Thoracoabdominal Aneurysms

  • Ashok Venkataraman
  • Jeffrey P. Schwartz


Thoracoabdominal aneurysm disease of the aorta (TAAA) is a complex process with significant associate morbidity. Increasing prevalence of TAAAs has been noted recently. The Crawford classification based on the anatomic extent of aneurysm is commonly used and indicates the subsequent type of intervention required. Development of TAAAs is multifactorial. Indications for repair have continued to evolve with improvements in open surgical techniques and the dawn of the endovascular era. Preoperative workup for these patients should be thorough and be focused on preventing the significant morbidity associated with the intervention for this disease process. The operative procedures for open repair will be discussed in detail along with important adjuncts to prevent complications. Spinal, cerebral, renal, and visceral protection strategies are important in the surgical management of these patients. Hybrid and endovascular approaches have evolved and play an increasing role in the surgical management of these patients. Overall, open TAAA repair outcomes have greatly improved over the years, and the surgical treatment of TAAAs will continue to evolve in the coming era of less invasive approaches.


Thoracoabdominal aneurysms Open repair Visceral protection Spinal protection Endovascular techniques 


  1. 1.
    Clouse WD, Hallett JW Jr, Schaff HV, Gayari MM, Ilstrup DM, Melton LJ 3rd. Improved prognosis of thoracic aortic aneurysms: a population-based study. JAMA. 1998;280(22):1926–9.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Etheredge SN, Yee J, Smith JV, Schonberger S, Goldman MJ. Successful resection of a large aneurysm of the upper abdominal aorta and replacement with homograft. Surgery. 1955;38(6):1071–81.PubMedPubMedCentralGoogle Scholar
  3. 3.
    DeBakey ME, Crawford ES, Garrett HE, Beall AC Jr, Howell JF. Surgical considerations in the treatment of aneurysms of the thoraco-abdominal aorta. Ann Surg. 1965;162(4):650–62.PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    Crawford ES. Thoraco-abdominal and abdominal aortic aneurysms involving renal, superior mesenteric, celiac arteries. Ann Surg. 1974;179(5):763–72.PubMedPubMedCentralCrossRefGoogle Scholar
  5. 5.
    Santilli JD, Santilli SM. Diagnosis and treatment of abdominal aortic aneurysms. Am Fam Physician. 1997;56(4):1081–90.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Bickerstaff LK, Pairolero PC, Hollier LH, Melton LJ, et al. Thoracic aortic aneurysms: a population-based study. Surgery. 1982;92(6):1103–8.PubMedPubMedCentralGoogle Scholar
  7. 7.
    Elefteriades JA. Natural history of thoracic aortic aneurysms: indications for surgery, and surgical versus nonsurgical risks. Ann Thorac Surg. 2002;74(5):S1877–80; discussion S1892–8.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Crawford ES, Crawford JL, Safi HJ, Coselli JS, et al. Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients. J Vasc Surg. 1986;3(3):389–404.PubMedPubMedCentralCrossRefGoogle Scholar
  9. 9.
    Safi HJ, Miller CC 3rd. Spinal cord protection in descending thoracic and thoracoabdominal aortic repair. Ann Thorac Surg. 1999;67(6):1937–9; discussion 1953–8.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    LaRoy LL, Cormier PJ, Matalon TA, Patel SK, Turner DA, Silver B. Imaging of abdominal aortic aneurysms. AJR Am J Roentgenol. 1989;152(4):785–92.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Olsson C, Thelin S, Ståhle E, Ekbom A, Granath F. Thoracic aortic aneurysm and dissection: increasing prevalence and improved outcomes reported in a nationwide population-based study of more than 14,000 cases from 1987 to 2002. Circulation. 2006;114(24):2611–8.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Ikonomidis JS, Barbour JR, Amani Z, Stroud RE, et al. Effects of deletion of the matrix metalloproteinase 9 gene on development of murine thoracic aortic aneurysms. Circulation. 2005;112(9 Suppl):I242–8.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Andreotti L, Bussotti A, Cammelli D, di Giovine F, et al. Aortic connective tissue in ageing–a biochemical study. Angiology. 1985;36(12):872–9.