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The Journal of Cardiovascular Surgery 2021 Jan 26

DOI: 10.23736/S0021-9509.21.11776-8


lingua: Inglese

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

Susan Y. GREEN 1, Hazim J. SAFI 2, Joseph S. COSELLI 1, 3, 4

1 Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; 2 Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA; 3 Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA; 4 Department of Cardiovascular Surgery, CHI St Luke’s Health-Baylor St Luke’s Medical Center, Houston, TX, USA

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. Reports from DeBakey and Cooley, Rob, and Etheredge and colleagues are commonly described as the earliest repairs of the thoracoabdominal aorta and relied on the use of donor homografts. Repair of thoracoabdominal aortic aneurysms (TAAAs) necessitated exposing the thoracic aorta above the diaphragm as well as 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. Voohees explored Vinyon-N as an aortic substitute, and DeBakey subsequently developed Dacron as graft replacement. The success of Dacron ushered in DeBakey’s extra-anatomic approach to TAAA repair, which remained popular for 2 decades. Ultimately, Crawford presented an anatomic approach to this repair, which facilitated shorter repair times and improved outcomes for patients. Additionally, Crawford was able to reincorporate the intercostal and lumbar arteries feeding the spinal cord into his repair. In time, adjuncts such as left heart bypass, cerebrospinal fluid drainage, and cold renal perfusion were adopted during repair; the historical context of these adjuncts are explored in depth. The success of TAAA repair depends on the contributions of many individuals, arguably none more so than E. Stanley Crawford-and those he trained. To date, more than 6,000 TAAA repairs have been performed by Crawford and his trainees, representing Crawford’s substantial imprint on this complex repair. The history of TAAA repair continues to evolve and remains indebted to the pioneering heroes, without whom, successful repair would not be possible.

KEY WORDS: History; Thoracoabdominal; Aorta; Aneurysm; Dissection; Cerebrospinal fluid drainage; Renal perfusion; Left heart bypass

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