Ann Thorac Surg 1998;65:955-960
© 1998 The Society of Thoracic Surgeons
Impact of Retrograde Cerebral Perfusion With Posterolateral Thoracotomy on Distal Arch Aneurysm Repair
Chojiro Yamashita, MDaa,
Masayoshi Okada, MDaa,
Tosiki Yoshimura, MDaa,
Takasi Azami, MDaa,
Keitarou Nakagiri, MDaa,
Hidetaka Wakiyama, MDaa,
Keiji Ataka, MDaa
a Division II, Department of Surgery, Kobe University School of Medicine, Kobe, Japan
Accepted for publication October 3, 1997.
Address reprint requests to Dr Yamashita, Division II, Department of Surgery, Kobe University School of Medicine, 7-5 Kusunoki-cho, Chuo-ku, Kobe, Japan 650
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Abstract
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Background. Repair of distal aortic arch aneurysms is difficult to accomplish through a median sternotomy or left thoracotomy, and stroke and respiratory disorders often become lethal complications with the use of circulatory arrest. We investigated the use of retrograde cerebral perfusion with a posterolateral thoracotomy in the repair of distal arch aneurysms.
Methods. Thirty-eight patients underwent repair of a distal arch aneurysm. They were divided into three groups according to the method of surgical repair used. Sixteen patients (group I) underwent proximal anastomosis of the graft with the use of an aortic cross-clamp. Eight patients (group II) underwent open proximal anastomosis with the use of retrograde cerebral perfusion (oxygenated blood perfusion through a superior vena cava cannula) and a median sternotomy and anterolateral thoracotomy. Fourteen patients (group III) also underwent open anastomosis with the use of retrograde cerebral perfusion (cerebral perfusion through blood returned to the right atrium with the patient in the Trendelenburg position) and a posterolateral thoracotomy.
Results. The operative mortality rate in group I was 25.0%; 4 of 16 patients died of stroke, myocardial infarction, and intestinal necrosis. In group II, 3 of 8 patients (37.5%) died of respiratory failure and aortic dissection. In group III, only 1 of 14 patients (7.1%) died, as a result of heart failure.
Conclusions. The use of retrograde cerebral perfusion with a posterolateral thoracotomy is an alternative method that minimizes the risk of stroke and respiratory failure during distal aortic arch operations.
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Introduction
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Circulatory arrest and profound hypothermia are used frequently during aortic arch operations. This method does not necessitate carotid or brachiocephalic cannulation, and it can be applied easily during typical cardiopulmonary bypass. With the use of this technique, open bloodless replacement of the aortic arch without cross-clamping is possible. The safe period for circulatory arrest, however, has not been well established in adults. In previous reports, cerebral complications occurred in 15% to 50% of patients. An ischemic period of greater than 45 minutes is associated with an increased risk of stroke. Morbidity and mortality increase significantly when circulatory arrest times exceed 60 minutes [1]. Since 1990, we have used retrograde cerebral perfusion (RCP) in the repair of distal aortic arch aneurysms. However, exposure of these aneurysms through a median sternotomy with a lateral thoracotomy often results in respiratory failure caused by phrenic nerve paralysis. The use of retrograde cerebral perfusion with a posterolateral thoracotomy often prevents these complications. Herein, we review our results with the use of this method.
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Material and methods
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Between 1986 and 1996, 49 patients underwent resection and reconstruction of a distal aortic arch aneurysm at our institution. This included 38 elective operations and 11 emergency operations involving aortic rupture. There were 26 men and 12 women ranging in age from 22 to 80 years. The distal arch aneurysms included 29 atherosclerotic lesions and 9 cases of chronic dissection. The 38 patients who underwent elective operations were divided into three groups according to the operative approach used (Table 1). Between 1986 and 1989, 16 patients (group I) underwent graft anastomosis with the use of aortic cross-clamping and left heart bypass. These aneurysms were exposed through a median sternotomy with an anterolateral thoracotomy in 9 patients and through a posterolateral thoracotomy in 7 patients (Table 2).
