Extent II open thoracoabdominal aortic aneurysm repair in severe cachexia

A 62-year-old woman with a symptomatic Crawford extent II thoracoabdominal aortic aneurysm (maximum diameter 73 mm) presented with severe dysphagia and dyspnoea and was deemed at very high operative risk because of profound underweight (35 kg, 1.65 m; body mass index 12.9) and chronic obstructive pulmonary disease stage Gold III. As endovascular repair was unlikely to provide relief of compressive symptoms and would have required extensive aortic coverage, an open strategy was selected. To improve physiological reserve, a period of preoperative conditioning was undertaken with nutritional support (including percutaneous endoscopic gastrostomy feeding) and respiratory optimization, achieving 43 kg at surgery (body mass index 15.8). Repair was performed through a left thoraco-phreno-laparotomy using femoral arterial and right atrial venous cannulation, deep hypothermia (18°C), and hypothermic circulatory arrest (24 minutes) to facilitate a controlled proximal anastomosis in a fragile, ulcerated aorta. Because sequential distal clamping was unsafe, selective visceral and renal protection was applied during reconstruction and reimplantation. The postoperative course was prolonged due to respiratory complications requiring tracheostomy, but no other major complications were observed. At 6-month follow-up, compressive symptoms had resolved and the patient was living independently.