Extra-anatomic Visceral Revascularization and Endovascular Stent-Grafting for Complex Thoracoabdominal Aortic Lesions

Open surgical treatment of lesions of the thoracoabdominal aorta is a formidable procedure. It is associated with significant perioperative morbidity and mortality as well as a prolonged recuperative period. Because of the magnitude of the surgery required, many patients with thoracoabdominal aortic lesions are considered a prohibitive surgical risk and are denied elective surgical intervention. Risk factors for open surgery include prior thoracoabdominal aortic procedures, underlying pulmonary, renal, or cardiac dysfunction, and advanced age. In an effort to reduce the surgical risk, a combined technique has been developed consisting of retrograde extra-anatomic revascularization of visceral vessels followed by thoracoabdominal aortic endografting. Our experience and reports from other institutions suggest that early outcomes are acceptable, even in high-risk patients otherwise deemed unacceptable candidates for open thoracoabdominal surgery. The general principles for patient selection, the surgical and endovascular techniques involved, and representative cases will be presented.