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Ann Thorac Surg 1994;58:19-23
© 1994 The Society of Thoracic Surgeons

Articles

Graft replacement of the descending thoracic aorta: Results of "open" distal anastomosis

Scott A. Scheinin, MD, Denton A. Cooley, MD*

Division of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas USA

* Address reprint requests to Dr Cooley, Texas Heart Institute, PO Box 20345, Houston, TX 77225.

With the advent of rapid autotransfusion, we began to repair aneurysms of the descending thoracic and thoracoabdominal aorta by using an "open" technique, in which a single cross-damp is placed proximal to the aneurysm to exsanguinate the lower body. To determine whether open distal anastomosis effectively protects against spinal cord injury, we studied 71 consecutive patients (50 men, 21 women) who underwent this procedure beginning in April 1989. The patients ranged in age from 31 to 83 years (mean, 63.3 years). Most patients were hypertensive (n = 61; 86%) and symptomatic (n = 54; 76%). Most had been diagnosed with medial degeneration (n = 45; 63.4%) or aortic dissection (n = 16; 22.5%). Five patients (7.0%) were admitted with aortic rupture. We replaced the entire descending thoracic aorta in 31 (43.7%), the thoracoabdominal aorta in 21 (29.6%), and a segment of the descending thoracic aorta in 19 (26.7%). The average distal ischemic time was 22.4 minutes (range, 11 to 42 minutes). The amount of blood returned through the autotransfusion device averaged 2,099 mL. Eight patients (11.3%) died within 30 days (multiple organ failure, 3; hemorrhage, 2; coexisting ischemic heart disease, 3). Spinal cord dysfunction occurred in 6 patients (8.5%) (lower extremity paraparesis, 4; paraplegia, 2). Renal insufficiency requiring dialysis occurred in 4 patients (5.6%). We believe that the low incidence of spinal cord injury and renal insufficiency in this series may have resulted from the free, draining of the intercostal and lumbar arteries during aortic occlusion, which decreases cerebrospinal fluid and central venous pressures. With the lower body exsanguinated, we can also perform the distal anastomosis efficiently with a short ischemic time. Based on these favorable results, we conclude that the open technique is an excellent option for resection of these challenging thoracic aneurysms.




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