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.