To demonstrate the utility of the left thoraco-retroperitoneal approach when explantation of an aortic endograft and open repair of abdominal aortic and iliac aneurysms are required in the presence of a hostile abdomen.

A 77 year old man was found to have a 7 cm abdominal aortic aneurysm (AAA) which was treated with endovascular exclusion using an aortic stent graft at another hospital. The endograft was found to have migrated distally and he developed a large Type I endoleak with a pulsatile aneurysm. He had a prior history of myocardial revascularization complicated by colon ischemia requiring colostomy, and acalculous cholecystitis requiring chloedochojejunostomy. He was transferred for evaluation and treatment.

After preoperative medical evaluation, including CT scanning and angiography with intravascular ultrasonography, it was determined that further endovascular repair was not feasible. Endograft excision and open aneurysm repair utilizing a Dacron aortobiiliac graft was accomplished through a left retroperitoneal, thoracoabdominal approach and the details are demonstrated in the video presentation. Postoperatively, a mild, transient coagulopathy was corrected and the patient had a subsequent uneventful recovery. He was discharged home on the eleventh postoperative day with normal renal function, bilateral dorsalis pedis pulses and normal lower extremity perfusion.

Endograft explantation for a large Type 1 endoleak with repair of abdominal aortic and iliac aneurysms in the presence of a hostile abdomen is facilitated by a left thoraco-retroperitoneal approach.