Dissect Superior Mesenteric, Celiac, and Left Renal Arteries
- Ligate and Divide Branches of Celiac
- Identify Sequential Clamp Sites
- Mobilize Left Pulmonary Vein and Ligament
- Left Inferior Pulmonary Vein Purse String
- Dissect Left Femoral Artery
- Left Femoral Artery Purse String
- Cannulate Left Inferior Pulmonary Vein
- Dilate and Cannulate Left Femoral Artery
- Clamp Proximal Aorta
- Open Aorta
- Anastomose Graft
- Check Anastomosis for Leaks
- Revise as Needed
- Clamp Middle Descending Aorta
- Divide Aorta Longitudinally
- Ligate Bleeding Vessels in Lumen
- Continue Sequential Clamping Distally
- Measure Graft Length
- Ligate Celiac Artery
- Clamp Infrarenal Aorta
- Quickly Divide Aorta
- Transect Aorta Below Right Renal Artery
- Control Bleeding Vessels
- Anastomose Graft (Distal)
- Check Anastomosis for Leaks
- Sequentially Open Distal Clamps (Clamp Time: 21 Min)
- Decannulate Left Inferior Pulmonary Vein
- Close Purse String Suture of Left Inferior Pulmonary Vein
- Decannulate Left Femoral Artery
- Create Side-Arm Exit Point in the Aortic Graft
- Anastomose Side-Arm Graft to Aortic Graft
- Check Anastomosis for Leaks
- End-to-End Anastomosis of Celiac Artery to Side-Arm Graft
- Check Anastomosis for Leaks
- Close Aneurysm Sac over Aortic Graft
- Repair Left Hemi-Diaphragm
- Insert Thoracic Drains
- Repair Thoracotomy
Transcription
CHAPTER 1
Hi, I am Virendra Patel. I'm one of the vascular surgeons here at Massachusetts General Hospital. Today we're gonna show you a video of a patient, a type one thoracoabdominal aortic aneurysm repair. This is a CT scan in the candy cane view of this patient's aneurysm. You can see that the aortic aneurysm starts just beyond the origin of the left subclavian artery and extends throughout her entire descending thoracic aorta and ends just at the level of her visceral segment. Our plan is to expose the entire thoracic thoracoabdominal and proximal infrarenal abdominal aorta. We will then perform control of all of the visceral vessels. We will put the patient on a left atrial femoral bypass to take heart from, blood from the left heart and perfuse the lower extremities and the spinal cord while performing the reconstruction. We will start with proximal anastomosis here and finish our distal anastomosis somewhere in this region. We may elect to reconstruct the celiac artery and the left renal artery if they require it. At the completion of the reconstruction, we will remove the cannulas and allow the periphery to perfuse on its own. And then we will do the abdominal closure.
CHAPTER 2
For an extent 1 through 3 thoracoabdominal aortic aneurysm, we prep the patient in a right lateral decubitus position. We allow the hips to fall back at about 45 degrees, giving us exposure to the chest and the abdomen. The patient is positioned such that the arm is taped forward. The spinal drain and motor evoked potential lines are here and there.
CHAPTER 3
All right. You guys can prep. So our fellow is Dr. English, is marking out the surgical incision. He is identifying the tip of the scapula and finding the midway point between the spine and the medial border of the scapula there. So the incision extends from the base of the neck along that line that he is marking below the tip of the scapula and then anteriorly parallel to the ribs and then down onto the abdomen below the umbilicus, somewhere midway between the symphysis pubis and the patient's umbilicus. So he will extend that mark onto the front of the patient across the thorax. We'll get started. I'm gonna take the other headlight here gentlemen and you're gonna get onto the abdominal wall and not get into the fascia. We are now just opening the skin, getting into the subcutaneous fat of the back and the abdomen. We dry up any bleeders that we create so that when the heparin is given, the blood loss is minimized. So this is the trapezius muscle here. The latissimus dorsi is here. Chest muscles on the back. And you're just gonna get right onto fascia and wait, Sean. If you're already there, then help me with some rakes on this side. This is the latissimus dorsi being divided now. That was the end of the latissimus dorsi. I will just create some flaps underneath it so that I can help reconstruct it later, okay. This is the trap now. So we're gonna divide the trapezius muscle. And I take it apart in layers and put it back together in layers. So I don't take the traps and rhomboids together as one big layer. I take them separately just because it's easier to put 'em back together. But some people take them as a single layer and suture it back together that way. These are the rhomboids. Let's have a marking stitch for the serratus. This is the serratus anterior. The posterior border is marked so that it can help us line up the repair later. Division of the serratus proceeds the anterior parallel to where the ribs are going. You can see it's starting to have some adhesions and fibrosis to the ribs to help prevent the scapula from being winged. So usually the first rib that you can feel up here is the second rib. It's not really the first rib. She's short and her serratus is nicely adherent, so I don't really want to disrupt it. If you feel in here now between the adhesions of the serratus right there is the first rib. It's the flat first rib. Yep. So that's one, two, three, four, five, count and confirm. DeBakey to me. One, two, three, four, five. Okay. So we'll mark the fifth rib. That's gonna be our entry point. I just wanna dry things up, up there and before we let all fall back down. Okay. Come on