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Carlson RG, Lillehei CW, Edwards JE. Cystic medial necrosis of the ascending aorta in relation to age and hypertension. Am J Cardiol. 1970;25(4):411–5.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Ruddy JM, Jones JA, Ikonomidis JS. Pathophysiology of thoracic aortic aneurysm (TAA): is it not one uniform aorta? Rule of embryologic origin. Prog Cardiovasc Dis. 2013;56(1):68–73.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Frederick JR, Woo YJ. Thoracoabdominal aortic aneurysm. Ann Cardiothorac Surg. 2012;1(3):277–85.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Panneton JM, Hollier LH. Nondissecting thoracoabdominal aortic aneurysms: part I. Ann Vasc Surg. 1995;9(5):503–14.PubMedPubMedCentralCrossRefGoogle Scholar
  18. 18.
    Ito S, Akutsu K, Tamori Y, Sakamoto S, Yoshimuta T, Hashimoto H, Takeshita S. Differences in atherosclerotic profiles between patients with thoracic and abdominal aortic aneurysms. Am J Cardiol. 2008;101(5):696–9.PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Catheter Cardiovasc Interv. 2010;76(2):E43–86.PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Dapunt OE, Galla JD, Sadeghi AM, Lansman SL, et al. The natural history of thoracic aortic aneurysms. J Thorac Cardiovasc Surg. 1994;107(5):1323–32; discussion 1332–3.PubMedPubMedCentralCrossRefGoogle Scholar
  21. 21.
    Elefteriades JA, Farkas EA. Thoracic aortic aneurysm clinically pertinent controversies and uncertainties. J Am Coll Cardiol. 2010;55(9):841–57.PubMedCrossRefGoogle Scholar
  22. 22.
    Griepp RB, Ergin MA, Galla JD, Lansman SL, et al. Natural history of descending thoracic and thoracoabdominal aneurysms. Ann Thorac Surg. 1999;67(6):1927–30; discussion 1953–8.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Davies RR, Gallo A, Coady MA, Tellides G, et al. Novel measurement of relative aortic size predicts rupture of thoracic aortic aneurysms. Ann Thorac Surg. 2006;81(1):169–77.PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    Elefteriades JA, Botta DM Jr. Indications for the treatment of thoracic aortic aneurysms. Surg Clin North Am. 2009;89(4):845–67, ix.PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg. 1993;17(2):357–68; discussion 368–70.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Svensson LG, Coselli JS, Safi HJ, Hess KR, Crawford ES. Appraisal of adjuncts to prevent acute renal failure after surgery on the thoracic or thoracoabdominal aorta. J Vasc Surg. 1989;10(3):230–9.PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    Huynh TT, van Eps RG, Miller CC 3rd, Villa MA, et al. Glomerular filtration rate is superior to serum creatinine for prediction of mortality after thoracoabdominal aortic surgery. J Vasc Surg. 2005;42(2):206–12.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Kim SC, Singh M, Huang J, Prestigiacomo CJ, Winfree CJ, Solomon RA, Connolly ES Jr. Matrix metalloproteinase-9 in cerebral aneurysms. Neurosurgery. 1997;41(3):642–66; discussion 646–7.PubMedGoogle Scholar
  29. 29.
    Ziganshin BA, Elefteriades JA. Guilt by association: a paradigm for detection of silent aortic disease. Ann Cardiothorac Surg. 2016;5(3):174–87.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    Hua HT, Cambria RP, Chuang SK, Stoner MC, et al. Early outcomes of endovascular versus open abdominal aortic aneurysm repair in the National Surgical Quality Improvement Program-Private Sector (NSQIP-PS). J Vasc Surg. 2005;41(3):382–9.PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Zierer A, Melby SJ, Lubahn JG, Sicard GA, Damiano RJ Jr, Moon MR. Elective surgery for thoracic aortic aneurysms: late functional status and quality of life. Ann Thorac Surg. 2006;82(2):573–8.PubMedCrossRefGoogle Scholar
  32. 32.
    Melissano G, Bertoglio L, Mascia D, Rinaldi E, et al. Spinal cord ischemia is multifactorial: what is the best protocol? J Cardiovasc Surg. 2016;57(2):191–201.Google Scholar
  33. 33.
    Safi HJ, Miller CC 3rd, Huynh TT, Estrera AL, et al. Distal aortic perfusion and cerebrospinal fluid drainage for thoracoabdominal and descending thoracic aortic repair: ten years of organ protection. Ann Surg. 2003;238(3):372–80; discussion 380–1.PubMedPubMedCentralGoogle Scholar
  34. 34.
