Open aortic surgery

Last updated
Open aortic surgery
SurgicalAAA 01 Base 275.jpg
Drawing of an open infrarenal aortic aneurysm repair using a tube graft
Other namesOpen aortic repair
Specialty Vascular surgery

Open aortic surgery (OAS), also known as open aortic repair (OAR), describes a technique whereby an abdominal, thoracic or retroperitoneal surgical incision is used to visualize and control the aorta for purposes of treatment, usually by the replacement of the affected segment with a prosthetic graft. OAS is used to treat aneurysms of the abdominal and thoracic aorta, aortic dissection, acute aortic syndrome, and aortic ruptures. Aortobifemoral bypass is also used to treat atherosclerotic disease of the abdominal aorta below the level of the renal arteries. In 2003, OAS was surpassed by endovascular aneurysm repair (EVAR) as the most common technique for repairing abdominal aortic aneurysms in the United States. [1]

Contents

Depending on the extent of the aorta repaired, an open aortic operation may be called an Infrarenal aortic repair, a Thoracic aortic repair, or a Thoracoabdominal aortic repair. A thoracoabdominal aortic repair is a more extensive operation than either an isolated infrarenal or thoracic aortic repair.

OAS is distinct from aortic valve repair and aortic valve replacement, as OAS describes surgery of the aorta, rather than of the heart valves. When the aortic valve is diseased in addition to the ascending aorta, the Bentall procedure is used to treat the entire aortic root. An axillary-bifemoral bypass is another type of vascular bypass used to treat aortic pathology, however it is not true open aortic surgery as it reconstructs the flow of blood to the legs from the arm, rather than in the native location of the aorta.

Medical uses

Open aortic surgery (OAS) is used to treat patients with aortic aneurysms greater than 5.5 cm in diameter, to treat aortic rupture of an aneurysm any size, to treat aortic dissections, and to treat acute aortic syndrome. It is used to treat infrarenal aneurysms, as well as juxta- and pararenal aneurysm, thoracic and thoracoabdominal aneurysms, and also non-aneurysmal aortic pathology. Disease of the aorta proximal to the left subclavian artery in the chest lies within the specialty of cardiac surgery, and is treated via procedures such as the valve-sparing aortic root replacement.

Prior to the advent of endovascular aneurysm repair (EVAR), OAS was the only surgical treatment available for aortic aneurysms. It is still preferred at some institutions and by some patients as it may be more durable than EVAR, [2] and does not require post-operative surveillance CT scans.

OAS is sometimes required for patients who have previously undergone EVAR but need further treatment, such as for degeneration of the EVAR seal zones leading to continued aneurysm growth. OAS is also sometimes required in cases of EVAR graft infection where the stent graft is removed to treat the infection. [3]

Open repair versus endovascular repair

The shift away from open aortic surgery towards endovascular surgery since 2003 has been driven by worse perioperative mortality associated with OAS, particularly in patients in relatively frail health. [4] Unlike endovascular repair, there are no strict anatomic contra-indications to open repair; Rather, open repair is viewed as the fall back option for patients with unfavorable anatomy for endovascular repair. [5] The main drawback of open repair is the larger physiologic demand of the operation, which is associated with increased rates of short term mortality in most studies. [6]

Patients younger than 50 years with descending and thoracoabdominal aortic aneurysm have low surgical risks, and open repairs can be performed with excellent short-term and durable long-term results. Open surgical repairs should be considered initially in younger patients requiring descending and thoracoabdominal aortic aneurysm repairs. Heritable thoracic aortic disease (HTAD) warrants closer postoperative surveillance. [7]

