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Ann Thorac Surg 1995;60:67-76
© 1995 The Society of Thoracic Surgeons
Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentAddendumAcknowledgmentsReferences |
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Methods. Fifty-one patients (age range, 22 to 79 years) with descending thoracic or thoracoabdominal aortic disease had resection and graft replacement of the diseased aortic segments using hypothermic cardiopulmonary bypass and intervals of circulatory arrest in situations where the location, extent, or severity of disease precluded placement of clamps on the proximal aorta (8 patients) or (in 43 patients) when extensive thoracic (11) or thoracoabdominal (32) aortic disease was present and the risk for development of spinal cord ischemic injury and renal failure was judged to be increased. Patent intercostal (below T-6) and upper lumbar arteries were attached to the graft whenever possible.
Results. Thirty-day mortality was 9.8% (5 patients). Paraplegia occurred in 2 and paraparesis in 1 of the 46 30-day survivors (6.5%). Among the 27 operative survivors with thoracoabdominal aneurysms, paraplegia occurred in 1 of 12 with Crawford type I (8%), 0 of 10 with type II, and 1 of 5 with type III aneurysms (20%). Paraplegia occurred in none of the 12 patients with aortic dissection and in 2 of the 15 patients with degenerative aneurysms. Renal failure requiring dialysis occurred in 1 (2.2%) of the 46 30-day survivors.
Conclusions. Hypothermic circulatory arrest is a valuable adjunct for the treatment of complex aortic disease involving the aortic arch and thoracoabdominal aorta. In patients with thoracoabdominal aneurysms, its use has been associated with a low incidence of renal failure and an incidence of paraplegia/paraparesis in traditionally high-risk subsets (type I and II aneurysms, aortic dissection), which may be less than that observed with other surgical techniques.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAddendumAcknowledgmentsReferences |
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Profound hypothermic circulatory arrest with an anterior approach is currently a widely used technique for protection of the central nervous system during operations for treatment of congenital and acquired cardiac lesions and for aneurysms and dissections of the ascending aorta and aortic arch. The technique has been used less frequently for treatment of aortic disease that necessitates posterolateral exposure. However, it has proved to be of considerable value for the treatment of disease of the aortic arch and descending thoracic aorta when placement of aortic clamps is not possible or is considered hazardous [1–8].
Hypothermia has been shown experimentally to have a marked protective effect on spinal cord function during periods of aortic occlusion [9–12] and in studies employing hypothermic cardiopulmonary bypass and circulatory arrest in large animals where resection and graft replacement of the thoracoabdominal aorta were simulated [13, 14]. We evaluated the role of elective hypothermic cardiopulmonary bypass and circulatory arrest in patients with aortic disease involving the distal aortic arch, the descending thoracic aorta, and the thoracoabdominal aorta where the location, extent, or severity of disease precluded placement of clamps on the aortic arch or the proximal descending thoracic aorta, and when extensive thoracic and thoracoabdominal aortic disease was present and the risk of spinal cord ischemic injury was judged to be increased.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAddendumAcknowledgmentsReferences |
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The clinical characteristics of the patients are described in Appendix 1. The etiology of the aortic disease was as follows: degenerative, 24; aortic dissection, 21 (acute, 3; chronic, 18); coarctation, 4; (primary repair with aneurysm, 1, false aneurysm, 2, recurrent [postrepair] stenosis, 1); false aneurysm, 1; and malfunction of ringed intraluminal prosthesis, 1. Degenerative disease with aneurysm formation was the most common indication for operation. The extent of aortic disease is shown in Table 1
. The decision to employ hypothermic cardiopulmonary bypass and circulatory arrest was made in 8 patients because the location, extent, and severity of the aortic disease precluded the safe placement of clamps on the aortic arch or the proximal descending thoracic aorta. In the remaining 43 patients, it was used because the aortic disease requiring graft replacement involved most or all of the entire descending thoracic aorta (11 patients) or the thoracoabdominal aorta (32 patients), with or without involvement of the distal aortic arch, and the risk of spinal cord ischemic injury was judged to be increased. Using the classification of Crawford and associates [15] 13 of the 32 thoracoabdominal aneurysms were type I, 13 were type II, and 6 were type III (see Table 1). During the study interval, patients with aortic disease confined to localized segments of the descending thoracic aorta (usually in the upper or middle one third) and those with Crawford type IV aneurysms (those confined to the infradiaphragmatic aorta) were treated using alternative techniques.