From 1990 to 1993, 8 patients (group II) underwent repair of an aortic aneurysm through a median sternotomy with an anterolateral thoracotomy (open door technique). Retrograde cerebral perfusion with deep hypothermia was used [2]. Cardiac arrest was induced 5 minutes before circulatory arrest by aortic cross-clamping, antegrade blood cardioplegia, and topical cooling with ice slush. An open proximal anastomosis was performed and the distal side of the graft was clamped. At this time, RCP was stopped and a separate extracorporeal perfusion through the ascending aorta and femoral artery was instituted. The distal anastomosis was completed during rewarming (Table 3).
From 1994 to 1996, 14 patients (group III) underwent aneurysm repair through a posterolateral thoracotomy made in the fourth intercostal space. Arterial cannulation was accomplished through the left femoral artery and venous cannulation through the femoral vein–right atrium and pulmonary artery. Cardiopulmonary bypass with core cooling was initiated and circulatory arrest was achieved at a rectal temperature of 20°C (Fig 1).
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Fig 1. Arterial perfusion from the femoral artery. Venous cannulation was performed from the right atrium and the pulmonary artery. Partial cardiopulmonary bypass with core cooling was initiated.
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The patients were placed in the Trendelenburg position to elevate the central venous pressure to 15 mm Hg. Femoral artery perfusion was started at a rate of 1.5 L/min. Consequently, RCP through blood returned to the right atrium was initiated. The aneurysm was incised longitudinally and the heart was arrested using St. Thomas’ cardioplegia with saline solution delivered through a balloon catheter placed in the ascending aorta. Topical cooling with ice slush was not used. An open proximal anastomosis was performed in the same manner as in group II (Fig 2). After completion of the anastomosis, the graft end was raised to eliminate residual air and the graft was filled with blood before clamping. The distal end of the graft was clamped and RCP was stopped. Arterial perfusion through the branch graft and femoral artery was instituted (Fig 3). The distal anastomosis then was completed during rewarming (Fig 4; Table 4).
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Fig 2. The aneurysm was incised and the heart was arrested using St. Thomas’ cardioplegia instilled through a balloon catheter placed in the ascending aorta. An open proximal anastomosis was performed.
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Fig 3. The distal side of the graft was clamped and retrograde cerebral perfusion was stopped. Arterial perfusion through the branch graft and femoral artery was instituted.
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Statistical analysis
Preoperative complications, postoperative complications, operative mortality, and hospital mortality among groups I, II, and III were analyzed by univariate analysis with 
2 tests or t tests. A p value of less than 0.05 was considered statistically significant.
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Results
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Preoperative complications
Among the three study groups, preoperative complications included angina pectoris and respiratory and renal dysfunction. There was no statistically significant difference in the incidence of these complications among the three groups (Table 5).
Surgical procedure and mortality rate
In group I, 11 patients underwent graft replacement and 5 patients underwent patch repair. Bypass time for the patients who underwent left heart bypass ranged from 15 to 167 minutes (mean, 74 ± 37.8 minutes). Four patients died, 1 of an intraoperative myocardial infarction, 1 of an embolus to the superior mesenteric artery, 1 of a brain infarction, and 1 of acute renal failure. The in-hospital mortality rate was 25.0% (4 of 16 patients).
In group II, 6 patients underwent graft replacement (including 5 with left subclavian artery reconstruction) and 2 patients underwent patch repair with concomitant coronary artery bypass grafting. The RCP time ranged from 28 to 70 minutes (mean, 53.4 ± 17.2 minutes). Three patients died of intraoperative aortic dissection and respiratory failure resulting from phrenic nerve paralysis and subsequent pneumonia. The in-hospital mortality rate was 37.5% (3 of 8 patients).