    Aftab M, Coselli JS. Renal and visceral protection in thoracoabdominal aortic surgery. J Thorac Cardiovasc Surg. 2014;148(6):2963–6.PubMedCrossRefGoogle Scholar
  35. 35.
    Coselli JS, LeMaire SA, Conklin LD, Köksoy C, Schmittling ZC. Morbidity and mortality after extent II thoracoabdominal aortic aneurysm repair. Ann Thorac Surg. 2002;73(4):1107–15; discussion 1115–6.PubMedCrossRefGoogle Scholar
  36. 36.
    Kulik A, Castner CF, Kouchoukos NT. Outcomes after thoracoabdominal aortic aneurysm repair with hypothermic circulatory arrest. J Thorac Cardiovasc Surg. 2011;141(4):953–60.PubMedCrossRefGoogle Scholar
  37. 37.
    Lemaire SA, Jones MM, Conklin LD, Carter SA, Criddell MD, Wang XL, Raskin SA, Coselli JS. Randomized comparison of cold blood and cold crystalloid renal perfusion for renal protection during thoracoabdominal aortic aneurysm repair. J Vasc Surg. 2009;49(1):11–9; discussion 19.PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Kuniyoshi Y, Koja K, Miyagi K, Uezu T, Yamashiro S, Arakaki K, Nagano T, Mabuni K, Senaha S. Selective visceral perfusion during thoracoabdominal aortic aneurysm repair. Ann Thorac Cardiovasc Surg. 2004;10(6):367–72.PubMedPubMedCentralGoogle Scholar
  39. 39.
    Köksoy C, LeMaire SA, Curling PE, Raskin SA, Schmittling ZC, Conklin LD, Coselli JS. Renal perfusion during thoracoabdominal aortic operations: cold crystalloid is superior to normothermic blood. Ann Thorac Surg. 2002;73(3):730–8.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Thoracoabdominal aortic aneurysms associated with celiac, superior mesenteric, and renal artery occlusive disease: methods and analysis of results in 271 patients. J Vasc Surg. 1992;16(3):378–89; discussion 389–90.PubMedPubMedCentralCrossRefGoogle Scholar
  41. 41.
    LeMaire SA, Jamison AL, Carter SA, Wen S, Alankar S, Coselli JS. Deployment of balloon expandable stents during open repair of thoracoabdominal aortic aneurysms: a new strategy for managing renal and mesenteric artery lesions. Eur J Cardiothorac Surg. 2004;26(3):599–607.PubMedPubMedCentralCrossRefGoogle Scholar
  42. 42.
    Browne TF, Hartley D, Purchas S, Rosenberg M, Van Schie G, Lawrence-Brown M. A fenestrated covered suprarenal aortic stent. Eur J Vasc Endovasc Surg. 1999;18(5):445–9.PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    Roselli EE, Greenberg RK, Pfaff K, Francis C, Svensson LG, Lytle BW. Endovascular treatment of thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg. 2007;133(6):1474–82.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Greenberg RK, Lu Q, Roselli EE, Svensson LG, et al. Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques. Circulation. 2008;118(8):808–17.PubMedPubMedCentralCrossRefGoogle Scholar
  45. 45.
    Eagleton MJ, Follansbee M, Wolski K, Mastracci T, Kuramochi Y. Fenestrated and branched endovascular aneurysm repair outcomes for type II and III thoracoabdominal aortic aneurysms. J Vasc Surg. 2016;63(4):930–42.PubMedPubMedCentralCrossRefGoogle Scholar
  46. 46.
    O’Callaghan A, Mastracci TM, Eagleton MJ. Staged endovascular repair of thoracoabdominal aortic aneurysms limits incidence and severity of spinal cord ischemia. J Vasc Surg. 2015;61(2):347–354.e1.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Mastracci TM, Greenberg RK, Eagleton MJ, Hernandez AV. Durability of branches in branched and fenestrated endografts. J Vasc Surg. 2013;57(4):926–33; discussion 933.PubMedPubMedCentralCrossRefGoogle Scholar
  48. 48.
    Yamaguchi D, Jordan WD Jr. Hybrid thoracoabdominal aortic aneurysm repair: current perspectives. Semin Vasc Surg. 2012;25(4):203–7.PubMedPubMedCentralCrossRefGoogle Scholar
  49. 49.
    Chao AB, Major K, Hood DB, Patel KR, Rowe VL, Weaver FA. Preliminary retrograde visceral artery reconstruction for thoracoabdominal aortic aneurysms. Ann Vasc Surg. 2007;21(2):123–8.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Ashok Venkataraman
    • 1
  • Jeffrey P. Schwartz
    • 2
  1. 1.Department of Cardiovascular & Thoracic SurgeryLoyola University Medical CenterMaywoodUSA
  2. 2.Lung Transplant Program & Aortic Center, Department of Cardiovascular & Thoracic SurgeryLoyola University Medical CenterMaywoodUSA

Personalised recommendations