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Operative Technique
The general technique employed has been described previously [16]. With increasing experience, a number of modifications have been introduced. Anesthesia was induced with midazolam and fentanyl and maintained with fentanyl and isoflurane. High-dose aprotinin was administered according to a standard protocol in an attempt to reduce blood loss in 8 patients [17]. In 13 patients, a thermistor probe (Model 511; Yellow Springs Instrument Co, Inc, Yellow Springs, OH) was introduced into the intrathecal space through the L3–L4 interspace for continuous measurement of temperature in the spinal canal. After placement of a right radial artery cannula, and pulmonary artery catheter, and a double-lumen endotracheal tube, the descending thoracic aorta was exposed through a posterolateral thoracotomy incision through the bed of the resected fourth or fifth rib. When necessary, the incision was extended obliquely across the costal margin to the midline of the abdomen below the umbilicus. The diaphragm was incised radially or circumferentially.
To reduce operative time, cardiopulmonary bypass was established immediately after the chest was entered. Methylprednisolone (7 mg/kg) was administered during this time. The left common femoral artery and vein were exposed through a vertical incision and a 28F or 32F long cannula was inserted and positioned in the right atrium. When a cannula of this size can be inserted into the atrium, flows of greater than 2.0 to 2.2 L • min-1 • m-2 can be achieved and cannulation of the pulmonary artery is not necessary. The femoral artery was cannulated with a 20F or 22F cannula. During the period of cooling, the abdominal portion of the incision was completed and the abdominal organs and the kidney were retracted medially after the peritoneum was incised in the left gutter. Thiopental (10 to 15 mg/kg) was given in divided doses during cooling.
The left lung was collapsed and gently retracted anteriorly to minimize manipulation and injury. After the heart fibrillated, a small incision was made in the pericardium and a sump-tipped venting catheter was placed in the left ventricle for decompression. The ascending aorta is no longer clamped, and cardioplegic solution was not administered to any patient. The aorta distal to the diseased segment was isolated circumferentially. The remainder of the aorta was not dissected to minimize bleeding. Cooling was continued until the nasopharyngeal temperature reached 12° to 14°C and the bladder or rectal temperature reached 15° to 19°C. There was good correlation between the spinal cord temperature and the nasopharyngeal temperature during cooling and during the period of circulatory arrest. Electroencephalographic monitoring was used and electrical quiescence always was achieved at these temperatures. Monitoring of somatosensory or motor evoked potentials was not used. When required, circulatory arrest was established after the patient was placed in the head-down position, and 1,000 to 1,500 mL of blood was drained from the patient into the reservoir of the pump-oxygenator system. The venting catheter in the left ventricle was occluded during this time to prevent suction of air into the heart.
For operations confined to the distal aortic arch and proximal descending thoracic aorta, resection and graft replacement were performed during a single period of hypothermic circulatory arrest. Clamps no longer are placed on the aortic arch or proximal aorta. The aorta distal to the involved segment was clamped or occluded intraluminally with a balloon catheter to minimize blood loss. As the final anastomosis was being completed, arterial perfusion was reestablished through the femoral artery. This maneuver assisted in the filling of the opened aorta and enhanced the evacuation of air. After completion of the final anastomosis, air was evacuated from the graft with an 18-gauge needle and cardiopulmonary bypass and rewarming were initiated. Cardiopulmonary bypass was discontinued when the rectal/bladder temperature reached 35°C.