In group III, distal arch graft replacement was carried out in 14 patients, including 3 with left subclavian artery reconstruction and 1 with coronary artery bypass grafting. The RCP time ranged from 27 to 70 minutes (mean, 53.7 ± 13.5 minutes). The mean cardiac ischemic time was 55.4 ± 13.5 minutes (range, 30 to 70 minutes) and the mean cardiopulmonary bypass time was 254 ± 106 minutes (range, 111 to 541 minutes). Only 1 (7.1%) of 14 patients died. Cardiac failure developed in this patient and cardiopulmonary bypass could not be discontinued (Table 6).
Postoperative complications
Postoperative complications, including causes of death, were compared among the three study groups. Embolic episodes such as brain infarction, intraoperative myocardial infarction, and intestinal necrosis (all confirmed by autopsy) were decreased prominently in group II. In addition, there were no embolic episodes in group III (p < 0.05). In group II, respiratory failure necessitating ventilatory care for longer than 3 weeks developed in 3 patients. The causes of respiratory failure included intrapulmonary bleeding through the open door thoracotomy (median sternotomy with anterolateral thoracotomy) with subsequent pneumonia and phrenic nerve paralysis resulting from topical cooling. In group III, pulmonary complications were decreased significantly compared with the other two groups. None of the patients who had a posterolateral thoracotomy needed respiratory care for more than 4 days (p < 0.05).
In group I, 1 patient died of a massive brain infarction, another had a minor cerebral infarction, and 1 had paraplegia. The patient with the minor cerebral infarction and the one with paraplegia recovered rapidly with the use of an active rehabilitation program. In group II, hemiplegia developed in 1 patient as the result of a small cerebral infarction. In group III, a small cerebral infarction occurred in 1 patient, but it resolved completely (Table 7).
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Comment
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Since 1980, the optimal approach for the repair of distal aortic arch aneurysms has been controversial. Kay and colleagues [3] reported that distal arch aneurysms could be repaired with the use of a single cross-clamp placed between the innominate and left carotid arteries through a posterolateral thoracotomy. The mean aortic cross-clamp time was 27 ± 10 minutes for graft replacement and the in-hospital mortality rate was 6%. There were no strokes; however, paraplegia occurred in 9.4% of patients, acute renal failure in 6.2%, and respiratory failure in 12.5%. The mean aortic cross-clamp time of 27 minutes in this study was too short to allow for the reconstruction of a fragile, atheromatous aorta. Adjunctive measures are necessary for the repair of distal arch aneurysms.
In 1984, Olivier and co-workers [4] reported that use of the Biomedicus (Eden Prairie, MN) centrifugal pump without heparin was helpful for repairing traumatic tears of the thoracic aorta. With the use of this method, the blood perfusion to the kidneys, visceral organs, and spinal cord was well preserved. From 1986 to 1990, we used this method for the repair of distal aortic arch aneurysms. However, cerebral infarction, myocardial infarction, and bowel necrosis occurred frequently. These complications may have been related to direct embolization of the atheromatous debris after release of the aortic cross-clamp.
Profound hypothermia with circulatory arrest has been a frequently used method of cerebral protection during operations on the aortic arch [5]. With the use of this technique, open bloodless replacement of the aortic arch without cross-clamping is possible. This procedure, however, allows only a limited time to perform the aortic repair, and it may lead to severe transient or permanent neurologic disorders, especially in elderly patients. Svensson and associates [6] reported that with the use of deep hypothermia and circulatory arrest, the risk of stroke is increased after 40 minutes. Moreover, the mortality rate is increased markedly after 65 minutes. In 1987, Crawford and colleagues [7] reported that thoracic aneurysms could be resected through a posterolateral exposure with the use of circulatory arrest, but the risks of this operation were greater than average in some of their patients and the mortality rate was higher than expected. Other investigators have reported aortic arch replacement carried out with the use of circulatory arrest and a posterolateral exposure. The early mortality rate was 13.9% and the rate of perioperative neurologic injury ranged from 11% to 19% [8–12].
