Emergency thoracoabdominal aortic repair: distal-first approach with two previous aortic repairs

Thoracoabdominal aortic aneurysm repair after prior endovascular intervention is among the most technically demanding procedures in aortic surgery. We present an emergency thoracoabdominal aortic aneurysm repair in a 59-year-old man with a history of preoperative haemodialysis, previous frozen elephant trunk for acute type A aortic dissection, followed by thoracic endovascular stent graft, complicated by partial spinal cord ischaemia and a type Ib endoleak. He presented with chest pain, and imaging demonstrated a 74 mm descending thoracic aortic aneurysm with impending rupture features. Multidisciplinary consensus deemed further endovascular intervention unsuitable, necessitating emergency open repair. A distal-first approach was used to overcome the distal perfusion challenges imposed by chronic aortic dissection. Following infrarenal clamping and the distal anastomosis to a branched graft, left heart bypass was established through its sidearm. Sequential visceral perfusion was performed, followed by anastomosis of the right renal and coeliac arteries to the graft branches. The proximal anastomosis incorporated both frozen elephant trunk and thoracic endovascular aortic repair, reinforced with double Teflon strips. The intercostal arteries were reimplanted. After declamping and de-airing, the superior mesenteric and left renal arteries were anastomosed. Motor-evoked potentials and cerebral monitoring were preserved. The patient recovered well and was discharged home 5 weeks postoperatively with a patent repair on imaging.