For procedures that required resection of all or the distal two thirds of the descending thoracic aorta and the abdominal aorta, circulatory arrest was established, the distal aorta was occluded, and the proximal aorta was transected at the appropriate level. After completion of the anastomosis of the Dacron graft to the proximal aorta, a metal-tipped aortic perfusion cannula or an 8-mm collagen-impregnated Dacron graft (Hemashield, Meadox Medicals, Inc, Oakland, NJ) connected to a second arterial line, oxygenator, and roller pump from the extracorporeal circuit was attached to the aortic graft. With the head of the patient in the dependent position, blood was infused into this line to remove air from the aortic arch. Flow through the lower perfusion circuit also was initiated to assist in the removal of air. The aortic graft then was occluded with a clamp distal to the proximal arterial line and flow into the upper aorta was established. Thirty-five percent of the total arterial flow was directed through the proximal arterial line and 65% through the distal line. The temperature of the perfusate was adjusted to maintain the rectal/bladder temperature less than 20°C (range, 15° to 19°C) and total flow was maintained at 1.0 to 1.5 L • min-1 • m-2. During the period of hypothermic low flow, the anastomoses between the aortic graft and aortic tissue surrounding the lower intercostal, lumbar, visceral, and renal arteries were completed. An attempt was made to attach all patent intercostal and lumbar arteries that were below the level of the sixth intercostal space to the aortic graft. Intercostal and lumbar arteries were attached to the graft in 36 of the 43 patients who had replacement of the distal descending thoracic or thoracoabdominal aorta. Whenever possible, the proximal aortic clamp was repositioned below the intercostal artery-to-graft anastomoses before the anastomoses were performed to the visceral and renal arteries and to the distal aorta, and rewarming was initiated at that time to minimize the duration of cardiopulmonary bypass. If this was not possible, rewarming to a rectal/bladder temperature of 35°C was not initiated until all anastomoses had been completed. The extent of aortic replacement in the 51 patients is shown in Table 1
. Variables related to cardiopulmonary bypass are shown in Table 2.
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Statistical Methods
The variables examined as potential risk factors for various events are presented in Appendix 1. Bivariable contingency tables of discrete variables, logistic transformation and trend analysis of ordinal variables, and t testing of continuous variables were used to explore the relation of an organized set of potential risk factors to each binary (no/yes) outcome variable. Thereafter, groups of related variables were entered sequentially into multivariable logistic regression analyses, beginning with patient variables, then procedural, support, and experience variables [18]. A p value of 0.1 was required for retention of a variable in the final model. Analysis of the continuous variables for blood loss and blood product use employed multiple linear regression on the logarithmic transformed variable. This was necessary because of the strong rightward skewness of the data.
The distribution of the interval between operation and death was estimated independently by a nonparametric life table method [19] and by a parametric method [20]. Risk factors for death were identified in the parametric domain by the hazard function regression methodology. For all analyses, a p value of 0.05 or less was considered significant.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAddendumAcknowledgmentsReferences |
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). Three patients died intraoperatively of myocardial failure. A 77-year-old man with an acute type B (Crawford type II) dissection had severe coronary artery disease in the anterior descending and circumflex systems, which was documented by preoperative coronary angiography. Intractable hypotension and ventricular tachycardia developed. In a 76-year-old man with a ruptured degenerative Crawford type II thoracoabdominal aneurysm, hypotension and bradycardia developed after discontinuation of cardiopulmonary bypass. He had undergone coronary artery bypass grafting 13 years previously. A 47-year-old man with Marfan's syndrome died of intractable ventricular arrhythmias after resection of a Crawford type III aneurysm associated with chronic aortic dissection. He had undergone two previous operations on the ascending aorta and aortic arch, one on the proximal descending thoracic aorta and one on the infrarenal abdominal aorta. A 62-year-old man with a ruptured degenerative Crawford type II aneurysm died on the first postoperative day of low cardiac output associated with a diffuse intravascular coagulopathy. He had undergone previous resection of the ascending aorta and aortic arch and of the infrarenal abdominal aorta. He also had a previous left pleurodesis for repeated pneumothoraces. He received aprotinin intraoperatively. The fifth patient, a 75-year-old woman with a Crawford type II degenerative aneurysm, died 3 days postoperatively of low cardiac output associated with diffuse intravascular coagulopathy. This patient also received aprotinin intraoperatively. Postmortem examination demonstrated multiple foci of acute myocardial infarction and renal infarction associated with extensive microvascular thrombosis [21]. Using multivariable analysis, none of the variables examined was an incremental risk factor for 30-day mortality. The p value (Fisher) for Crawford type II and III aneurysms versus all other patients was 0.060.
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Morbidity
BLEEDING AND TRANSFUSION REQUIREMENTS.
Reoperation for bleeding was required in two patients. The volumes of red blood cells, fresh frozen plasma and platelets transfused intraoperatively and postoperatively are shown in Table 4. Three patients received cryoprecipitate. Four patients (7.8%) received no blood products intraoperatively and 17 (35%) of the 48 patients who survived the operation required no transfusions postoperatively. Using multiple linear regression analysis, the presence of a Crawford type II thoracoabdominal aortic aneurysm and a longer elapsed time of cardiopulmonary bypass were significant (p 
0.05) incremental risk factors for the intraoperative and early postoperative use of platelets and fresh frozen plasma.
