Thoracoabdominal Refenestration

• This type of surgery in a selected subgroup of patients is indicated if no major aneurysm is present at the tear site, but dangerous distal side branch morphology is present.

• Through left thoracophrenolaparotomy along the 7th or 8th intercostal space and pararectal line, the thora-coabdominal aorta can be dissected.

• The removal of the dissected intimal membrane leaves double lumen at the thoracic aorta, decreases tension of the false lumen, creates a common cavity at the visceral segment providing direct circulation to all organs and prevents further acute progress.

• Fixation of the periorificial dissected intima and removal of loosened flaps stop further dissection of side branches.

• Infrarenal intimal fixation is not necessary if refenes-tration at the bifurcation provides stable circulation for the limbs.

• If no re-entry is present the distal intima should be fixed by suture, glue, sandwich technique or by stent placement if the gap is small.

In the case of a large false lumen under tension, graft replacement in the subrenal position may be indicated.

This more proximal refenestration has achieved a further reduction of the mortality rate to 4.5% [14, 15] (Figs. 4.2.29-4.2.38).

Radish Discoloration Aortic Intima

Fig. 4.2.29 Thoracoabdominal exposure of the aorta. Note the bluish discoloration of the intramural haematoma caused by dissection

Fig. 4.2.30 Schematic view of the thoracoabdominal dissected aorta

Fig. 4.2.29 Thoracoabdominal exposure of the aorta. Note the bluish discoloration of the intramural haematoma caused by dissection

Fig. 4.2.30 Schematic view of the thoracoabdominal dissected aorta

Aortotomy Image

Fig. 4.2.31 Thoracoabdominal exposure of the aorta. Through longitudinal aortotomy the dissection is visible. Note the dissected right renal orifice

Surgical Exposure Sma

Fig. 4.2.32 Schematic view of the thoracoabdominal dissected aorta after aortotomy

Fig. 4.2.31 Thoracoabdominal exposure of the aorta. Through longitudinal aortotomy the dissection is visible. Note the dissected right renal orifice

Fig. 4.2.32 Schematic view of the thoracoabdominal dissected aorta after aortotomy

Carotid Endarterectomy Procedure Steps

Fig. 4.2.33 Thoracoabdominal exposure of the aorta. Through longitudinal aortotomy the dissection is visible. The coeliac trunk, SMA and right renal artery are controlled by balloons. The dissected membrane from the lower thoracic segment down to the subrenal aorta has been removed. The double lumen remains in the proximal aorta

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