Visceral Segment Aortic Endarterectomy with Aorto-Aortic Bypass Using a Cardiopulmonary Bypass Circuit
Daniel H. Newton, MD, Samuel H. Chen, MD, Nathan Belkin, MD, Nimesh D. Desai, Paul J. Foley, MD.
University of Pennsylvania, Philadelphia, PA, USA
DEMOGRAPHICS: The patient is a 60-year-old man who presented with postprandial abdominal pain, fatigue, leg claudication, and 30 pound weight loss over the previous six weeks.
HISTORY: The patient underwent a CT angiogram of the abdomen and pelvis which showed a large atheroma in the visceral segment of the aorta extending into and occluding the SMA and celiac arteries, while the renal arteries were relatively spared. Given the burden of the aortic occlusive disease, he was not thought to be a candidate for endovascular repair, and his lower extremity symptoms made visceral bypass a suboptimal option.
PLAN: The patient was offered endarterectomy of his visceral aorta. Because the atheroma appeared to extend well into the SMA and celiac, and the calcified appearance of the aortic wall on imaging left doubts as to the aortic wall integrity after endarterectomy, the case was planned with aortic bypass using a cardiopulmonary bypass circuit in case complex reconstruction was required.
DISCUSSION: A standard retroperitoneal exposure of the visceral aorta was performed. The diaphragm was not fully taken down, but partially opened to facilitate chest wall mobilization. The distal thoracic aorta, abdominal aorta and all of the visceral branches were exposed to healthy segments and controlled. The distal thoracic and distal abdominal aorta were cannulated for bypass. The visceral segment of the aorta was opened in a trap-door fashion, exposing a friable, gravel-like atheroma that was removed piecemeal. Visceral perfusion catheters were placed in the left renal and celiac arteries while meticulous endarterectomy of the aorta and SMA was performed. Celiac perfusion enabled vigorous back-bleeding of the SMA which assisted in clearing plaque particles. The aorta and its branches were then flushed thoroughly and the aorta closed with a dacron patch. The use of the bypass circuit enables meticulous endarterectomy, continuous visceral perfusion, and reduced blood loss via the use of pump-suckers. Cannulation of the distal thoracic aorta minimizes the risk of CPB-related stroke. For this challenging case, we found it to be a very useful adjunct.
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