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Among the 27 operative survivors with thoracoabdominal aortic disease, paraplegia occurred in 1 (8.3%) of the 12 with Crawford type I, in none of the 10 with Crawford type II, and in 1 (20%) of the 5 with Crawford type III aneurysms. Paraplegia occurred in none of the 13 patients with aortic dissection and in 2 of the 14 patients with degenerative aneurysms. In 1 patient with a Crawford type I aneurysm in whom paraplegia developed, two pairs of intercostal arteries above T-6 were sacrificed. The left intercostal artery at the T-9 level was implanted into the graft and the small right intercostal artery at this level, which was surrounded by severe aortic atherosclerosis, was sacrificed. No other intercostal or lumbar arteries were patent. In the other patient, who had a Crawford type III aneurysm, a single patent intercostal artery at the T-10 level was implanted into the graft. A single patent lumbar artery located several centimeters below the renal arteries was sacrificed. No other intercostal or lumbar arteries were patent. In a multivariable analysis, no incremental risk factors for the development of spinal cord ischemic injury were identified. The relation between the duration of spinal cord ischemia, defined as the time between onset of circulatory arrest or aortic clamping and the establishment of flow to the intercostal arteries below the T-6 interspace, and the incidence of paraplegia or paraparesis is shown in Figure 1.
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PULMONARY DYSFUNCTION.
Thirty-two of the operative survivors were extubated within 24 hours and 2 within 48 hours of operation. Prolonged (>48 hours) mechanical ventilation was required in 14 (29%) of the operative survivors. Five patients (10%) required a tracheostomy. Three patients received antibiotic therapy for pneumonitis. In a multivariable analysis employing all variables, older age at operation and use of aprotinin were significant incremental risk factors for prolonged mechanical ventilation.
CARDIAC COMPLICATIONS.
Of the 46 30-day survivors, 2 patients required inotropic support for more than 48 hours for low cardiac output.
The median length of stay in the intensive care unit was 4 days (range, 1 to 48 days). Fourteen patients remained in the intensive care unit for less than 48 hours. The median postoperative length of stay was 12 days (range, 6 to 69 days). Nineteen patients were discharged by the 10th postoperative day.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAddendumAcknowledgmentsReferences |
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The rationale for use of hypothermic cardiopulmonary bypass with or without a period of circulatory arrest for extensive disease involving the descending thoracic and thoracoabdominal aorta is to increase the tolerable duration of spinal cord ischemia so that attachment of intercostal and lumbar arteries and reestablishment of aortic flow can be completed before the onset of permanent cord injury. In studies in baboons and pigs, we demonstrated that hypothermia (15°C) induced and maintained by cardiopulmonary bypass in a model where resection of the thoracoabdominal aorta was simulated and the aorta was occluded proximally and distally for 60 minutes provided superior spinal cord protection when compared with normothermic bypass [13, 14]. Before the technique is applied widely, however, the safety as well as the effectiveness of hypothermic cardiopulmonary bypass should be demonstrated. Comparison of mortality and morbidity rates with those of other currently used techniques is also necessary.
In our study, no incremental risk factors for 30-day mortality were identified. Aprotinin was used in 3 of the 6 patients who died in the hospital. The deaths of 2 of these patients could be attributed directly to use of this drug, and we no longer use it in patients who require hypothermic cardiopulmonary bypass and circulatory arrest [17, 21]. When all deaths were analyzed, acute dissection or rupture of the aneurysm, the presence of a Crawford type II or type III aneurysm and increasing age were incremental risk factors for death. These variables have been found to be significant incremental risk factors for early and late death in patients with thoracic and thoracoabdominal aortic disease in whom other techniques (simple proximal aortic clamping and distal perfusion) have been employed [15, 22, 23].
When compared with series of patients having resection of extensive thoracic or thoracoabdominal aneurysms in which alternative techniques were employed (simple aortic clamping, atriofemoral bypass, or femoral-femoral bypass) the frequency of reoperation for bleeding and the perioperative transfusion requirements in our patients did not differ from those reported with these techniques [15, 22, 24–29]. The ability to return virtually all shed blood into the pump-oxygenator system with full cardiopulmonary bypass and heparinization reduces the need for salvage of red cells from cell-saving devices. Use of membrane oxygenators and impermeable grafts may have reduced the requirements for platelets, fresh-frozen plasma, and cryoprecipitate.
