Rethinking circulatory management in thoracoabdominal aortic repair: split-body perfusion for continuous end-organ flow.

Thoracoabdominal aortic aneurysm (TAAA) repair involving the proximal descending thoracic aorta remains among the most technically demanding operations in cardiovascular surgery. Conventional approaches may require systemic hypothermia and periods of circulatory arrest to facilitate proximal aortic reconstruction, potentially exposing the brain, spinal cord, and abdominal viscera to ischemic injury. Strategies that permit complex proximal reconstruction while maintaining continuous perfusion to multiple vascular territories remain limited. We describe a split-body circulation technique designed to preserve uninterrupted upper- and lower-body perfusion during open TAAA repair. Split-body cardiopulmonary bypass is established using separate upper- and lower-body perfusion circuits, permitting independent control of cerebral and distal systemic blood flow. The operative strategy incorporates temporary left common carotid chimney graft for initial systemic and subsequently selective cerebral perfusion, distal-first aortic reconstruction, and selective visceral perfusion during sequential reimplantation of critical perivisceral vessels. Following completion of the distal reconstruction, proximal aortic replacement is performed while continuous selective cerebral perfusion is maintained. This video demonstrates the principal operative steps, circuit configuration, perfusion transitions, and technical considerations required to coordinate aortic reconstruction with continuous end-organ perfusion. The split-body configuration enables maintenance of cerebral, spinal cord, visceral, and distal systemic perfusion throughout the major phases of reconstruction while avoiding full-body deep hypothermic circulatory arrest. Independent upper- and lower-body circuits provide flexibility in adjusting regional flow according to the requirements of each operative phase and allow sequential reconstruction without complete interruption of systemic perfusion. This technique is particularly applicable to complex TAAA pathology extending proximally into the proximal descending aorta/distal aortic arch, where conventional proximal reconstruction may otherwise necessitate prolonged deep hypothermic circulatory arrest. Split-body circulation provides a reproducible perfusion framework for selected complex open TAAA repairs requiring proximal descending thoracic aortic reconstruction. By combining separate upper- and lower-body perfusion with selective cerebral and visceral perfusion, this strategy prioritizes continuous end-organ blood flow while facilitating extensive aortic reconstruction. Further experience is required to define optimal patient selection, reproducibility, and comparative clinical outcomes.