Technique

Simulated open aortic surgery for an infrarenal aortic aneurysm. The clamp seen is above the aneurysm and below the renal arteries Open infrarenal aortic repair model.jpg
Simulated open aortic surgery for an infrarenal aortic aneurysm. The clamp seen is above the aneurysm and below the renal arteries
Simulated clamp placement for open repair of an infrarenal aortic aneurysm InfraClampsProxDistalSim.jpg
Simulated clamp placement for open repair of an infrarenal aortic aneurysm
Simulated proximal suture line using "parachute" technique for an open infrarenal aortic aneurysm repair InfraProxSewingSim.jpg
Simulated proximal suture line using "parachute" technique for an open infrarenal aortic aneurysm repair
Completed proximal suture line of a simulated infrarenal open aortic repair with a dacron bifurcated graft Infrarenal graft in place.jpg
Completed proximal suture line of a simulated infrarenal open aortic repair with a dacron bifurcated graft

Open surgery typically involves exposure of the dilated portion of the aorta and insertion of a synthetic (Dacron or Gore-Tex) graft (tube). Once the graft is sewn into the proximal (toward the patient's head) and distal (toward the patient's foot) portions of the aorta, the aneurysmal sac is closed around the graft. Alternatively, the anastomosis can be carried out with expandable devices, a simpler and quicker procedure [8] [9]

The aorta and its branching arteries are cross-clamped during open surgery. This can lead to inadequate blood supply to the spinal cord, resulting in paraplegia, when repairing thoracic aneurysms. A 2004 systematic review and meta analysis found that cerebrospinal fluid drainage (CFSD), when performed in experienced centers, reduces the risk of ischemic spinal cord injury by increasing the perfusion pressure to the spinal cord. [10] A 2012 Cochrane systematic review noted that further research regarding the effectiveness of CFSD for preventing a spinal cord injury is required. [11]

Approach

The infrarenal aorta can be approached via a transabdominal midline or paramedian incision, or via a retroperitoneal approach.

The paravisceral and thoracic aorta are approached via a left-sided posteriolateral thoracotomy incision in approximately the 9th intercostal space. [12] For a thoracoabdominal aortic aneurysm, this approach can be extended to a median or paramedian abdominal incision to allow access to the iliac arteries.

Sequential aortic clamping

At medical centers with a high volume of open aortic surgery, the fastest option for open aortic surgery was sequential aortic clamping or "clamp-and-sew", whereby the aorta was clamped proximally and distally to the diseased segment, and a graft sewn into the intervening segment. [13] This technique leaves the branches of the aorta un-perfused during the time it takes to sew in the graft, potentially increasing the risk of ischemia to the organs which derive their arterial supply from the clamped segment. Critics of this technique advocate intra-operative aortic perfusion. [14] In infrarenal aneurysms, the relative tolerance of the lower extremities to ischemia allows surgeons to clamp distally with low risk of ill effect.

Techniques to limit ischemia

A number of techniques exist for maintaining perfusion to the viscera and spinal cord during open thoracoabdominal aortic aneurysm repair, including left heart bypass, balloon perfusion catheter placement in the visceral arteries, selective spinal drainage and cold crystalloid renal perfusion. [15] There is limited evidence supporting these techniques. [16]

Graft configuration

The abdominal aorta is anastomosed preferentially to the main limb of a tube or bifurcated graft in an end-to-end fashion to minimize turbulent flow at the proximal anastomosis. If normal aorta exists superior to the iliac bifurcation, a tube graft can be sewn distally to that normal aorta. If the distal aorta is diseased, a bifurcated graft can be used in an aorto-billiac or aorto-bifemoral configuration. If visceral vessels are involved in the diseased aortic segment, a branched graft can be used with branches sewn directly to visceral vessels, or the visceral vessels can be separately revascularized.[ citation needed ]

Reimplantation of the inferior mesenteric artery

Because of collateral blood flow from the superior mesenteric artery (SMA) via the marginal artery, the inferior mesenteric artery usually does not have to be reimplanted into the aortic graft when performing an open abdominal aortic aneurysm repair.

