Thoracoabdominal aortic aneurysms. A review and current status.

Surgical management of the thoracoabdominal aortic aneurysm is a formidable undertaking. Presently two fairly distinct operative methods are available. The conventional technique, pioneered by Etheredge, involves replacement of the aneurysm with a synthetic graft and then, step by step, revascularization of the abdominal organs with prosthetic side limbs taken from the primary graft. Individual organ ischemic time is limited to that time required for the performance of each distal side limb anastomosis. The second operative method, first described by Crawford, consists of proximal and distal control of the aneurysm, followed by its incision to simultaneously expose the origin of all four major intra-abdominal arteries. Replacement is then rapidly performed with a tubular Dacron graft including anastomosis of these major intra-abdominal arteries to four elliptical graft incisions, from within the aneurysm. Total operating time is reduced at the expense of prolonged organ ischemia. The conventional method allows for step-by-step intraoperative planning and action, and this technique is accordingly recommended to most surgeons, who have had little experience with this unusual lesion. Our recent successful experience with two cases of extensive thoracoabdominal aortic aneurysms is described as well as a discussion of additional measures which may become useful in certain cases to favor a successful outcome. Finally the problem of potential resultant paraplegia is discussed.