In clinical studies, the largest experience with extensive resections of the descending thoracic and thoracoabdominal aorta has involved the use of simple aortic clamping without distal perfusion [15, 22–25]. These studies all have demonstrated a clear correlation between the extent of aorta that is resected or the time required to effect this resection and the incidence of spinal cord ischemic injury. For aneurysms involving most or all of the descending thoracic aorta, the incidence of paraplegia or paraparesis has ranged from 6% to 13% [23, 25]. In subgroups of patients with prolonged aortic clamp times (>30 minutes), the incidence was 15% or greater [23]. For aneurysms of the thoracoabdominal aorta, the incidence of ischemic injury has ranged from 5% to 21% [15, 22, 25, 30–34]. The highest incidence occurred with type II aneurysms [15, 32–34], and the incidence was substantially higher for patients with aortic dissection than for those with degenerative aneurysms [15, 33]. As an example, for patients in the study by Crawford and associates [15] with type II aneurysm and dissection, the incidence of paraplegia or paraparesis was 40% (23 of 57 patients).
In our series, the extent of aorta replaced or the duration of spinal cord ischemia did not correlate with the incidence of spinal cord ischemic injury (see Fig 1, Appendix 1). Furthermore, paraplegia or paraparesis developed in only 1 (4.5%) of the 22 30-day survivors with Crawford type I or type II thoracoabdominal aortic aneurysms. Although the number of cases is small, these findings are in marked contrast to those observed with simple aortic clamping. In a comparison using Fisher's exact test of our series with the results of Crawford and associates [15], Golden and co-workers [32], and Cox and colleagues [33] the incidence of paraplegia or paraparesis was significantly lower in our series for patients with Crawford type II aneurysm (p = 0.02, 0.02, and 0.005, respectively).
None of the 6 patients in our series with extensive thoracic aneurysms and dissection and none of the 12 patients with Crawford type I, II, or III thoracoabdominal aneurysms and dissection had development of paraplegia or paraparesis. In two other series employing hypothermic circulatory arrest for extensive thoracic and thoracoabdominal aneurysms (a total of 29 patients), where the type of aortic disease was documented, paraplegia and paraparesis occurred in only 2 patients who had atherosclerotic aneurysms [4, 35]. No spinal cord ischemic injury occurred in any of the patients with aortic dissection. Patent intercostal and lumbar arteries were reattached in these patients whenever possible. Taken together, these findings suggest that the technique of profound hypothermic cardiopulmonary bypass may offer substantial protection of the spinal cord during these extensive procedures, particularly in patients with aortic dissection, and that it can safely extend the duration of spinal cord ischemia for up to 90 to 100 minutes.
The incidence of renal failure requiring dialysis in our series is lower than that reported with simple aortic clamping for extensive descending thoracic and thoracoabdominal aneurysms [15, 30–33] and with techniques employing normothermic distal perfusion for thoracoabdominal aneurysms [31, 36]. Use of distal perfusion with moderate hypothermia also has been associated with a low incidence of renal failure [27, 28]. These observations suggest that hypothermia has an important protective effect on renal function during these extensive procedures.
Although a standard methodology has not been used to report pulmonary complications after extensive resections of the thoracic aorta, the incidence of major pulmonary complications (prolonged mechanical ventilation, need for tracheostomy) in our series did not differ appreciably from that reported in patients in whom simple aortic clamping was used [22, 25, 30, 31, 33]. Cardiac complications occurred infrequently in our series and in the reports by Caramutti and colleagues [3] and Kieffer and co-workers [4], where elective hypothermic cardiopulmonary bypass was used, indicating that hypothermic fibrillation and venting of the heart, when appropriate, provide adequate myocardial protection. We believe that internal or external occlusion of the ascending aorta and infusion of cardioplegic solution is not necessary for myocardial protection during these procedures, and that occlusion of the ascending aorta increases the potential for embolization of atheromatous debris into the brachiocephalic arteries.
