Moderate hypothermic circulatory arrest with antegrade cerebral perfusion for the open repair of juxtarenal abdominal aortic aneurysm repair with shaggy aorta

Abstract

Shaggy aorta is severe luminal surface degeneration of the aorta leading to an increased risk of plaque destabilization and embolization to the peripheral or visceral vessel beds. It represents a challenging clinical entity for both endovascular and open repair owing to potential atheroembolization, increased early morbidity and mortality, and poor long-term survival. Patients may be denied repair owing to its high risks. Herein, we present a novel approach to open repair of a juxtarenal abdominal aortic aneurysm with shaggy aorta using moderate hypothermic circulatory arrest with antegrade cerebral perfusion and concurrent flow modification to mitigate the risk of atheroma embolism.

Fig 1

Preoperative computed tomography reconstructions of descending and abdominal aorta with extensive shaggy morphology and abdominal aneurysm in (A) sagittal view, (B) axial view of descending thoracic aorta, and (C) axial view of infrarenal aorta with severe stenosis of left renal artery.

Fig 2

(A) Complete operative exposure with bypass circuit (RCFV access and RAA), suprasternal, and midline transperitoneal incisions. (B) Abdominal aortic exposure through transperitoneal approach (white arrow notates cephalad direction). (C) Close up of suprasternal incision used to obtain control of the great vessels to prevent backbleeding. (D) Completion of aortic repair with left renal bypass (white arrow notates cephalad direction). RAA, Right axillary artery; RCFV, right common femoral vein; RRA, right renal artery; LRV, left renal vein; SMA, superior mesenteric artery.

Fig 3

Comparison of preoperative (left) and 6 months postoperative (right) computed tomography angiography (CTA) (axial views) showing atheroma-free paravisceral abdominal aorta with patent renal bypass graft.