Thoraco-abdominal aortic aneurysmectomy
When is this procedure indicated?
More extensive aneurysms (type I-II-III according to Crawford's classification) require a large replacement of the aorta in both the descending thoracic and abdominal tracts. The main purpose of the procedure is to eliminate the risk of aneurysm rupture and/or the risks associated with thoracoabdominal aortic dissections (cerebral, visceral, medullary, lower limb malperfusion). This procedure can also be used in cases of surgical conversion after previous endovascular procedures, when the latter are complicated by endoleak (reperfusion of the aneurysm sac) or endoprosthesis infection.
How is it performed?
The intervention consists in the replacement of the aorta tract affected by pathology with a prosthesis made of biocompatible material. The surgical technique makes use of some anesthesiological devices to protect the organs vascularized by the aorta (left heart bypass, measurement of sensory and motor potentials, perfusion of visceral arteries, CSF drainage). The intervention involves the following steps:
incision of the chest wall (between the ribs) and abdominal (median) wall;
release of the aneurysmal/dissected aorta from adhesions with surrounding tissues. This phase can be very delicate due to the delicate relationships of the aorta at the thoracic and abdominal level (lungs, nerves, intestines, pancreas, etc.);
closure (clamping) of the aorta proximal and distal to the diseased tract and initiation of left heart bypass and other monitoring, perfusion and drainage strategies;
replacement of the diseased aorta with dedicated prostheses;
completion of the suture between prosthesis and aorta and reconstruction of all vessels arising from the latter (visceral arteries and, if indicated, intercostal arteries).
After discharge, a patient still needs a recovery period at rehabilitation of 2-4 weeks before fully resuming activities During this period, it is normal to feel rather weak and have no appetite. In this period, it is important to resume physical activity gradually, first with the help of physiotherapy and then trying, in progressive autonomy, to take short walks, with the aim of doing every day something more than the previous day.
Complications following such a major surgery are still frequent; they can be less impactful in the long term, such as surgical wound infections, or urinary and respiratory infections, but they can also be very serious, causing stroke, spinal cord ischemia with transient/permanent paraplegia, ischemia of abdominal organs (intestinal, renal), bleeding, re-injury, respiratory or cardiovascular failure. Mortality for this type of intervention, despite technical progress, is still around 10%.
These are the data related to the complications observed in our Aortic Center (referring to about 1200 patients treated with this technique until 2020).
Long-term complications include:
- chronic renal failure;
- surgical wound infection causing dehiscence, requiring advanced dressings for its healing by second intention;
- sudden or progressive occlusion that may cause viscera or lower extremity ischemia;
- prosthesis infection;