Annotation for Point J
If hypotension persists following thoracotomy and pericardotomy, the descending thoracic aorta should be occluded to maximize coronary perfusion and to decrease the required effective circulating volume to facilitate resuscitation. Typically, the thoracic aorta is cross-clamped inferior to the left pulmonary hilum; alternatively, it can be clamped above the lung in the more proximal descending aorta. Although some advocate taking down the inferior pulmonary ligament to better mobilize the lung, this is unnecessary and risks injury to the inferior pulmonary vein. Dissection of the thoracic aorta is optimally performed under direct vision by incising the mediastinal pleura and bluntly separating the aorta from the esophagus anteriolaterally and from the prevertebral fascia posteriorly; if excessive hemorrhage or protruding lung limits direct visualization, which is the more realistic clinical scenario, blunt dissection with one’s thumb and ﬁngertips can be performed to isolate the descending aorta. If the aorta cannot be easily isolated from the surrounding tissue, digitally occlude the aorta against the spine to effect aortic occlusion.