Risks and complications

OAS is widely recognized as having higher rates of perioperative morbidity and mortality than endovascular procedures for comparable segments of the aorta. For example, in infrarenal aneurysms, perioperative mortality with endovascular surgery is approximately 0.5%, against 3% with open repair. [17]

Besides the risk of death, other risks and complications with OAS depend on the segment of aorta involved, and may include renal failure, spinal cord ischemia leading to paralysis, buttock claudication, ischemic colitis, embolization leading to acute limb ischemia, infection, and bleeding. [18] Development of spinal cord injury is associated with increased perioperative mortality after the complex aortic repair. [19]

Aortic graft infections occur in 1-5% of aortic prosthetic placements. It can result in limb amputation, pseudo-aneurysm formation, septic emboli, aorto-enteric fistulae, septic shock and death. The most frequently involved pathogens are Staphylococcus aureus, and coagulase-negative staphylococci, followed by Enterobacterales and uncommon bacteria. In case of gut involvement also fungi may play a role. For patients unable to undergo major surgery, the outcome of conservative approach remains uncertain but usually provides for life-long suppressive antibiotic therapy. In selected cases an attempt of stopping antibiotic treatment after 3-6 months can be done. [20]

Recovery after OAS

Recovery time after OAS is substantial. Immediately following surgery, patients can expect to spend 1–3 days in the intensive care unit, followed by 4–10 days on the hospital ward. After discharge, patients will take 3–6 months to fully recover their energy and return to their pre-operative daily activities.[ citation needed ] However, enhanced recovery after surgery (ERAS) protocols can improve recovery following surgery. [21]

TAAA repair requires a very large incision that cuts through muscles and bones making recovery very difficult and painful for the patient. Intraoperative intercostal nerve cryoanalgesia has been used during procedure to help reduce pain after TAAA. [22]

History

The aortic surgery dates back to Greek surgeon Antyllus, who first performed surgeries for various aneurysms in the second century CE. Many advancements of OAS have been developed in the past century.

In 1955, cardiovascular surgeons, Drs. Michael DeBakey and Denton Cooley performed the first replacement of a thoracic aneurysm with a homograft. In 1958, they began using the Dacron graft, resulting in a revolution for surgeons in the surgical repair of aortic aneurysms. [23] DeBakey was first to perform cardiopulmonary bypass to repair the ascending aorta, using antegrade perfusion of the brachiocephalic artery.

By the mid-1960s, at Baylor College of Medicine, DeBakey’s group began performing surgery on thoracoabdominal aortic aneurysms (TAAA), which presented formidable surgical challenges, often fraught with serious complications, such as paraplegia, paraparesis and renal failure. DeBakey protégé and vascular Surgeon, E. Stanley Crawford, in particular, began dedicating most of his time to TAAAs. In 1986, he classified TAAA open surgery cases into four types: [24] Extent I, extending from the left subclavian artery to just below the renal artery; Extent II, from the left subclavian to below the renal artery; Extent III, from the sixth intercostal space to below the renal artery; and Extent IV, from the twelfth intercostal space to the iliac bifurcation (i.e. total abdominal).

In 1992, another classification, Extent V, characterized by Hazim J. Safi, MD, identified aneurysmal disease extending from the sixth intercostal space to above the renal arteries. Safi's group used experimental animal models for a prospective study on the use distal aortic perfusion, cerebrospinal fluid drainage, moderate hypothermia and sequential clamping to decrease in the incidence of neurological deficit. In 1994, they presented their experiences, showing that the incidence for Extent I and II dropped from 25% to 5%. [25] This marked a new era for protecting the spinal cord, brain, kidneys, heart and lungs during OAS on TAAA.