In 1990, we introduced the use of RCP for aortic arch operations. Distal arch aneurysms were exposed through a median sternotomy with an anterolateral thoracotomy [12]. With the use of this approach, the operative field is simplified and the risk of air and debris emboli to the brain is minimized [13]. In 1988, Ueda and associates [14] used this technique for operations on the aortic arch. Imamaki and co-workers [15] reported that 90 minutes of circulatory arrest was possible using RCP at a flow rate of 250 to 300 mL/min and a rectal temperature of 20°C. This allowed time for secure proximal anastomosis of distal arch aneurysms. In our series, recovery of consciousness was complete in all surviving patients.
Pulmonary complications occurred frequently, however, and long-term respiratory care often was necessary. The causes of respiratory failure included presumed intrapulmonary bleeding with the open door thoracotomy, which led to the development of pneumonia. In addition, a case of phrenic nerve paralysis occurred as a result of topical cooling using ice slush. Crawford and associates [7] reported that the incidence of complications, particularly pulmonary complications, was considerably higher when circulatory arrest was used. This was the case even in younger, good-risk patients. These pulmonary complications were caused primarily by pulmonary injury resulting from retraction in patients who were fully heparinized. Acute respiratory distress syndrome developed, and prolonged respiratory support often was necessary. Scheld and co-workers [8] also reported that aortic arch replacement could be carried out with the use of circulatory arrest and a posterolateral exposure. However, the patients needed ventilatory support for about 6 days because of pulmonary insufficiency. Kouchoukos and colleagues [16] reported that collapse and gentle retraction of the left lung during aortic replacement, accurate reversal of heparin with protamine after the operation, and avoidance of excessive transfusion of blood products should lessen the prevalence of serious pulmonary complications.
Since 1994, we have altered our operative approach to include RCP [17]. Distal arch aneurysms are exposed through a posterolateral thoracotomy. A left posterolateral thoracotomy has the following advantages: (1) the proximal anastomosis is very easy to perform and is performed as an open proximal anastomosis; (2) when the aneurysm extends into the descending aorta, the distal anastomosis is accessible and hemostasis of the suture line is easy to achieve in a well-exposed operative field; and (3) surgical stress to the body is less than with the open door thoracotomy [18]. Retrograde cerebral perfusion is performed by elevating the right atrial pressure using arterial perfusion at a flow rate of 1.5 L/min with the patient’s head in the Trendelenburg position. Topical cooling with ice slush is not used so as to prevent phrenic nerve paralysis. After a proximal open anastomosis has been performed, cardiopulmonary bypass with perfusion from the branch graft and femoral artery is begun. The need for long-term respiratory care as a result of phrenic nerve paralysis and pneumonia has ceased with the use of this technique.
Of the 14 patients in group III who underwent elective operations, 2 could not be weaned from cardiopulmonary bypass because of low cardiac output syndrome. These patients required venoarterial bypass after operation. Fortunately, 1 patient was weaned from venoarterial bypass after 17 hours. This patient recovered completely without additional complications. During a posterolateral thoracotomy with RCP, the heart is surrounded by the pericardium and the size of the fibrillating heart cannot be estimated during core cooling. The complications that occurred in these 2 patients during weaning from bypass were presumed to have resulted from myocardial ischemia caused by left ventricular expansion during ventricular fibrillation. Kouchoukos and colleagues [16] reported that hypothermic fibrillatory arrest is well tolerated in the normal heart, particularly if venting is performed. However, in the presence of significant aortic insufficiency or coronary artery disease, myocardial perfusion may be impaired significantly even with venting. For patients with extensive coronary artery disease, coronary artery bypass grafting before elective aortic resection may be advisable. After observing these complications, we began to use left ventricular venting from the apex during core cooling. Thereafter, cardiac failure during weaning from cardiopulmonary bypass was not encountered.
We conclude that retrograde cerebral perfusion with pharmacologic brain protection is useful for cerebral protection during distal aortic arch aneurysm repair. Respiratory failure as a result of phrenic nerve paralysis is not observed during left posterolateral thoracotomy when topical cooling with ice slush to the heart is not used. Finally, left ventricular venting during core cooling is necessary to prevent cardiac failure caused by myocardial ischemia.
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References
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Abstract
Introduction