out with the retractor now. we're gonna go back to rakes and get this custom margin exposed. I'll take another. Here and here. Actually, we're going over the top of the sixth rib, aren't we? That would be a fourth inter-space, yeah. So I'll expose the rib for you so you can see. And then we'll just come across here, so... So, we're slowly dividing the intercostal muscles here. So my initial error was trying to mobilize the fifth rib. It's really the below the sixth rib that we're entering the chest. Let's have a large Kelly to me. Take this first, Sean. Now come underneath the costal margin. Rotate some more please. The diaphragm's attached here. I'm going to just burn along the back edge of the bone there so we can get it off. There you go. Okay. It's enough. Let's have a large Kelly and a house heavy straight scissor. That's good. Close. Okay. Close. Don't scissor. Just close. Watch where the tips, lower tips going, please. There you go. There you go. You're gonna lift up here. You're gonna see if there are any bleeders underneath and you're gonna grab them and kill them. And get your hand out of there. You don't need it. I guess you do need it. Maybe a rake on there would be nice. Can you give Jahan a rake, please? Okay. You're gonna lift the rib up here. I'm gonna come underneath here and mobilize some of this pericardial fat off. I'll take that, DeBakey. Move your finger back here and lift up that way. There you go. Can I have a pickup now? Take this away, Bruce. Now where's our phrenic nerve? Hold that for a second. Right in there, I bet. Okay. Let's have a marking stitch to me. Just make sure there's no phrenic nerve in here. Okay. So this way I know where the GIA stapler needs to go now. Okay, let's have a GIA stapler to Sean. You are gonna pass it across this way. You are gonna keep away from the central diaphragm here. Right there. Close. Cut. And don't change the angle as you're starting to come down. So it's good. Get my blues fire. Needle back. Another stitch. Jahan, keep it long. Just don't, we will cut 'em at the end so we can use them as a handle. Does that feel better? Yes. Thank you. Now may I have a pickup? And Sean, take a Bovie please. I'm gonna take some of these lung adhesions off. We're gonna keep working away in the muscular portion of the diaphragm as we divide it. So Bovie the adhesions of the lung. Get me a DeBakey, Bruce, please. Don't keep pushing on the heart. We're pushing on the heart guys, okay. Okay. That should be enough. Let's take another GIA stapler fire. Now, that one's a little too central. I want you to come out that way. Let's have a large bladder pickup the stuff I'm trying to divide. Here's the aorta. Dry that bleeder off there. It's inferior pulmonary vein coming up. That's enough. Do you have a Duval lung clamp for me please? Right angle back. Open that up. Pick that up and kill it. So now we have exposure in the chest here. We still have to mobilize some more lung, which is stuck to the aneurysm. Yeah, left lung looks great. Thank you.
CHAPTER 4
Now that we've opened this up, let's give this a little bit more retraction. Right angle back please. Pull, Sean. Char that branch that's crossing right now. Divide. Now don't burn the diaphragm up. Here is the fibrous stuff. You can see my fingers edge right underneath. Thank you. Kidney is up now. Right angle. Rotate the table back towards me, guys. Char it, please. Let's have the endo GIA stapler to me. Let's have a stitch. Another fire. Another stitch. You guys rotate the table towards me some more please. Take that out please. Right here. Yep. Some more? Yeah. Here's our inferior pulmonary ligament vein. We've divided inferior pulmonary ligament. Schnidt, please. Pick this up here. Right angle. She'll take the Bovie. Get this line outta my way. Line, wire. Let's have a palm. I'll have another Duval lung clamp. Grab this stuff down here. Lemme see if I can get a little bit more mobilized down there. It's gonna start to be into pericardium soon. Okay. There's pericardium. So when I did this with Josh, he used to say, "Just get into the pericardium." The problem is when you take your stitch into the vein and you stick it into the pericardium, you don't really get the vein. So we'll probably put our cannulation purse-string right there. The subclavian is right here. So our proximal anastomosis is gonna be right in here. Let's shingle this ribs. Pick up to me. Now take, you can get on the upper edge of the rib and just Bovie it right all the way through, right? So get 1-centimeter to 1.5-centimeter hole on the upper edge of that rib. I'll take a right angle please. Bovie to me. Starting to see it coming through. Keep coming. Okay. You can see there's the notch that I've cleared up where the intercostal vessel usually runs. Peel it off up towards me. Stay on the bone. Peel off this stuff on the backside. Good. Let's have a scissor. And slide down and cut. And then slide up a centimeter and cut. Bovie. You can put some Bovie in bone wax or whatever you want there. Divide slowly. Don't pass point deep 'cause that's renal artery underneath. Buzz. Buzz here, what I'm holding open. I see what you're doing. Char slowly. Okay, one more. There you go. Another stitch. Heavy scissor. Okay, get ready to buzz me, Jahan. Ready. Buzz. Buzzing. Buzz Buzz. Buzz. Buzz. Buzz here. I think that's the seal, the SMA, left lower than I thought it was gonna be. Suck here as the celiac that leaves. Celiac's got some small branch coming off of it early on. Suck, suck, suck. Suck. Let's have a dry sponge and a pickup.
