Presently we favor heparinless femorofemoral venoarterial bypass for all descending thoracic aneurysm resections. The advantages are minimal blood loss due to the absence of heparin, ease of insertion, especially in large aneurysms where it would be difficult to insert a temporary shunt, distal aortic perfusion, possibly a safety factor in preventing spinal cord and visceral ischemia, and prevention of left heart overload and myocardial failure. In acute traumatic ruptures, simple aortic cross clamping is a suitable alternative. It is safe and can be carried out expeditiously in any community hospital where bypass facilities may not be available. Proximal hypertension can be controlled pharmacologically. We have also used this successfully in ruptured atherosclerotic aneurysms. We have no experience with temporary tridodecylmethylamonium (TDMAC) shunts; several groups have used them successfully. We believe they may be difficult to insert in the proximal aorta with a large mediastinal hematoma or extensive aneurysm. Cannulation of the left ventricular apex necessitates cardiac manipulation and may produce effective aortic valve insufficiency. In patients with aortoesophageal and bronchoesophageal fistula, permanent extrathoracic bypass is preferable to a prosthetic graft in a contaminated field. We propose using a permanent bypass with a no. 10 or 12 right axillofemoral bypass. Our experience is limited to only two patients. This is also a method of treating a mycotic aneurysm or infected thoracic aortic graft.
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