Our experience with hypothermic cardiopulmonary bypass and circulatory arrest confirms the safety and efficacy of the technique for operations that required resection of the aortic arch through a lateral approach. Our results suggest that for patients with extensive descending thoracic and Crawford type II thoracoabdominal aneurysms, the incidence of spinal cord ischemic injury may be less than that observed with simple aortic clamping techniques. The technique is associated with an incidence of renal failure that appears to be lower than that observed with simple aortic clamping and with normothermic distal perfusion techniques. The incidence of other major complications does not appear to be higher than those observed with other techniques.
The optimal level of hypothermia that will provide maximal protection of the spinal cord and kidneys is undetermined. It is possible that a lesser degree of hypothermia may be equally protective and will be associated with less mortality and morbidity than the technique we have reported. However, hypothermia and circulatory arrest will be required for aortic disease that necessitates resection of the aortic arch. Techniques involving the use of distal perfusion with normothermia or mild hypothermia also have been associated with a lower incidence of spinal cord ischemic injury than the simple aortic clamping technique [26–28, 36]. However, these techniques require the use of sequential aortic clamping to minimize the duration of spinal cord ischemia, and this will not be possible in all patients [26].
Because the etiology of spinal cord ischemic injury associated with operations on the descending thoracic and thoracoabdominal aorta is probably multifactorial, it is unlikely that any single intervention such as the use of profound hypothermia will eliminate the paraplegia and paraparesis that occurs after these operations. However, hypothermia appears to increase substantially the tolerable duration of spinal cord ischemia. We believe that continued evaluation and use of the technique is indicated.
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Addendum |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAddendumAcknowledgmentsReferences |
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Acknowledgments |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAddendumAcknowledgmentsReferences |
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We are grateful to Dr Eugene H. Blackstone for assistance with the statistical analyses, to Dr Thomas H. Wareing who operated on 3 of the patients, and to Ms Mary Sue Williams for preparation of the manuscript. William Klausing, JoAnn Sabelli, Timothy Burns, Patrick O'Donnell, and Deanne Barlas-Collins provided superb cardiopulmonary perfusion.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAddendumAcknowledgmentsReferences |
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Presented at the Thirty-first Annual Meeting of The Society of Thoracic Surgeons, Palm Springs, CA, Jan 29–Feb 1, 1995.
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References |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAddendumAcknowledgmentsReferences |
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 Y. Moriyama, G. Yotsumoto, K. Hisatomi, H. Matsumoto, R. Toda, and M. Kaieda Thoracoabdominal Aortic Aneurysms Repair Under Abdominal Cavity Cooling with Visceral Shunting Technique: A Case Report Vascular and Endovascular Surgery, May 1, 2001; 35(3): 229 - 232. [Abstract] [PDF]
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Y. Moriyama, Y. Iguro, K. Hisatomi, G. Yotsumoto, H. Yamamoto, and R. Toda Thoracic and thoracoabdominal aneurysm repair under deep hypothermia using subclavian arterial perfusion Ann. Thorac. Surg., January 1, 2001; 71(1): 29 - 32. [Abstract] [Full Text] [PDF]
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T. E. Rasmussen and J. M. Panneton Ischemic Complications of Distal Aortic Dissections: Open Surgical or Endovascular Management? Perspectives in Vascular Surgery and Endovascular Therapy, January 1, 2001; 14(2): 57 - 71. [Abstract] [PDF]