CHAPTER 5
Okay. Suck here. Let's see if we get around the infrarenal aorta here. First the clamp is going to go in for it. Initially, we're gonna do a clamp and a clamp for sequential. And we're gonna do clamp, clamp, take the celiac off, do a bevel distal anastomosis right here. I'm gonna probably just do a bevel right below celiac and reimplant the celiac, okay? Nope, we don't need to go that low. No. Lot of inflammation back here. It's really stuck. So we were stuck. We have partially cut open one of those intercostals. There was the other pair that was adherent back there. So that's why I cut the other one, mobilized it this way, got behind both of them. Was able to rotate the aorta around and then repair it. Here you go. One more please. And remember, don't be rough with the celiac artery 'cause it will rip. And here. Yep. Move the vessel north a little bit. Suck. Gimme a buzz here. You're gonna need your... Suck here. Right angle, please. Get a Surgicel. Get vessel loop. Snap. Another vessel loop, please. Shove it in there. Yep. Do you have another piece? And another? And with that piece that was still back there, the lumbar that was still attached, if we kept rolling the aorta more, I was creating a larger adventitial hole, which is why I stopped and mobilized more to prevent that. Toe in here. Suction. Can I have a Metz? I'm gonna do that side. Just grab opposite me below in there. That's that first branch that we saw. Once that's gone, we can mobilize more. Now don't keep pulling harder. Just pull with your left hand. Hold that towards you. Let's have a 15 blade. Let's have a scissor. Let's have a suction. Can you tie that up, Sean? I need a fine right angle on a 3-0 silk tie back. Small clip. Small clip. A nice slot. Trying to prevent stuff from going down there, you know. Metz. So can you nudge the artery that way with your forceps? Or even that will help. Yep. And then toe in. Put the sucker in there. Grab that stuff behind. That stuff right there. Much better to sew too. I said it looks like a much better vessel to sew too. Is it free? Let go. Okay. That's good enough. Rotate the table the other way now. Away from you? Yep. I'm gonna go to the other side now.
CHAPTER 6
Let's see. One, two sequential clamp sites. Sounds good. Pickups and a Schnidt to me. Bovie to Sean. Let's have a scoopy go around. Feel that with your finger. Just put a finger right through. Feel that I'm on adventitia the whole way around. You know, otherwise we'll get the azygos back there. Let's have another string. Another string, please. Grab it, pull it, drag it around. Feed it to yourself. Suction, please. You guys rotate the table away from me some more. Now hang on one second. Just fold it and put your hand parallel to the aorta and just put your... That's nice. Let's have a Schnidt. I'm gonna want the large, the usual, the large, straight, big ugly. Gonna want an angled one up here. Maybe an angled one for down here. And then we'll just work our way down. Let's have another string. Now we have to look for bronchial branches in here. Let's have the scoopy go round. Buzz right hand. Buzz. Buzz. And I wanna see where I cut here, Sean, 'cause the only other structure that's here, and I don't want you to poke in there is in the pulmonary artery, okay? Suck here. Here's the ligament. Now, if you can grab with a forceps here and hold this up so I can see where the structures are underneath and then somebody else can, Bovie. How's this? It's all just lymphatic in the mediastinum. You can see maybe recurrent laryngeal nerve going back down that way. The pulmonary artery's gonna be on that side. Scissor. Move the vetted nerve out of the way like this with just with the closed forceps. Buzz, please Take this please. Pull this up with your one hand. That's the pulmonary ligament that I'm tying right now. Please. Forceps. You are just gonna gently hold there. we're gonna work on the above the cephalad portion of the structures here. Here's your subclavian artery. There's subclavian. Pick it up and hold it out. Thank you. Put a dry sponge on the arch and gently drag it with your fingers. All right. Hold onto to this. Now subclavian is right there. So this is where our clamp goes full show. Anastomosis is gonna have to be right in here. Jahan, gently pull on aorta here. You have the arch in your hands. Okay. Let's feel that now. It's a little much more looser. We got our vagus, our recurrent laryngeals running, gonna be running back in here 'cause we didn't cut anything. There's our ligament. There's our phrenic. Okay. Okay. Let's have a little Duval lung clamp for me. Hold here. Let's have a dry lap. Gently. Pickups to me. Another branch coming up there. And can I have a dry sponge please, Bruce? And you're gonna hold it up just like that. That's perfect. Stop moving around, please. And you're pulling too hard. Things are ripping up here. You see that? Okay, let's have that stitch. Let's put this one through a pledget here. Can you push your fingers in a little more, Sean? You can see the needle sticking into the heart. It would be nice if you can get your fingers down there and help. Because this vein is so damn small, I need to get really wide bites here. Hold it like this. I'm gonna hook it here. You're gonna feed it in. And then when the needles are, when I get the... The egg? Yeah. When I get the strands on my side of the blue thing, you're gonna hold at the needles. That's why I asked you to do that. Now you're gonna feed in, feed me, feed me, feed me, feed me. Cut the needles right next to your finger. Snap, please. Okay. Take the Duval lung clamp off for now. Bovie this stuff off. Close here. Right angle back. Suction would be nice, guys. Take that other one and put it through a pledget, please. Okay. Let's stop there. Yep. Let me know when it's been five minutes. Let's have a pickup to me. And let's have those cannulas real quick. Scissor cut this. Okay. Let's have the venous. Heavy silk. So it's usually the 5 or the 10. The 5, right? Yep. Okay. Let's have a little T-Berg. Give Sean a line clamp now. And when I tell you... Yep. So we're gonna put the cannula in, then you're gonna put this down. Actually, maybe just keep it right here for a second. Okay. You're gonna hold the cannula here and not let it slide down while I cinch down on it, okay? And we're gonna tie this two