title: A minimally invasive approach for open surgical thoracoabdominal aortic replacement: experimental concept for a novel surgical procedure.
abstract: We aimed to develop a simple, reliable, and timesaving technique for the therapy of thoracoabdominal aortic (TAA) aneurysms that are not suitable for endovascular repair.
  
  
  
  In this pilot study, we sought to combine the advantages of classic open vascular procedure with the use of endoscopic surgical tools and small skin incisions to develop a minimally invasive approach for TAA replacement. The following procedures were used: endoscopic exposure and closure of the lower intercostal arteries; small posterolateral thoracotomy and left retroperitoneal incisions to expose the anastomotic regions of the aorta; partial anticoagulation; passive bypass and sequential aortic clamping; tunnelling of the graft through the native aortic lumen (endoaneurysmorrhaphy) and open performance of vascular anastomosis.
  
  
  
  Five mixed-breed dogs (25-35 kg) underwent minimally invasive TAA replacement. All animals survived the operation without blood transfusion (lowest Hb = 5.5 mg/dl). Total operation time was 364 ± 46.3 min. Clamping times were 17.6 ± 3.2 min for proximal anastomosis, 33.2 ± 2.48 min for visceral patch and 11 ± 2.3 min for distal anastomosis. The pull-through procedure of graft through the native aorta was performed during the visceral clamp time.
  
  
  
  Surgical replacement of the TAA through small transverse incisions of the thoracic and abdominal wall is feasible and allows open performance of all vascular anastomosis with no leakage at any anastomotic site. Further experimental studies and clinical implementation are needed to establish the safety and long-term outcome of minimally invasive TAA replacement as a possible primary therapeutic tool for complex aneurysms that are not suitable for endovascular treatment and require open surgical repair.
authors.affiliation: Department of Thoracic, Cardiac and Vascular Surgery, University of Göttingen, Germany.
authors.forename: Terézia B
authors.initials: TB
authors.lastname: Andrási
authors.affiliation: Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
authors.forename: Violetta
authors.initials: V
authors.lastname: Kékesi
authors.affiliation: Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
authors.forename: Béla
authors.initials: B
authors.lastname: Merkely
authors.affiliation: Department of Thoracic, Cardiac and Vascular Surgery, University of Göttingen, Germany.
authors.forename: Marius
authors.initials: M
authors.lastname: Grossmann
authors.affiliation: Department of Thoracic, Cardiac and Vascular Surgery, University of Göttingen, Germany.
authors.forename: Bernhard C
authors.initials: BC
authors.lastname: Danner
authors.affiliation: Department of Thoracic, Cardiac and Vascular Surgery, University of Göttingen, Germany.
authors.forename: Friedrich A
authors.initials: FA
authors.lastname: Schöndube
mesh_terms: D000818:Animals; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D004285:Dogs; D004724:Endoscopy; D023421:Models, Animal; D010865:Pilot Projects; D012187:Retroperitoneal Space; D013908:Thoracotomy
keywords: Endoaneurysmorrhaphy; Endoscopic exposure; Minimal invasive repair; Thoracoabdominal aneurysm