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E. Gygax, P. Schupbach, and T. P. Carrel Thoracoabdominal aortic repair in a 190-kg patient: optimized perfusion with two oxygenators Ann. Thorac. Surg., January 1, 2001; 71(1): 347 - 349. [Abstract] [Full Text] [PDF]
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P. de Haan, I. Vanicky, M. J. H. M. Jacobs, O. Bakker, J. Lips, S. A.G. Meylaerts, and C. J. Kalkman Effect of ischemic pretreatment on heat shock protein 72, neurologic outcome, and histopathologic outcome in a rabbit model of spinal cord ischemia J. Thorac. Cardiovasc. Surg., September 1, 2000; 120(3): 513 - 519. [Abstract] [Full Text] [PDF]
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T. P. Carrel, P. A. Berdat, J. Robe, J. Gysi, T. Nguyen, B. Kipfer, and U. Althaus Outcome of thoracoabdominal aortic operations using deep hypothermia and distal exsanguination Ann. Thorac. Surg., March 1, 2000; 69(3): 692 - 695. [Abstract] [Full Text] [PDF]
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R. Kunitomo, H. Goto, J. Utoh, and N. Kitamura Thoracoabdominal aortic aneurysm combined with aortic occlusion Ann. Thorac. Surg., February 1, 2000; 69(2): 623 - 625. [Abstract] [Full Text] [PDF]
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J. S Coselli, D. F Ledesma, S. A LeMaire, E. Tayama, S. A Raskin, S. Ohtsubo, S. Harlin, N. G Browning, and Y. Nose Comparison of Nikkiso and Bio-Medicus Pumps in Thoracoabdominal Aortic Surgery Asian Cardiovasc Thorac Ann, December 1, 1999; 7(4): 353 - 358. [Abstract] [Full Text] [PDF]
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P. Mastroroberto and M. Chello EMERGENCY THORACOABDOMINAL AORTIC ANEURYSM REPAIR: CLINICAL OUTCOME J. Thorac. Cardiovasc. Surg., September 1, 1999; 118(3): 477 - 481. [Abstract] [Full Text] [PDF]
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H. Niinami, S. Aomi, O. Tagusari, A. Hashimoto, and H. Koyanagi Extensive aortic reconstruction for aortic aneurysms in Marfan syndrome Ann. Thorac. Surg., June 1, 1999; 67(6): 1864 - 1867. [Abstract] [Full Text] [PDF]
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N. T. Kouchoukos and C. K. Rokkas Hypothermic cardiopulmonary bypass for spinal cord protection: rationale and clinical results Ann. Thorac. Surg., June 1, 1999; 67(6): 1940 - 1942. [Abstract] [Full Text] [PDF]
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J. D. Galla, M. A. Ergin, S. L. Lansman, J. N. McCullough, K. H. Nguyen, D. Spielvogel, J. J. Klein, and R. B. Griepp Use of somatosensory evoked potentials for thoracic and thoracoabdominal aortic resections Ann. Thorac. Surg., June 1, 1999; 67(6): 1947 - 1952. [Abstract] [Full Text] [PDF]
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 C. A. Nienaber, R. Fattori, G. Lund, C. Dieckmann, W. Wolf, Y. von Kodolitsch, V. Nicolas, and A. Pierangeli Nonsurgical Reconstruction of Thoracic Aortic Dissection by Stent-Graft Placement N. Engl. J. Med., May 20, 1999; 340(20): 1539 - 1545. [Abstract] [Full Text] [PDF]
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E. E. Tseng, M. V. Brock, C. C. Kwon, M. Annanata, M. S. Lange, J. C. Troncoso, M. V. Johnston, and W. A. Baumgartner Increased intracerebral excitatory amino acids and nitric oxide after hypothermic circulatory arrest Ann. Thorac. Surg., February 1, 1999; 67(2): 371 - 376. [Abstract] [Full Text] [PDF]
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E. E. Tseng, M. V. Brock, M. S. Lange, J. C. Troncoso, C. J. Lowenstein, M. E. Blue, M. V. Johnston, and W. A. Baumgartner Nitric oxide mediates neurologic injury after hypothermic circulatory arrest Ann. Thorac. Surg., January 1, 1999; 67(1): 65 - 71. [Abstract] [Full Text] [PDF]
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S. Sasaguri, T. Fukuda, T. Yamamoto, K. Nishimura, K. Kudo, M. Goto, and Y. Hosoda TRANSAPICAL AORTIC OCCLUSION FOR CARDIOPLEGIC DELIVERY DURING RECONSTRUCTION OF THORACOABDOMINAL AORTIC ANEURYSM WITH DEEP HYPOTHERMIC CIRCULATORY ARREST J. Thorac. Cardiovasc. Surg., January 1, 1999; 117(1): 186 - 188. [Full Text] [PDF]