together. Okay. And then you're gonna take that inner cannula out and you're gonna keep the catheter down so that the left atrial blood can come up into it. And then I'll clamp below and then we will bring it underneath, okay? Can you gimme a little bit more T-Berg? And you're gonna keep tension on this so I can come against you to push in here, okay. And then let's have a suction up please. And then that Schnidt is next. Okay, hold your breathing please. Okay, holding ventilation. It's out. Good. Schnidt. Schnidt. Cannula. Okay, stop for a second. Give this to me. Okay, hold it down here, Sean, with your left hand. Got it. I guess here, give the line clamp. Pull tension up on that Schnidt now. There you go. Okay. Slide it back. Bruce. Hold this with your, actually can you hold this right here, Bruce? You can breathe. Okay, let's have a heavy silk stitch. No, just a tie. Sorry. There you go. Somebody have a scissor ready? Sorry, my hands. Yep, that's not for you. I'll take a scis. Okay Sean, you can let go now. Switch hands. Switch hands so that this here holds this here and this holds this here. We'll take an asepto next. And then three snaps. Scissor first. Let's have a stitch. Let's have a vessel loop and a snap. Take this with your right hand, Jahan, the snap please. Move it outta my way so I can stitch the cannula here. Here we go. Just hold the wires taut. Don't pull it out. Okay. Walk this off over wire. I got wire. Like let it go. Pull it off. Let's go. Let's have the next dilator. I got wire. Hold it down a little bit. Push wire in. Pull. Walk it off. Next level dilator, please. Walk it off. Let's have the cannula next. Just hold this. Jahan, you're gonna hold wire, and Bruce, you're gonna hold the red and the white together. Okay, just stay right there for a second. Okay, let's have a line clamp please. You're gonna put your thumb over the hole when the wire comes out. Wire out. Go ahead. Walk it out. Don't pull my cannula out, please as you're grabbing it with the... Okay, now you're gonna take the white dilator out. Does this pop out or is it? There you go. You gotta come out a little faster, guys. Let go. Okay, let's have an asepto, please. Help me out here. Let go. I just want you to help me out and get it in my view. Oh, we got some air here. Let's have a syringe, please. Okay. Take it off. Let's have a little bit of saline to drip drip here. Okay, your line's open. Start to run at 500 an hour. Okay. Let's have a hep - antibiotic-soaked sponge. Let's have a half sheet here. And let's have a stitch for me. Going on. Let's have a tie please First. Hold this up. I'm gonna need it on the right angle please like the usual. All right. Your flows are good? Yeah. Okay. We're gonna shoot for a distal perfusion of about 70 mean. Okay. Scissors, please. Let's have a heavy scissor to me. Yeah, go ahead. And a stitch. Let that fall, please. Help me out with your other hand. You see me getting caught. Let go. Let's have another one of these.
CHAPTER 7
And you're gonna lay flat the whole time now. Yeah. Line clamp is back to you, Bruce. And let's see my clamp. Can you load up my, can you look on the CT scan and let me know where her thrombus ends. I think it's all in this bubble, right? And relax for one second 'cause I want to be a little higher up. How are you doing as far as flows there, Ralph? You ready for a clamp? Yeah. Okay. Gimme a few minutes. Okay. Up in there. I need a straight hydro. And then yeah, you're gonna hook these and do that so I can put the clamp up near the subclavian artery, okay? Can I see the clamps? And where's that suction or where's that debris, Mike? Pickup to me. This is PA. Leave it alone. Suction. I'll take a pickup please, Bruce. Okay, turn your flows down for a second. Okay, down. Okay, back up. Okay. Okay. I have a clamp on the infrarenal. The mid-descending, proximal descending thoracic. Let's have the proximal here. Ready? Suck. Okay. Scissor. Metz. You gotta move back a little bit, Sean. I can't feel here. And we're gonna have a... Suck in here, please. Move back. Try to give him the sucker. Might help you. Right here? Yeah, please. Okay. Pick up this aorta here for me, please. Suck and toe in towards you so we can see what we're cutting. Make sure it's not juice, right? Okay. Okay. Let's have a silk 2-0 silk stitch. Take that clamp. Take this. That's good, here. Let's have a Metz. Please hold this lower aorta for me. Okay. Relax for a second. That means you, Sean. Okay, let's have four white towels. Get another one. I need you down here. And now that's... Your fingertips are on PA, so don't dig in. Just flat. Another shod? Grab a forceps, Sean. You grab yours. Yeah, Jahan's side of the graft. Thank you. Okay, let's have a shod, please. Does this 3-0 come in a longer stitch than this? It's the longest. Okay. Forceps in your hand, Sean. Let go. Bruce, can you hold the graft back here for me? Hold here. Keep it on tension. Shod please. Shod. Hold on. You're hooked around me. You want me to follow you? Yeah, that'll be good. Here, Bruce? Yep. Just put a snap on it please. Give me another DeBakey, please. And let's have a sharp hook. That's enough there. No more. Don't pull any harder. Okay, hold that on tension. Now stop pulling it up this way 'cause we have to come around that way with the mosis, okay? So, Jahan, put the suction down. Give that to Sean and you follow from your angle. Driver. Thanks for keeping the needle out of the PA. Pull up on tension. Gotta change - just let it go so I can orient it properly. Otherwise we're gonna create a big pucker right in there. Okay, Sean, driver. You keep that on tension. Here you go. Come closer to me. Got it on tension. Yeah. Hang on. I'll follow you. Get a forceps in your hand. Yep. Take a bite of that. Yep. Bring it through. Now, your next one's gonna go that way and you're gonna creech it over onto itself. You are gonna get a nice deep bite with that thing without grabbing the... Now creech it towards yourself instead of up the aorta. So if you can't do it, then let it go and creech back. Let me use right hand where I can get the angle better. Like I want this suture line to be up here near the clamp is what I'm trying to say. Yep. Deeper. There you go. Now bring it back. There, it's nice. Deeper. There you go. Creech it back 'cause that's all dilated up there. You need to bring it as