Midline Abdominal incision with Left Transverse extension (MALT approach) - for Type IV thoracoabdominal aortic aneurysm repair

Sep 28, 2026

Uploaded by Oliver

Describes the MALT approach for Crawford type IV thoracoabdominal aortic aneurysm repair using a midline abdominal incision with left transverse extension in a supine position, avoiding thoracotomy. Six patients (median age 73) with true aneurysms, chronic dissection, or an aortoduodenal fistula underwent reconstruction with four-branched or bifurcated grafts under selective visceral perfusion. All patients were discharged; one needed reoperation for bleeding and one developed an incisional hernia. The technique provides adequate exposure for anastomoses and supports concurrent abdominal procedures while minimizing respiratory complications.

LanguageEnglish

CategoryHealthcare

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Pages3

Reading Time8 min

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Abstract

Technique

Exposure and incision details

Perfusion and graft reconstruction

Results

Discussion

Midline abdominal incision with left transverse extension for type IV thoracoabdominal aortic aneurysm repair Yorihiko Matsumoto, MD, PhD,a Tsutomu Ito, MD, PhD,b Norimasa Haijima, MD, PhD,c Hirofumi Kasahara, MD, PhD,d Motohiko Osako, MD, PhD,e and Hideyuki Shimizu, MD, PhD,a Tokyo, Ichikawa, Wako, Hiratsuka and Meguro, Japan ABSTRACT We describe a technique for repairing Crawford type IV thoracoabdominal aortic aneurysms using a midline abdominal incision with left transverse extension, performed in the supine position without thoracotomy. Six patients (median age, 73 years) underwent this approach for true aneurysms, chronic dissection, or aortoduodenal fistula. Aortic reconstruction was performed with four-branched or bifurcated grafts under selective visceral perfusion. All patients were discharged home; one required reoperation for bleeding, and one developed an abdominal wall incisional hernia. This approach provided sufficient exposure for proximal and distal anastomoses and facilitated concurrent abdominal procedures while minimizing respiratory complications. (J Vasc Surg Cases Innov Tech 2026;12:102062 . ) Keywords: Abdominal surgery; Crawford type IV; Suprarenal aortic aneurysm; Thoracoabdominal aortic aneurysm In repairing type IV thoracoabdominal aortic aneurysms (TAAAs) per Crawford’s classification,1 left lateral thoracotomy is often used.2,3 However, this approach has drawbacks, including a large thoracotomy, diaphragmatic incision, and right-side lateral position. We propose an alternative: a Midline Abdominal incision with Left Transverse extension (MALT approach) in a supine position, avoiding thoracotomy to preserve respiratory function and improve access to the iliac arteries and abdominal organs. Patient consent was obtained from all patients who were included in this report. TECHNIQUE In a supine position with their left arm raised anteriorly, a T-shaped laparotomy is made with a combination of amidline abdominal incision and a left-side transverse incision from the upper umbilicus to the lower margin of the left rib arch (Fig 1) . The left costal arch is retracted cranially with a Kent hook (Fig 2) . The retroperitoneal From the Department of Cardiovascular Surgery, Keio University School of Medicine, Tokyoa; the Department of Cardiovascular Surgery, Tokyo Dental College, Ichikawa General Hospital, Ichikawab; the Department of Cardiovascular Surgery, National Hospital Organization Saitama Hospital, Wakoc; the Department of Cardiovascular Surgery, Hiratsuka City Hospital, Hiratsukad; and the Department of Cardiovascular Surgery, National Hospital Organization Tokyo Medical Center, Meguro.e Correspondence: Yorihiko Matsumoto, MD, PhD, Department of Cardiovascular Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan ([e-mail:](e-mail: yori.matsumoto@keio.jp)[ yori.matsumoto@keio.jp](e-mail: yori.matsumoto@keio.jp)) . The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 2468-4287 © 2025 The Author(s) . Published by Elsevier Inc. on behalf of Society for Vascular Surgery. This is an open access article under the CC BY license ([http://creativecommons.org/licenses/by/4.0/](http://creativecommons.org/licenses/by/4.0/)) . [https://doi.org/10.1016/j.jvscit.2025.102062](https://doi.org/10.1016/j.jvscit.2025.102062) space is opened along the left paracolic gutter, and the abdominal aorta and the left common iliac artery are exposed. The proximal abdominal aorta is exposed by medial mobilization of the spleen and left kidney en bloc. The distal part of the descending aorta is exposed with the division of the left diaphragmaticcrus (Fig 2) . The right side of the iliac artery is exposed with a transperitoneal approach. During the aortic repair, the lower body and abdomin

FAQs

What is the MALT approach for repairing Crawford type IV thoracoabdominal aortic aneurysms?

It uses a midline abdominal incision combined with a left transverse extension performed with the patient supine, avoiding thoracotomy while still providing exposure for proximal and distal anastomoses.

How is aortic reconstruction performed in this technique?

Reconstruction is done using commercially available four-branched grafts or bifurcated grafts, with perfusion supported by partial cardiopulmonary bypass and selective visceral perfusion during the repair.

What were the main postoperative outcomes reported?

All six patients were discharged home; one required reoperation for bleeding and one developed an abdominal wall incisional hernia.

Sep 28, 2026

Uploaded by Oliver