Advantages of combined distal-first and visceral branch-first technique: A universal fit for extensive thoracoabdominal aortic aneurysm?

Minimization of end ‐ organ ischemia is a key tenet in successful thoracoabdominal aortic aneurysm (TAAA) surgery. In recent years various techniques have been inspired and refined to reduce the duration and risk of visceral ischemia such as mild, moderate, or deep hypothermic repair with left heart bypass, or complete or partial cardiopulmonary bypass combined with selective perfusions to vital viscera, the lower extremities, and the spinal cord. 1 – 3 Despite advances in surgical technique and organ protection strategies, open surgical repair for TAAA remains associated with considerable levels of morbidity and mortality. Moulakakis and colleagues conducted a meta ‐ analysis that summarized the surgical outcomes of 9963 patients in experienced surgical centers and found that the mortality after repair of extent I – IV TAAA was 11.3%. 4 These results can be attributed to the nature of open surgical repair of TAAA, which represents the pinnacle of invasive cardiovascular surgery and comes with the burden of a relatively high association of comorbidities. Estrera et al. reported the “ distal first approach ” assumes the advantage of providing a distal fenestration and ensuring adequate antegrade blood flow at an early stage for patients with chronic aortic dissection. 5 Previous reports have described the utility of “ visceral branch ‐ first techniques ” in reducing visceral ischemic time with minimal reperfusion injury. 6,7 Marchenko et al. also successfully devised a novel “ iliac branch first ”