close to the clamp as possible. Deep. Roll back. Get in there. That's nice. Don't raunch on the aorta. Now take it out. Grab it. Now orient it so you come way out there. And don't stick this thing 'cause I don't wanna leave it behind. And then if you can, great. If you can't, then come back in a second bite. You have to grab... Yeah, I am. But you have to grab a little bit further back on the needle so we're not struggling like that. Go left in there? Sure. Drive. Roll the needle back. Drive higher up. You go back there? Yeah. Yes, I am. And I'd like you to come all the way through with the big needle on the back. There you go. Now flip it over and stick it through. And just hold your left forceps there. And just grab the needle out and readjust it with your hands. What's the time, guys? You want cross clamp time? No, there's no cross clamp time 'cause we have no ischemia anywhere. I wanna know the ischemia time later for the visceral segment. Drive the needle back. Drive it up. Now just let it go and bring it through, the needle. Okay, let your forceps go. Grab the needle, roll it out, and then creech it back so that as it gets here, it's gonna be a little tight. So learn to show with some respect. We're right next to the clamp here. You gotta creech. There you go. That's all you need. You don't need a... It's like two more bites here. Yeah. Drive it right across. You can see the subclavian artery, that knob up there above our, to the left side of our clamp, Jahan, is the subclavian artery. That's a good sign that it's not clamped off. And you've got a nice tension there, Jahan? I do. And that's going in there, right across. You want me to cross it or come in the middle between? I'd rather you just go right to it and then maybe if you want to cross it, you could do that too. Okay. Come through. Tie it up. Let's have an asepto. Watch the problemary artery. Give him a cut, squirt. Trig, trigger, trigger. Good. Scissor. The asepto to me. So this is a good way to test the mosis. Have the suction up here please. Okay. Move the white towels back a little bit. Jahan, move your hand back a little. Proximal clamps coming off here. Of course. Let's have a Crayford cowork. Take this. I need a pledgeted 4-0 stitch, please. Let go. Let go. Cut square please, Bruce. Squirt the right hand. Scissor. Bruce your hand hit my... Okay. When you're doing that, you gotta show this artery respect. The slightest torquing to get your creech right is tearing a hole somewhere else that's more important than your creech. So you can always do your creech in two. Right. There's something else bleeding back there now. Cut. Here you go. Let's have another angled hydro slip clamp, if we can have it please. Let's have a dry lap pad. We don't have the big ugly. Give me the big ugly and a pickup. You have those thrombeanies? Say again. Thrombeanies. Yeah. Let's have them Dry it up in there. I wanna see what's bleeding. Nothing. Okay. Let's have some more. Let's have a dry lap again.
CHAPTER 8
Let's have you hold here gently now your heart and lungs. You have that straight hydro slip clamp. Come down on your flows please. Okay. Down? Yep, it's down. Okay. And back up? Back up. Run a motor again. Okay. Now we have the mid-descending thoracic aorta clamped. We're gonna take this clamp off. We're going buzz this, Bovie this open, and you're gonna suck in there and show me where the bleeders are. Okay. And I'm going to tie them all off. I'll take that Bovie. And then we'll take some 2-0s. Put the sucker in there and open it up. There you go. Grab more, Sean. Help me out. Okay, let's have a stitch next. DeBakey's, please. You get a scissor in your hand, Jahan. Okay, scissors. Move your forceps out of my way. It's not helping me. And out here? Yeah. Make sure the goose is not in there. Cut here. As I tie this down, you find the next bleeder that I need to tie off. Cut this, Jahan. Pick up another stitch. Where's the goose, here? Out there. Okay. Make sure I don't stick it on the other side, Jahan. I am good. Flip it over and check. Good. Let go. And then get it outta my way. And then we're gonna find the next one. Yep. That right there and here. You can go out. DeBakey's. Pickup. It's the next one. Yep. Yeah, I know. So Jahan, move the goose over. Lift up. I'll just take a small bite. That's how you get an aorto... Cut. I got it. Okay. Anything else? Thank you. Can I have a new right glove please? Where's our next one, Sean. Next one's here. Okay. Pickups and another stitch. Suction and show me where the next one is. Right here. Right here. Yep. So the nice thing about the sequential clamp technique is, you minimize the blood loss and work in a small segment here. Cut. Let's have a... What's the distal profusion? Here you go. Stitch. Pickup. Suck. Here you go. Cut. Suck, suck, suck. Find the next one. Pickup. Yep. There it is right there. Stitch. Bruce, can you cut for me? Here you go. I can. Okay. Cut please, Bruce. Okay, turn your pump down for a second please. Yeah. Right there. Now we're gonna get... Flow down? Yep. Go back up. Okay, back up. Is there still there a clamp down? No, we're still, we're just doing sequentials down. Check another motor please. Let's have a Bovie. Great. Grab here and pull out. Give me a pickup. You can just take back to the office. Can you take this off in a second there Jahan or one of you? Go ahead. Take it off. They're good. Yeah. Thank you. You ready? Go. Let's get sucking in there please. Okay, let's have a pickup and a stitch. Yeah. Cut. Cut. Stitch. Show it to me and then keep it showing. Let's warm the room up a little bit for her please. Okay. What is her temp, Raf? 34. Okay. Is that a one right there or is that coming from the clamp? Not sure which one. This one right there. Cut. Let's have a stitch. Okay. Sean's gonna go to the other side now. Okay. Scissor. Actually, give me a medium clip please. And let's have a scissor. You wanna wedge here like that? Yeah. Can I have a Crayford cowork. This is gonna be the visceral ischemia time. Marking pen to me. Okay, let's have a Kelly. Do you wanna go up on the flow a little bit? I'm sorry, not a Kelly. A 2-0 silk stitch and a Kelly. Raf, what's our, BP is good? I'm sorry? There you go. Distal perfusion is good. Yeah. Okay, I'm gonna give you, I'm gonna ligate the celiac artery here for you, okay? Yeah. Fine right angle.
