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INTRODUCTION:
We report a successful treatment of extent III thoracoabdominal aortic aneurysm that was complicated by Takayasu arteritis with stenoocclusive visceral branches and iliac arteries.
METHODS:
The patient is a 27-year-old Asian female with a past medical history of Takayasu arteritis on steroid, who was recently diagnosed thoracoabdominal aortic aneurysm. The patient also complained of intermittent claudication of the left leg. The preoperative computed tomography demonstrated type 2 (thoracoabdominal involvement) Takayasu arteritis and an extent III thoracoabdominal aortic aneurysm. The superior mesenteric artery, right renal artery, left common iliac artery and right external iliac artery were occluded. The celiac axis and left renal arteries had severe stenosis at the orifices. The preoperative serum creatinine was 1.22mg/dL. The patient was taken to the operative room electively. Because of the bilateral iliac artery occlusion, the distal first technique with bypass to femoral artery was planned to maintain pelvic circulation. She was positioned in an oblique right lateral decubitus manner and thoracoabdominal aorta was approached through the 6th intercostal space. The left heart bypass was established with pulmonary vein drainage and arterial return via an 8-mm graft, which was beveled and sutured to the left common femoral artery in an end-to-side fashion. The infrarenal abdominal aorta was clamped and abdominal aorta was opened. The orifice of left common iliac artery was occluded. A #5 Fogarty balloon was inserted into the right common iliac artery to obtain distal control. A 26-mm side-branched thoracoabdominal aortic graft (STAG) was cut to length. The distal anastomosis was performed using a running 3-0 Prolene suture. Upon completion, distal aortic perfusion was switched from the left femoral artery to the side arm of the graft. Then proximal end of the femoral artery graft was delivered underneath the inguinal ligament into the pelvis, and anastomosed to the main body of the aortic graft in end-to-side fashion using a running 4-0 Prolene. The aorta was cross-clamped distal to the left subclavian artery and the proximal anastomosis to the mid-decending aorta was using 3-0 Prolene suture. A Carrel button was created for the celiac axis, bilateral renal arteries. The superior mesenteric artery that only a chord remained from chronic occlusion. An endarterectomy was performed on the right renal artery. The visceral branches were reconstructed separately with the side branches of the STAG graft. During the proximal and visceral branch anastomoses, sequential clamping and visceral perfusion technique was applied. All the patent intercostal arteries were ligated after confirming there were no signal changes in the motor evoked potentials. On completion of all of the above anastomoses, there was noted to be excellent pulses in the visceral and femoral arteries.
RESULTS:
. Postoperative course was uneventful. The serum creatinine improved to 0.53mg/dL. The distal first technique combined with femoral artery bypass and endoarterectomy of the visceral branches is seemed to be a feasible option to treat thoracoabdominal aortic aneurysm with visceral and iiac artery stenooclusive disease.