Progress and future challenges

Postoperative paraplegia and paraparesis have been the scourge of thoracoabdominal aortic repair since the inception of the procedure. [26] However, with evolving surgical strategies, identification of predictors, and use of various adjuncts over the years, the incidence of spinal cord injury after thoracic/thoracoabdominal aortic repair has declined. Embracing a multimodality approach offers a good insight into combating this grave complication [27]

See also

Related Research Articles

<span class="mw-page-title-main">Aortic dissection</span> Injury to the innermost layer of the aorta

Aortic dissection (AD) occurs when an injury to the innermost layer of the aorta allows blood to flow between the layers of the aortic wall, forcing the layers apart. In most cases, this is associated with a sudden onset of agonizing chest or back pain, often described as "tearing" in character. Vomiting, sweating, and lightheadedness may also occur. Damage to other organs may result from the decreased blood supply, such as stroke, lower extremity ischemia, or mesenteric ischemia. Aortic dissection can quickly lead to death from insufficient blood flow to the heart or complete rupture of the aorta.

<span class="mw-page-title-main">Aneurysm</span> Bulge in the wall of a blood vessel

An aneurysm is an outward bulging, likened to a bubble or balloon, caused by a localized, abnormal, weak spot on a blood vessel wall. Aneurysms may be a result of a hereditary condition or an acquired disease. Aneurysms can also be a nidus for clot formation (thrombosis) and embolization. As an aneurysm increases in size, the risk of rupture, which leads to uncontrolled bleeding, increases. Although they may occur in any blood vessel, particularly lethal examples include aneurysms of the circle of Willis in the brain, aortic aneurysms affecting the thoracic aorta, and abdominal aortic aneurysms. Aneurysms can arise in the heart itself following a heart attack, including both ventricular and atrial septal aneurysms. There are congenital atrial septal aneurysms, a rare heart defect.

<span class="mw-page-title-main">Interventional radiology</span> Medical subspecialty

Interventional radiology (IR) is a medical specialty that performs various minimally-invasive procedures using medical imaging guidance, such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound. IR performs both diagnostic and therapeutic procedures through very small incisions or body orifices. Diagnostic IR procedures are those intended to help make a diagnosis or guide further medical treatment, and include image-guided biopsy of a tumor or injection of an imaging contrast agent into a hollow structure, such as a blood vessel or a duct. By contrast, therapeutic IR procedures provide direct treatment—they include catheter-based medicine delivery, medical device placement, and angioplasty of narrowed structures.

<span class="mw-page-title-main">Vascular surgery</span> Medical specialty of the blood/lymph vessels

Vascular surgery is a surgical subspecialty in which vascular diseases involving the arteries, veins, or lymphatic vessels, are managed by medical therapy, minimally-invasive catheter procedures and surgical reconstruction. The specialty evolved from general and cardiovascular surgery where it refined the management of just the vessels, no longer treating the heart or other organs. Modern vascular surgery includes open surgery techniques, endovascular techniques and medical management of vascular diseases - unlike the parent specialities. The vascular surgeon is trained in the diagnosis and management of diseases affecting all parts of the vascular system excluding the coronaries and intracranial vasculature. Vascular surgeons also are called to assist other physicians to carry out surgery near vessels, or to salvage vascular injuries that include hemorrhage control, dissection, occlusion or simply for safe exposure of vascular structures.

<span class="mw-page-title-main">Aortic aneurysm</span> Excessive enlargement of the human aorta

An aortic aneurysm is an enlargement (dilatation) of the aorta to greater than 1.5 times normal size. Typically, there are no symptoms except when the aneurysm dissects or ruptures, which causes sudden, severe pain in the abdomen and lower back.

<span class="mw-page-title-main">Abdominal aortic aneurysm</span> Localized enlargement of the abdominal aorta

Abdominal aortic aneurysm (AAA) is a localized enlargement of the abdominal aorta such that the diameter is greater than 3 cm or more than 50% larger than normal. An AAA usually causes no symptoms, except during rupture. Occasionally, abdominal, back, or leg pain may occur. Large aneurysms can sometimes be felt by pushing on the abdomen. Rupture may result in pain in the abdomen or back, low blood pressure, or loss of consciousness, and often results in death.

<span class="mw-page-title-main">Thoracic aortic aneurysm</span> Medical condition

A thoracic aortic aneurysm is an aortic aneurysm that presents primarily in the thorax.

