Figure 1. Anatomical aspects and surgical approach to extent II
thoracoabdominal repair.
A. The chest is entered through the sixth intercostal space. Left medial
visceral rotation and circumferential division of the diaphragm enable
exposure of the entire thoracoabdominal aorta. B. Left heart bypass
(LHB) is commonly used to offload the heart from stressors of aortic
surgery; LHB is initiated by placing a cannula in the left atrium via a
left inferior pulmonary venotomy and then connecting it to the drainage
line of the LHB circuit. After initiation, the proximal aortic clamp is
placed. The distal aortic clamp is placed across the mid-descending
thoracic aorta. The aortic segment between the two clamps is opened
longitudinally using electrocautery. A stand-alone circuit to provide
cold renal perfusion is prepared for later use. C. Following completion
of the proximal anastomosis, the aorta is opened longitudinally to the
aortic bifurcation. Crucial intercostal and lumbar arteries are
reattached. Cold renal perfusion and selective visceral perfusion are
provided to protect the visceral organs.