CHAPTER 9
And then let's have a bulldog. Three bulldogs. Okay. You ready for visceral ischemia time? Here it comes. Celiac is ligated. Get a scissor in somebody's hand quickly. Okay, celiac is clamped. Let's have a straight bulldog. Cut. We're getting collateral flow. Let's have that straight hydro slip clamp now. Turn your flows down. Suck in here. And show me what I'm clamping. Okay, go back up please. Okay. Back up. Visceral segment is completely ischemic. Run another motor. Let's have a red rubber and stuff here like we did before. And get your suction in your hand. Give that to him. He can do that. Put a forceps in your hand. 'cause we need to open this and get this open. And I'm gonna need those 2-0 silk ties. Ready? Here we go. Scissors. Stitches, sorry. Pickups and Metz. Come on. Yeah, they're in there. Suck in here. Show me on this side so I can get this aorta divided. Show me where the right renal artery is in here. Here it is right there. Okay. Can I have that Metz? Okay. Let's have a heavy straight scissor. Pickups to me, yep, and four white towels up. Actually let's have a 2-0 silk before we get that going. Cut. Yes. Another stitch. We need a few more of these stitches, Bruce, okay? And then we'll get to the... Motors are okay? Yeah. These are the critical intercostals. The motors are okay from the distal aortic profusion. They go. If you were worried about 'em, you could - cut, let's go - you could put Pruitts in them. You have some Pruitts? That's good. If you gimme the counter traction, that helps. Cut. Put the suction on there and hold it there under pressure. Tamponade it off. Cut. Let's have that Pruitt and a forceps. Lock it. Now, if you were worried about that intercostal, you could. I'm not really, but we'll just leave it there for now. Yeah, that didn't work. Okay, let's have a stitch. You can see what happens if you're worried about the visceral segment. Remind us if there's ever issues. That's the one we're gonna reimplant. Run a motor please. What's the distal pressure, guys? Cut. How long since the clamp went on? Right now it's been five minutes. Thank you. Let's have a stitch for the aorta next. Scissor first. Got it, okay.
CHAPTER 10
Let's have four white towels. Sorry. You can let go of this. I wanted a red rubber and a snap on it, but suck in there please. Thank you. Now it's your turn to not be able to see anything, Jahan. Can we have a shod, please. Shod please. Yep. Give me a little. Let's hold that, shod. I'm gonna want some, I'm gonna want I'm some transition stitches with pledgets here, Bruce, okay? So I'm gonna raise it to 15. A squirt for the strands. We're not pulling up there. We're doing this very gently. Okay. Stop there. Keep bouncing. Stop there. Pull on it. Pull on it. Stop for a second, then don't pull on it when I, when you see a loop like that. Okay. Pull. Hold it on tension now. Okay. Shod, Sean. Let's have a transition stitch to me with a pledget. Just leave it outta my way now. Put that through the pledget. Pull your, let's put that other one through the pledget as well. Hold these two like this. Gimme a driver. Nope, just gimme a driver. Pickup to me. Pardon me? Nevermind. Jahan's helping me out. Need a pickup. Need more of those 3-0 SHs please. Hold that one on tension still, Sean. Come on guys. We have visceral ischemia time here. Hold this one. That's gonna be my next runner. Let go. Yeah. Thank you. A scissor please. Shod that one to Jahan. We're gonna do one on my side. Actually, gonna run up my side and do the same. How long's it been on the visceral ischemia? 15. 15 minutes. Thanks. Can I cut this? Yes, cut it. Don't cut the other one though. The empty driver, please. Suck in there. Put the pledget on that one. Give me the other stitch so we can put that pledget through it as well. The first runner. Give this one to me. Pull this one up on tension. Cut, squirt, please. Take this. Too many of course. Take this one. Gimme that. Empty driver right hand. Take this. Shod that one. Gimme the other one. Pull it up nice and snug please. Motor's still good? How's motors? They're good. Take the other one off the shod. Hold that one up on tension. I'm gonna follow myself. You're gonna want a pledget, Bruce. Yeah, go ahead and put it on that. Okay. Visceral layer, visceral segment's gonna open up here in a second. Yeah. Drop your pump. Pump flows down, but don't turn it off. I'm gonna give a little backward flush here. Down. Okay. Okay. Back up. Okay, back up. Okay. Let's have, you guys already have the pledget on? Good man. Can we cut square, please. Let go. Cut square, please. Okay, we're gonna take the distal clamp off now and we're gonna turn the pump flow down to 500 in a second here, okay. And you might have a, if you need a squeeze on the graft because of the visceral and the legs are coming back, let me know though. The legs have been fine, so it's just a viscera. Yeah. Cut. Take this. Okay. Turn your pump down please to 500. Down to 500. Okay. Legs are open. Right renal is open and SMA just opened. So everything's open. How long was the clamp time? 20 minutes? 21. Yeah, you had right renal SMA and celiac ischemia at the same time. How we doing as far as distal perfusion? Good? Let's run a motor please. You know, what? Warm 'em up a little bit and then, 'cause I'm ready to take the cannulas out actually. So distal profusion, I want greater than 60 mil, mean of 65 at all times, but I want her blood pressure like systolic about 120 ish post-op, okay, minimum. Pickups please. I'm gonna want some Seprafilm on the field, guys. Okay. Let's have another dry lap please. Okay, let's have some Thrombeanies if you don't mind.
