Ann Thorac Surg 1997;63:535-537
© 1997 The Society of Thoracic Surgeons
Case Report
Operation for Type B Aortic Dissection Using Hypothermic Selective Cerebral Perfusion
Keiichiro Tayama, MD,
Hidetoshi Akashi, MD,
Shuji Fukunaga, MD,
Kenichi Kosuga, MD,
Shigeaki Aoyagi, MD
Second Department of Surgery, Kurume University School of Medicine, Kurume, Japan
Accepted for publication August 13, 1996.
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Abstract
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A 56-year-old man who had a huge type B dissecting aortic aneurysm extending from the distal arch to the thoracoabdominal aorta underwent replacement of the descending thoracic and thoracoabdominal aorta under hypothermic circulatory arrest with selective cerebral perfusion. The intercostal arteries at the T-8 to T-11 level were preserved with beveled distal anastomosis, and the celiac artery and the intercostal arteries at the T-5 and T-6 levels were reconstructed. The patient recovered uneventfully and is presently doing well 1 year after the operation.
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Introduction
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In operation for type B aortic dissection, various support techniques such as profound hypothermic circulatory arrest (HCA) with or without retrograde cerebral perfusion (RCP) [1–3], atriofemoral bypass, and femorofemoral bypass [4, 5] have been used for surgical treatment of type B aortic dissection. Among these techniques, HCA with or without RCP is the most common procedure at present. We recently performed replacement of the descending thoracic and thoracoabdominal aorta using HCA with selective cerebral perfusion (SCP) through the anterolateral thoracotomy incision in a patient with type B aortic dissection.
A 56-year-old man was referred to our hospital for close examination of an abnormality on a roentgenogram of the chest. Two-dimensional echocardiography showed a normally sized ascending aorta with no intimal flap and no aortic regurgitation. Computed tomographic scans revealed a dilated descending aorta of 8 cm in diameter, in which there was an intimal flap. Aortography delineated aortic dissection extending from the descending aorta just below the left subclavian artery to the thoracoabdominal aorta distal to the celiac artery (Fig 1
). The diagnosis of type B chronic aortic dissection was made.
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Fig 1. . Digital subtraction angiography showing a dilated false channel of the distal aortic arch and descending aorta.
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At operation, before thoracotomy, we anastomosed 8-mm Dacron vascular grafts to the right subclavian artery and right femoral artery for access of extracorporeal circulation. The descending aorta and thoracoabdominal aorta were exposed through an anterolateral thoracotomy and thoracoabdominal incision. Extracorporeal circulation was started by way of the right subclavian artery and a long venous catheter inserted to the right atrium from the right femoral vein, and a venting catheter was placed in the left atrium. Cardiac arrest was provided by cold cardioplegic solution through the aortic root, while the ascending aorta was clamped. When the rectal temperature reached 20°C, the systemic perfusion was stopped and the descending aorta was opened after the arch vessels were clamped. Then SCP via three arch vessels was established with a flow rate of 12 mL•kg-1• min-1 using a single roller pump separated from the systemic circulation (Fig 2). To prevent ischemic injury of the spinal cord, the distal anastomosis was completed first, and then distal aortic perfusion and rewarming on extracorporeal circulation through the right femoral artery was initiated. The intercostal arteries at the T-8 to T-11 level were preserved with a beveled distal anastomosis, and the celiac artery and the intercostal arteries at the T-5 and T-6 levels were reconstructed with short segments of Dacron vascular grafts. The descending aorta was transected 1 cm distal to the left subclavian artery, and proximal anastomosis was performed using a 22-mm Dacron vascular graft (Hemashield; Meadox Medicals Inc, Oakland, NJ). When the proximal anastomosis was achieved, SCP was stopped and systemic perfusion via the right subclavian artery was started. Extracorporeal circulation was discontinued when the rectal temperature reached 36°C. The patient recovered uneventfully, and he is doing well 1 year after the operation.
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Fig 2. . System of antegrade selective cerebral perfusion. Blood was perfused to three aortic arch vessels using a single roller pump separated from the systemic circulation (inserting balloon-tipped cannulas to the left common carotid and subclavian arteries from the aortic lumen). (Ao = aorta; RA = right atrium.)
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Comment
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Avoidance of injury of the aortic wall resulting from aortic clamping and prevention of ischemic damage of the spinal cord are the key points in surgical treatment of type B aortic dissection. To achieve these goals, various support techniques such as profound HCA with or without RCP [1–3], atriofemoral bypass, and femorofemoral bypass [4, 5] have been used for surgical treatment of type B dissection. Among these techniques, HCA with RCP is the most common technique at present. Hypothermic circulatory arrest has the advantage of being simple without the need for special equipment or cannulation of arch vessels, and systemic hypothermia protects not only the brain but also the spinal cord from ischemic damage. However the limited safe duration of circulatory arrest is a major drawback of this technique. The safe duration of HCA has been generally estimated to be 40 minutes even at a rectal temperature of less than 18°C [2]. Retrograde cerebral perfusion combined with HCA, which was introduced to aortic surgery by Ueda and colleagues [6], has certainly provided prolongation of the safe duration of HCA in adult brain. Usui and colleagues [7] demonstrated that less than 60 minutes of RCP could be tolerated with minimal risk of brain complication. In addition, this simple technique requires no dissection or manipulation of arch vessels and provides a much better operative field than SCP. However, the safe duration of HCA with RCP is also not clearly established. Moreover, the technique has the possibility of malperfusion of the cerebral blood flow [8].
Many investigators have emphasized the usefulness and reliability of SCP under hypothermia in surgical treatment of aortic arch aneurysms [9, 10]. In this case, we replaced the descending aorta and thoracoabdominal aorta using SCP under deep hypothermia and open proximal and distal techniques. Hypothermic SCP offers reduction of basic metabolic requirements and provides uninterrupted oxygen and nutrient supply to the brain; therefore, it may prevent ischemic damages of the brain even in patients requiring more complicated reparative procedures. However, this technique requires complicated arterial access for extracorporeal circulation and cumbersome dissection of the head vessels.
In summary, we reported a patient with type B dissection who underwent replacement of the descending aorta using hypothermic SCP via a left thoracotomy. Although hypothermic SCP requires complicated arterial access for extracorporeal circulation and cumbersome dissection of arch vessels, more radical and secure operations such as descending, thoracoabdominal, and abdominal aorta replacement can be safely performed using this technique, even in patients with type B dissection.
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Footnotes
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Address reprint requests to Dr Tayama, Second Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830 Japan.
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References
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- Kouchoukos NT, Daily BB, Rokkas CK, Murphy SF, Bauer S, Abboud N. Hypothermic bypass and circulatory arrest for operation on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg 1995;60:67–77.[Abstract/Free Full Text]
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Abstract
Introduction