<span class="mw-page-title-main">Artery of Adamkiewicz</span> Largest anterior segmental medullary artery

In human anatomy, the artery of Adamkiewicz is the largest anterior segmental medullary artery and the dominant segmental feeding vessel to the thoracic cord, supplying the anterior aspect of the cord via the anterior spinal artery. It is a radiculomedullary artery arising from the spinal dorsal branch of the segmental artery, which in turn arises from the descending aorta. It typically arises from a 9th to 12th left posterior intercostal artery, enters through the L2-L3 intervertebral foramen to join the anterior spinal artery and supply much of the inferior half of the spinal cord. The artery is named after pathologist Albert Wojciech Adamkiewicz.

<span class="mw-page-title-main">Aortoiliac occlusive disease</span> Medical condition

In medicine, aortoiliac occlusive disease is a form of central artery disease involving the blockage of the abdominal aorta as it transitions into the common iliac arteries.

<span class="mw-page-title-main">Traumatic aortic rupture</span> Medical condition

Traumatic aortic rupture, also called traumatic aortic disruption or transection, is a condition in which the aorta, the largest artery in the body, is torn or ruptured as a result of trauma to the body. The condition is frequently fatal due to the profuse bleeding that results from the rupture. Since the aorta branches directly from the heart to supply blood to the rest of the body, the pressure within it is very great, and blood may be pumped out of a tear in the blood vessel very rapidly. This can quickly result in shock and death. Thus traumatic aortic rupture is a common killer in automotive accidents and other traumas, with up to 18% of deaths that occur in automobile collisions being related to the injury. In fact, aortic disruption due to blunt chest trauma is the second leading cause of injury death behind traumatic brain injury.

<span class="mw-page-title-main">Endovascular aneurysm repair</span> Surgery used to treat abdominal aortic aneurysm

Endovascular aneurysm repair (EVAR) is a type of minimally-invasive endovascular surgery used to treat pathology of the aorta, most commonly an abdominal aortic aneurysm (AAA). When used to treat thoracic aortic disease, the procedure is then specifically termed TEVAR for "thoracic endovascular aortic/aneurysm repair." EVAR involves the placement of an expandable stent graft within the aorta to treat aortic disease without operating directly on the aorta. In 2003, EVAR surpassed open aortic surgery as the most common technique for repair of AAA, and in 2010, EVAR accounted for 78% of all intact AAA repair in the United States.

<span class="mw-page-title-main">Randall B. Griepp</span> American cardiothoracic surgeon (1940–2022)

Randall Bertram Griepp was an American cardiothoracic surgeon who collaborated with Norman Shumway in the development of the first successful heart transplant procedures in the U.S. He had an international reputation for contributions to the surgical treatment of aortic aneurysms and aortic dissection and in heart and lung transplantations. He received nearly $8 million in grants from the National Heart, Lung, and Blood Institute.

<span class="mw-page-title-main">Thoracic aorta injury</span> Medical condition

Injury of the thoracic aorta refers to any injury which affects the portion of the aorta which lies within the chest cavity. Injuries of the thoracic aorta are usually the result of physical trauma; however, they can also be the result of a pathological process. The main causes of this injury are deceleration and crush injuries. There are different grades to injuries to the aorta depending on the extent of injury, and the treatment whether surgical or medical depends on that grade. It is difficult to determine if a patient has a thoracic injury just by their symptoms, but through imaging and a physical exam the extent of injury can be determined. All patients with a thoracic aortic injury need to be treated either surgically with endovascular repair or open surgical repair or with medicine to keep their blood pressure and heart rate in the appropriate range. However, most patients that have a thoracic aortic injury do not live for 24 hours.