CHAPTER 11
Let's have another one. Let's get ready to decannulate here. Do you need more volume here? No. Let's get all the Bovie and the cell saver up here without losing it this time. Here you go. Rotate towards me. Whenever you want. I'm just gonna, should we take the venous out and pump through or you want none of that blood? Should we dump it into the field and then give you a cell saver? Yeah. Do that? That sounds good. Okay. Just leave it going for 500 for now. A what? A large Sepra? Yeah, let's not worry about that until I'm closing. I'm sorry, but - I know I did ask for it. Thanks for getting it so quick. Normally no one ever has it. Now let's get this loosened up here. Let's get the, you can let that go. It's not going anywhere. Let's open up this and get this line outta here. Let's have a Duval lung clamp please. Now, whoever's holding the clamp, which is gonna be you, you're gonna pull it on tension when we take it out but then when I start to tie it down, you're gonna let it go so that I don't rip the vein, okay? Okay, Jahan, instead of this let's, yep, please. Spread your hands and... Okay. Take this. Don't do anything. Not yet. Not yet. You guys, get ready to hold your breathing here in a second. Okay. Let's have a line clamp. Put the line clamp here. I can clamp down here. Okay, well we got it. Go ahead. Go ahead. Hold your pump. All right, we're off. Clamp all the way across. Click, click, click. Let's go. Sean, pull the cannula out when I say. Okay. Go ahead. Slide it out. Go ahead and breathe. Sucker to me. Scissors. So you don't want the volume, yes? Correct? Yeah, we'll get it to the cell saver. Okay. Or can you take it now? Cut. Okay. Rotate the table towards me. Drop the table height. And let's have an angled Gerbode and a pickups please. Let's have angled hydro grip. Take - put the venous cannula in the warm bucket of saline. Give me the arterial cannula here. Where's the arterial cannula? It's Right here. Okay. Let's have the cell saver. Put that in there. Keep it on the bottom. Go ahead and... Yes, take the clamp off. Take this please, Bruce. Put the cell saver right in here. Right down there. Okay, I've got my clamp open here as well. Go ahead and pump slowly into the field. All good? Yep. Go ahead. Okay. Yep. Put the cell saver down here. That's good. Yep. Yeah, keep going. All right. When we see the stuff turning clear, we'll give you your lines back. Let's have a line clamp back to both me and Jahan. We're almost at the bottom. We've got about 400 cc. Yeah, I put the clip down here. Whatever you wanna, Okay. Let's give a little bit more. Okay. Okay. That looks good. Clamp, clamp.
CHAPTER 12
Okay, everybody move that way so we can give him his line clamps back or his lines back. Okay. You guys wanna close this up? Jahan, you close it. You know how to do it right? Yeah. Okay. Let's have... Let's have our retractors back. Now we're gonna put a little side biter on here and put this celiac artery in. Thanks. Probably a little more now that... Do you have that 8-millimeter Dacron graft? We'll do it right here, slightly over to the right line and just, okay. Can I have a Schnidt? Give him an 11 blade. Let's have a side-biting Satinsky clamp I hope not. Let's have a vessel loop and a snap. Can you run a motor? Yeah. It's filling back up. See how it's filling? Yep. I squeeze it and it fills. Okay. Let's put it on tension. Gimme an 11 blade. Forceps. Can I see that cut, Brett? What are we doing here? 5-0s? We're gonna do 4-0s, please. Okay. Let's have four white towels. Give Sean a 5-0 as well to get started just to open this up a little. You were saying? Stays, exactly. Two 5-0s for stays and then with the 4-0 for the anastomosis. I'll take that shod. Thank you. A little slightly longer driver. Even them out. Good. Go ahead. Right up the pike. A little less. Keep going. Around to three. Can we have a shod please? Move back for one second. Did you flush it well proximally and distally first? Distally first then proximally? Yep. Good. I'll take a shod. Relax for a second on your side. Okay, bounce Shod this one. I'll have another stitch to me? Lefty. Shod this one? Yes. It's already on a shod. Thank you. Are we gonna give more heparin? No. Okay. We're gonna reverse once the celiac's opened up, okay? Okay. I do 2-0 PDS, 3-0 PDS in the groin, guys. No vicryl? Nope. Tie this up. Oh, we got a hook. If you need to charge your battery, now's a good time. Do wanna change this memory or whatever... Okay, shod. Empty driver to Sean, please. Take cut square to me please. Get ready to sew with your other side. Do we have much in the way of a lactic acidosis after that clamp time or no? Probably not. 21 minutes. How are the coags and stuff? Okay. What? Motors are still good. Thank you. Yep. Scissor. Yeah, that's what I'm saying. Snap please. Actually, can I have a hydro grip clamp? Have another stitch please, Bruce. A lefty. Another 4-0. I need that Satinsky back. Stitch to me please. Cut. Squirt. I need a scissor please. I had to reclamp partially here. You make sure that distal profusion stays up 'cause I've got like a 50% clamp on the aorta here. Cut this one. That's... Scissor. Please stop pulling up on it. It's gonna keep ripping, the graft. It's got 5,000 stitches in it now. Suck all that stuff out. Can I have a round forceps please. A forceps. How about... Yeah. Thank you. Can I have another one of these? Do you have the renal artery forceps now? Do have a Potts scissor? Let's I have a white sponge. Got it. And a marking pen. Let's have another hydro grip please. Let's have a scissor. Let's have a 5-0 Prolene stitch to me. You grab this corner and pull it. Grab this corner. Pull it that way, yeah. No. Let go. One, two. Suck on the surface here so I can see what's what. Gently. Shod to me please. Shod right here. Squirt really well. You're gonna hold this graft down. Just let that go. I'm gonna sharp hook it back so that we don't tear this artery. So you're gonna hold this down like so. I'll take that sharp hook. Let's have a blue towel for the, to put underneath the clamp. Let's have another stitch to me please. There's a pocket on the front of the back side. We're gonna take three of these. Shod. Grab the black line with your forceps and push the graft down so that I can tie the toe down. Okay. Go ahead and follow, Jahan. Don't pull hard now. This is a very delicate vessel. Let go. We're gonna want some more sutures here with pledges. Round handle forceps to me. Hey, give her protamine and start reversing her please. That just happened over the... Okay, well let's tank her up 'cause that's not acceptable, that pressure. Run a motor please. Sure. Okay. Okay. We got most of the bleeding stopped here. Lots of FFP and platelets now guys, okay? Can we have some warm irrigation in the room? Let's take this guys. Can you rotate the table away from me. Let's have some more warm irrigation. Rotate away from me some more. Okay. Lots of protamine, coags, and platelets now, guys. Last chance to look at the anastomosis.
