Under fluoroscopic guidance, the balloon is directed to the thoracic aorta. The balloon should be positioned above the aortic aneurysm between the pararenal and retrocardiac aorta. The quality of aorta should also be appreciated on preoperative axial imaging to avoid areas with thrombus, plaque, and calcification. Placing the balloon in the thoracic aorta at the level of the 12th vertebral body will allow working room for imaging below the balloon and it will facilitate delivery of the main endograft from the ipsilateral side. Even with this position, the balloon may require partial deflation to allow the nose cone on the endograft to pass. A 60 cc syringe with contrast is used to inflate the balloon under direct visualization. The volume of contrast required to achieve aortic apposition is marked. During test inflation, it is also important to support the back of the balloon with the sheath to avoid balloon displacement down the aorta (Fig. 12.2). When this occurs, the balloon is not fully opposed to the aortic wall, and downward pressure causes the balloon to drag down the aortic wall. This can result in aortic plaque embolization. Once test inflation and positioning is complete, the balloon is deflated. The position of the balloon is marked on the table with a sterile marker, the sheath is also marked or sutured in place, and the volume of contrast used to create aortic occlusion is recorded. Balloon inflation is then reserved for hemodynamic support. At this step, the surgeon may proceed with open or endovascular repair.

With open surgery, proximal aortic occlusion may be required to support anesthesia induction and laparotomy. Aortic occlusion provides afterload needed to support cerebral and coronary perfusion; this will reduce the amount of cardiac pressors and fluid administered for induction. In addition, optimizing coronary perfusion will improve cardiac output. The surgeon primary goal is to place an infrarenal clamp at the infrarenal location. Once infrarenal control and distal control are obtained, the balloon can be deflated and then pull back through the infrarenal neck. At this stage, the surgeon can digitally control the aorta and feel the balloon and wire pass through this point. Aortic clamps can then be positioned for open repair.

When general anesthesia is chosen, the aortic occlusion balloon provides the same advantages described for open repair. If the balloon is not required, the stent graft can be deployed in a standard fashion. If the balloon is required to support hemodynamics, the main body of a bifurcated device can be deployed below the balloon in an infrarenal location. If the patient can tolerate balloon deflation, pulling the balloon down into the aneurysm sac just prior to proximal stent graft deployment avoids trapping the balloon beyond the stent graft and proximal stents. If the proximal AOB must remain inflated due to patient condition, it is my preference to ensure the contralateral sheath is well above the stent graft seal zone. This allows the AOB to be re-sheathed in the proximal aorta, and then the sheath and balloon can be pulled caudally between the stent graft and the aortic wall. The goal is to avoid stent graft displacement. Once the bifurcated system has been deployed, the AOB can be placed from the ipsilateral approach while the contralateral limbs are deployed.