<span class="mw-page-title-main">Hybrid cardiac surgery</span>

A hybrid cardiac surgical procedure in a narrow sense is defined as a procedure that combines a conventional, more invasive surgical part with an interventional part, using some sort of catheter-based procedure guided by fluoroscopy imaging in a hybrid operating room (OR) without interruption. The hybrid technique has a reduced risk of surgical complications and has shown decreased recovery time. It can be used to treat numerous heart diseases and conditions and with the increasing complexity of each case, the hybrid surgical technique is becoming more common.

Endovascular and hybrid trauma and bleeding management is a new and rapidly evolving concept within medical healthcare and endovascular resuscitation. It involves early multidisciplinary evaluation and management of hemodynamically unstable patients with traumatic injuries as well as being a bridge to definitive treatment. It has recently been shown that the EVTM concept may also be applied to non-traumatic hemodynamically unstable patients.

<span class="mw-page-title-main">Resuscitative endovascular balloon occlusion of the aorta</span> Temporary procedure for trauma patients

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally-invasive procedure performed during resuscitation of critically-injured trauma patients. Originally developed as a less invasive alternative to emergency thoracotomy with aortic cross clamping, REBOA is performed to gain rapid control of non-compressible truncal or junctional hemorrhage. REBOA is performed first by achieving access to the common femoral artery (CFA) and advancing a catheter within the aorta. Upon successful catheter placement, an occluding balloon may be inflated either within the descending thoracic aorta or infrarenal abdominal aorta. REBOA stanches downstream hemorrhage and improves cardiac index, cerebral perfusion, and coronary perfusion. Although REBOA does not eliminate the need for definitive hemorrhage control, it may serve as a temporizing measure during initial resuscitation. Despite the benefits of REBOA, there are significant local and systemic ischemic risks. Establishing standardized REBOA procedural indications and mitigating the risk of ischemic injury are topics of ongoing investigation. Although this technique has been successfully deployed in adult patients, it has not yet been studied in children.

<span class="mw-page-title-main">Nicolai L. Volodos</span> Ukrainian surgeon (1934–2016)

Nicolai Leontievich Volodos, was a Soviet/Ukrainian cardiovascular surgeon and scientist. An innovator, Volodos developed and introduced into clinical practice the world's first endovascular stent graft for the treatment of stenotic and aneurysmal diseases of arterial system. Volodos was described by his colleagues as "a pioneer innovator and a giant in vascular and endovascular surgery" and "a giant of historic proportions in the vascular and endovascular specialties, and the father of endovascular grafting".

<span class="mw-page-title-main">Hazim J. Safi</span> Physician

Hazim J. Safi, MD, FACS, is a physician and surgeon who is well known for his research in the surgical treatment of aortic disease. Safi and his colleagues at Baylor College of Medicine were the first to identify variables associated with early death and postoperative complications in patients undergoing thoracoabdominal aortic operations. Safi now serves as professor of cardiothoracic surgery, and founding chair at McGovern Medical School at The University of Texas Health Science Center in Houston, TX.

Gustavo S. Oderich is a Brazilian American vascular and endovascular surgeon who serves as a professor and chief of vascular and endovascular surgery, and is the director of the Advanced Endovascular Aortic Program at McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Health System. He previously served as chair of vascular and endovascular division at the Mayo Clinic in Rochester, Minnesota. Oderich is recognized for his work in minimally invasive endovascular surgery and research in fenestrated and branched stent-graft technology to treat complex aortic aneurysms and dissections.

Spinal cord stroke is a rare type of stroke with compromised blood flow to any region of spinal cord owing to occlusion or bleeding, leading to irreversible neuronal death. It can be classified into two types, ischaemia and haemorrhage, in which the former accounts for 86% of all cases, a pattern similar to cerebral stroke. The disease is either arisen spontaneously from aortic illnesses or postoperatively. It deprives patients of motor function or sensory function, and sometimes both. Infarction usually occurs in regions perfused by anterior spinal artery, which spans the anterior two-thirds of spinal cord. Preventions of the disease include decreasing the risk factors and maintaining enough spinal cord perfusion pressure during and after the operation. The process of diagnosing the ischemic and hemorrhagic spinal cord stroke includes applying different MRI protocols and CT scan. Treatments for spinal cord stroke are mainly determined by the symptoms and the causes of the disease. For example, antiplatelet and corticosteroids might be used to reduce the risk of blood clots in ischaemic spinal stroke patients, while rapid surgical decompression is applied to minimize neurological injuries in haemorrhagic spinal stroke patients instead. Patients may spend years for rehabilitation after the spinal cord stroke.

