A history of open thoracoabdominal aortic aneurysm repair: perspective from Houston

Abstract

As late as the early 1950s, ligation, cellophane wrapping, endoluminal wiring, endoaneurysmorrhaphy, and other techniques were well-accepted treatments for aneurysm. Techniques aimed at repair of syphilitic and saccular aneurysms of the proximal aorta were largely unsuitable for the larger, fusiform atherosclerotic aneurysms of the thoracoabdominal aorta. The earliest replacements of the thoracoabdominal aorta relied on the use of donor homografts. Repair of thoracoabdominal aortic aneurysms (TAAAs) necessitated exposing the thoracic aorta above the diaphragm and the abdominal aorta below the diaphragm. Furthermore, these repairs were complicated by incorporating the branching visceral arteries, as well as the risk of life-threatening distal ischemia during repair. Although many of the early centers for aortic surgery were able to quickly develop aortic banks to prepare and store homografts, in time, it became clear that homografts were not ideal for aortic replacement. The ideal aortic replacement would be nontoxic, hypoallergenic, durable, elastic, pliable, and readily available in multiple sizes and shapes. Although Vinyon-N and other materials were explored as synthetic aortic substitutes, ultimately Dacron (Dacron, Kennesaw, GA, USA) was determined to be the most suitable material for aortic graft replacement. The success of Dacron ushered in extra-anatomic approach to TAAA repair, which remained popular for 2 decades. In time, the graft inclusion technique (which followed an anatomical approach) was adopted, which facilitated shorter repair times and improved outcomes for patients. rotective adjuncts-such as left heart bypass, cerebrospinal fluid drainage, and cold renal perfusion-were incorporated into surgical repair; the historical context of these adjuncts is explored in depth. The success of TAAA repair depends on the contributions of many individuals. The history of TAAA repair continues to evolve and remains indebted to the pioneering heroes, without whom, successful repair would not be possible.