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L. G. Svensson, K. R. Hess, R. S. D'Agostino, M. H. Entrup, K. Hreib, W. A. Kimmel, E. Nadolny, and D. M. Shahian Reduction of neurologic injury after high-risk thoracoabdominal aortic operation Ann. Thorac. Surg., July 1, 1998; 66(1): 132 - 138. [Abstract] [Full Text] [PDF]
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M. K. Heinemann, F. Brassel, T. Herzog, C. Dresler, H. Becker, and H. G. Borst The Role of Spinal Angiography in Operations on the Thoracic Aorta: Myth or Reality? Ann. Thorac. Surg., February 1, 1998; 65(2): 346 - 351. [Abstract] [Full Text] [PDF]
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L. N. Girardi and J. S. Coselli Repair of Thoracoabdominal Aortic Aneurysms in Octogenarians Ann. Thorac. Surg., February 1, 1998; 65(2): 491 - 495. [Abstract] [Full Text] [PDF]
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E. E. Tseng, M. V. Brock, M. S. Lange, M. E. Blue, J. C. Troncoso, C. C. Kwon, C. J. Lowenstein, M. V. Johnston, and W. A. Baumgartner Neuronal Nitric Oxide Synthase Inhibition Reduces Neuronal Apoptosis After Hypothermic Circulatory Arrest Ann. Thorac. Surg., December 1, 1997; 64(6): 1639 - 1647. [Abstract] [Full Text]
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N. T. Kouchoukos and D. Dougenis Surgery of the Thoracic Aorta N. Engl. J. Med., June 26, 1997; 336(26): 1876 - 1889. [Full Text] [PDF]
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N. Shiiya, K. Yasuda, T. Murashita, Y. Suto, T. Kanaoka, Y. Matsui, and S. Sasaki TRANSAPICAL AORTIC CANNULATION FOR HYPOTHERMIC AORTIC OPERATION THROUGH A LEFT THORACOTOMY: AN ALTERNATIVE TO AVOID RETROGRADE ARTERIAL PERFUSION J. Thorac. Cardiovasc. Surg., June 1, 1997; 113(6): 1113 - 1114. [Full Text]
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K. Tayama, H. Akashi, S. Fukunaga, K. Kosuga, and S. Aoyagi Operation for Type B Aortic Dissection Using Hypothermic Selective Cerebral Perfusion Ann. Thorac. Surg., February 1, 1997; 63(2): 535 - 537. [Abstract] [Full Text]
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L. G. Svensson Central Nervous System Injury After Aortic Operations: Profits of Amending Old Ways Ann. Thorac. Surg., January 1, 1997; 63(1): 9 - 11. [Full Text]
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J. S. Coselli, S. A. LeMaire, L. P. de Figueiredo, and R. P. Kirby Paraplegia After Thoracoabdominal Aortic Aneurysm Repair: Is Dissection a Risk Factor? Ann. Thorac. Surg., January 1, 1997; 63(1): 28 - 36. [Abstract] [Full Text]
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J.-i. Hayashi, S. Eguchi, K. Yasuda, S. Komatsu, K. Tabayashi, M. Masuda, R. Yozu, K. Amemiya, E. Takeuchi, S. Nakano, et al. Operation for Nondissecting Aneurysm in the Descending Thoracic Aorta Ann. Thorac. Surg., January 1, 1997; 63(1): 93 - 97. [Abstract] [Full Text]
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L. G. Svensson INTRAOPERATIVE IDENTIFICATION OF SPINAL CORD BLOOD SUPPLY DURING REPAIRS OF DESCENDING AORTA AND THORACOABDOMINAL AORTA J. Thorac. Cardiovasc. Surg., December 1, 1996; 112(6): 1455 - 1461. [Abstract] [Full Text]
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R. B. Griepp, M. A. Ergin, J. D. Galla, S. Lansman, N. Khan, C. Quintana, J. McCollough, and C. Bodian SURGERY FOR ACQUIRED HEART DISEASELOOKING FOR THE ARTERY OF ADAMKIEWICZ: A QUEST TO MINIMIZE PARAPLEGIA AFTER OPERATIONS FOR ANEURYSMS OF THE DESCENDING THORACIC AND THORACOABDOMINAL AORTA J. Thorac. Cardiovasc. Surg., November 1, 1996; 112(5): 1202 - 1215. [Abstract] [Full Text]
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R. M. Bojar, D. D. Payne, R. E. Murphy, S. L. Schwartz, J. R. Belden, L. R. Caplan, and H. Rastegar Surgical Treatment of Systemic Atheroembolism From the Thoracic Aorta Ann. Thorac. Surg., May 1, 1996; 61(5): 1389 - 1393. [Abstract] [Full Text]
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J. S. Coselli Thoracoabdominal Aortic Aneurysms Ann. Thorac. Surg., January 1, 1996; 61(1): 269 - 270. [Full Text]
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