References

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  2. ↑ Conrad MF, Crawford RS, Pedraza JD, et al. (October 2007). "Long-term durability of open abdominal aortic aneurysm repair". J. Vasc. Surg. 46 (4): 669–75. doi: 10.1016/j.jvs.2007.05.046 . PMID   17903647.
  3. ↑ Chaufour, Xavier; Gaudric, Julien; Goueffic, Yann; Khodja, Réda Hassen; Feugier, Patrick; Malikov, Sergei; Beraud, Guillaume; Ricco, Jean-Baptiste (February 2017). "A multicenter experience with infected abdominal aortic endograft explantation". Journal of Vascular Surgery. 65 (2). For the AURC (French University Surgeons Association) collaborators: 372–380. doi: 10.1016/j.jvs.2016.07.126 . PMID   27720319.
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  10. ↑ Cinà, C.; Abouzahr, L.; Arena, G.; Laganà, A.; Devereaux, P.; Farrokhyar, F. (2004). "Cerebrospinal fluid drainage to prevent paraplegia during thoracic and thoracoabdominal aortic aneurysm surgery: a systematic review and meta-analysis". Journal of Vascular Surgery. 40 (1): 36–44. doi: 10.1016/j.jvs.2004.03.017 . PMID   15218460.
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  12. ↑ Coselli, Joseph (2008). "Tips for successful outcomes for descending thoracic and thoracoabdominal aortic aneurysm procedures". Semin Vasc Surg. 21 (1): 13–20. doi:10.1053/j.semvascsurg.2007.11.009. PMID   18342730.
  13. ↑ Estrera AL, Miller CC, Chen EP, et al. (October 2005). "Descending thoracic aortic aneurysm repair: 12-year experience using distal aortic perfusion and cerebrospinal fluid drainage". Ann. Thorac. Surg. 80 (4): 1290–6, discussion 1296. doi:10.1016/j.athoracsur.2005.02.021. PMID   16181856.
  14. ↑ Estrera AL, Miller CC, Chen EP, et al. (October 2005). "Descending thoracic aortic aneurysm repair: 12-year experience using distal aortic perfusion and cerebrospinal fluid drainage". Ann. Thorac. Surg. 80 (4): 1290–6, discussion 1296. doi:10.1016/j.athoracsur.2005.02.021. PMID   16181856.
  15. ↑ Coselli, Joseph (2008). "Tips for successful outcomes for descending thoracic and thoracoabdominal aortic aneurysm procedures". Semin Vasc Surg. 21 (1): 13–20. doi:10.1053/j.semvascsurg.2007.11.009. PMID   18342730.
  16. ↑ Hsu, CC; Kwan, GN; van Driel, ML; Rophael, JA (14 March 2012). "Distal aortic perfusion during thoracoabdominal aneurysm repair for prevention of paraplegia" (PDF). The Cochrane Database of Systematic Reviews. 3 (3): CD008197. doi:10.1002/14651858.CD008197.pub2. PMID   22419329.
  17. ↑ Schermerhorn, Marc (2008). "Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population". N Engl J Med. 358 (5): 464–74. doi: 10.1056/NEJMoa0707348 . PMID   18234751. S2CID   205089378.
  18. ↑ Crawford, E. S.; Crawford, J. L.; Safi, H. J.; Coselli, J. S.; Hess, K. R.; Brooks, B.; Norton, H. J.; Glaeser, D. H. (March 1986). "Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients". Journal of Vascular Surgery. 3 (3): 389–404. doi: 10.1016/0741-5214(86)90101-1 . ISSN   0741-5214. PMID   3951025.