CHAPTER 13
All right. We're seeing clot in the field, so thank you. Okay, let's have Bonnie's and a 2-0 silk. Let's see. Is that gonna narrow that graft? Try it. Don't close it completely then. You think so? Yeah, it's good. That's fine. We're gonna close it up here. So got one here and one under Sean's left hand. Does she have a PET CT? This one? No. Suck up here so it doesn't drip all over my leg. 68, 69, 70, 71, 72. Let's have another long silk runner please. Shod this or snap it. Yeah. A small clip please, Laura? Yep. Can I have a Bonnie's? Where's all this blood coming from? I need a slack on that guys. Some more irrigation here. And the coags are okay? Or are you waiting on those? Coags have been okay. We'll get additional platelets here... Can you get some more FFP as well please? Thank you. Far and away. Far enough away from goose there. That's good. Okay, let's take this. I'll take another one of those heavy Vicryl runners for the aneurysm sac. Now, it should be dry as a chip up here. And it is. Relax for one second please. It's a lot of mediastinum opened up here. Can I have the Bonnie's back please. If anyone has to re-explore this later, remember I put that stitch there. Grab this with a Bonnie and pull it over so that it doesn't rip it up. I'm gonna try to tie it down. There's still a lot of oozing up here. Cut. All right. Keep doing, working on the coags and platelets and stuff, guys. There's still a lot of raw surface that's just oozing now. Bonnie's. Thank you. Yeah. Especially up near the neck. Let's run up this one. Let's see. Can I have a Vicryl stitch? You can stop doing it. We're done. Thank you. And what's the blood pressure been? 120s. That's perfect. Yeah, 120 is fine. 120 is fine? Do like 120 to 140. Don't overshoot, but... Okay, let's do this and let's just close this up a little bit to get a little tamponade. You have that Vicryl stitch? And another Thrombeanie for me. Okay, I'll take that Vicryl stitch next. Cut that one. And follow with your other hand for me? Let it go. You ease up with the pull on your right hand as you pull up. Yep. Ease up on the pull. Okay. I mean, it will tamponade out nicely if we can get it closed up. Okay. It's gonna be good enough. Tie it up. Pull up on it. There you go. Let's take this off. Actually, let's take it off just, yep, go ahead. Let's have a heavy silk stitch for me. We will look at this spleen in a second. Let's have a Bonnie's. Give us a head up in Berg. Head up in Berg coming. More? That's good. Too much. Cut this please. Cut. Let's check that pulse in that celiac artery. You have a doppler on? You take it out of a less head down, up in Berg and gimme a little rotation towards me please. Less head down? Yeah, sort of more flat. The other way. You want more head down? Yeah. Okay. Let's have that heavy Ethibond runner. Let's do a little bit head down and drop the table height all the way if you can. Let's have that Ethibond runner. Just hold the spleen and kidney over gently. Okay, I'll take that Ethibond. Bonnie's. Cut. Take that. Driver. Yep. Jahan, can you cut these out? Yeah. Preserve the central trend but does that, and the phrenic nerve, but does that really preserve function? Who knows? Let me tie myself. Okay. Okay. Don't poke a skunk. Cut it. Kocher please. Suctioned. Feet down in Berg. Okay. Feet down in Berg. That's good right there. Yeah. Get your fingers deeper down in there. Hold this for a second. Pull yourself up. Let's have a Kocher to me. Okay Jahan, you hold this? Yeah. Yep. Thank you. Yep. Plow through. Close her up. Yeah. That's good. Yeah. Don't stretch the tissues to get your needle in. Move your needle to get your tissues. This one is supposed to be down here so you've gotta make more... It's headed up to here? That one's headed up to there. Let's see how much travel you, this one's gotta be made to here. So smaller travel there. Bigger travel on that side. Scissor. You do that first and then close it. Watch your fingers. There you go. Now this fram's gotta go all the way to there. So it's much smaller bites, much bigger travels, okay? Keep going. You're following yourself. I'm not following you anymore, I'm... Okay. Take that off please. Let's have a Kocher to me. Let's have a knife and a Schnidt tube. Okay, knife. Okay. Easy for a second now. You got to make up this all the way to there. Okay. Can you give us a little head down in Berg. Okay. Okay. Get another stitch please. Another - just tie this. Yeah, no. Another Ethibond. Long running Ethibond. Good bite. Don't stick the heart. Now we're not gonna pull it up. We're just gonna sort of keep running it. Yeah, I pulled it up. Sorry. Rotate towards me. Can we go anymore or no? I think so. Rotating towards you. Keep going all the way, Raf. Jahan, get a forceps and a scissor and cut this marker stitch out. Just the edge now. That and that. Let's have that heavy Vicryl runner please. Scissor. Thank you. Yep. Thanks. Bonnie's. And then follow here. Here you go. Let's have the rake back. Another one of these heavy Vicryls. Another loop? Yeah. You close them up just as nicely as you open 'em up and everything works out just fine.