  19. ↑ Sef, D; Thet, MS; Miskolczi, S; Velissaris, T; De Silva, R; Luthra, S; Turina, MI (1 June 2023). "Perioperative neuromonitoring during thoracoabdominal aortic aneurysm open repair: a systematic review". European Journal of Cardio-Thoracic Surgery. 63 (6). doi:10.1093/ejcts/ezad221. PMID   37233116.
  20. ↑ Antonello, Roberta Maria; D'Oria, Mario; Cavallaro, Marco; Dore, Franca; Cova, Maria Assunta; Ricciardi, Maria Chiara; Comar, Manola; Campisciano, Giuseppina; Lepidi, Sandro; De Martino, Randall R.; Chiarandini, Stefano; Luzzati, Roberto; Di Bella, Stefano (2019). "Management of abdominal aortic prosthetic graft and endograft infections. A multidisciplinary update". Journal of Infection and Chemotherapy. 25 (9): 669–680. doi:10.1016/j.jiac.2019.05.013.
  21. ↑ Melnyk, M; Casey, RG; Black, P; Koupparis, AJ (October 2011). "Enhanced recovery after surgery (ERAS) protocols: Time to change practice?". Canadian Urological Association. 5 (5): 342–8. doi:10.5489/cuaj.11002. PMC   3202008 . PMID   22031616.
  22. ↑ Tanaka, Akiko; Al-Rstum, Zain; Leonard, Samuel D.; Gardiner, Bri’Ana D.; Yazij, Ibrahim; Sandhu, Harleen K.; Miller, Charles C.; Safi, Hazim J.; Estrera, Anthony L. (January 2020). "Intraoperative Intercostal Nerve Cryoanalgesia Improves Pain Control After Descending and Thoracoabdominal Aortic Aneurysm Repairs". The Annals of Thoracic Surgery. 109 (1): 249–254. doi: 10.1016/j.athoracsur.2019.07.083 . PMID   31521592.
  23. ↑ De Bakey, M. E.; Cooley, D. A. (1953-06-20). "Successful resection of aneurysm of thoracic aorta and replacement by graft". Journal of the American Medical Association. 152 (8): 673–676. doi:10.1001/jama.1953.03690080017005. ISSN   0002-9955. PMID   13044606.
  24. ↑ Crawford, E. S. (May 1974). "Thoraco-abdominal and abdominal aortic aneurysms involving renal, superior mesenteric, celiac arteries". Annals of Surgery. 179 (5): 763–772. doi:10.1097/00000658-197405000-00032. ISSN   0003-4932. PMC   1356071 . PMID   4274686.
  25. ↑ Safi, H. J.; Miller, C. C. (June 1999). "Spinal cord protection in descending thoracic and thoracoabdominal aortic repair". The Annals of Thoracic Surgery. 67 (6): 1937–1939, discussion 1953–1958. doi: 10.1016/s0003-4975(99)00397-5 . ISSN   0003-4975. PMID   10391343.
  26. ↑ Safi, Hazim J.; Estrera, Anthony L.; Azizzadeh, Ali; Coogan, Sheila; Miller, Charles C. (March 2008). "Progress and future challenges in thoracoabdominal aortic aneurysm management". World Journal of Surgery. 32 (3): 355–360. doi:10.1007/s00268-007-9256-3. ISSN   0364-2313. PMID   17952499. S2CID   206947384.
  27. ↑ Panthee, Nirmal; Ono, Minoru (February 2015). "Spinal cord injury following thoracic and thoracoabdominal aortic repairs". Asian Cardiovascular & Thoracic Annals. 23 (2): 235–246. doi:10.1177/0218492314548901. ISSN   1816-5370. PMID   25178467. S2CID   33287424.
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