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Ann Thorac Surg 1999;67:593-594
© 1999 The Society of Thoracic Surgeons

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Correspondence

Surgical management of the ruptured aortic arch

^a Department of Thoracic Cardiovascular Surgery, Niigata University School of Medicine, 1-757 Asahimachi-dori, Niigata City 951-8510 Japan

We read with great interest the article by Prêtre and associates [1]. The surgical approach for operating on the ruptured aortic arch is one of the most difficult problems in the field of cardiovascular surgery, as they indicated. It is particularly important to control bleeding and to protect the brain and the myocardium when the patient is in a hemodynamically unstable condition because of continuous bleeding. Since January 1995, we have developed and performed a new procedure on 5 patients with a ruptured thoracic aortic aneurysm; 3 patients had a true aneurysm and 2 patients a type A dissection.

Before the chest was opened, cardiopulmonary bypass was established with cannulation of the iliac artery and vein and both common carotid arteries in the neck. The initial bypass flow was 0.5 L/min to the carotid arteries and 0.5 L · min^-1 · m^-2 to the iliac artery. The body was cooled to 34°C, and the brain, to 28°C with another heat exchanger. After the carotid arteries in the neck were clamped, a median sternotomy was performed. To control bleeding, venous drainage was increased until the entire sternum was divided. Extension of the aortotomy on the ascending aorta to the aortic arch was then carried out. After the aortotomy, occlusion balloons were inserted into the descending aorta and the left subclavian artery. Myocardial protection was achieved by selective coronary perfusion of cold blood cardioplegia and by cardiac venting. The bypass flow to the iliac artery was increased, and the flow to the carotid arteries was kept at 0.5 L/min.

The advantages of our procedure can be summarized as follows: The bilateral common carotid arteries in the neck are easily exposed, and selective cerebral perfusion through them is begun immediately to help prevent cerebral ischemia resulting from nonhomogeneous cooling of the brain [1]. It is not necessary to delay the operative procedure, until core cooling has occurred or to provide compression on the bleeding site [1]. Myocardial damage from cardiac distention caused by aortic regurgitation or ventricular fibrillation during core cooling can be avoided. Four of our 5 patients with tamponade are alive without neurologic deficits and myocardial dysfunction; 1 died of multiorgan failure.

Recently, we [2] have expanded the indications for this procedure to include elective reoperation on thoracic aortic aneurysms. To control bleeding, the occlusion balloon in the femoral artery is inserted into the descending thoracic aorta [2].

We believe that our procedure is advantageous for patients who undergo emergency operation for a ruptured thoracic aorta, elective operation for a large retrosternal aneurysm, and reoperation on the thoracic aorta.

References

1. Prêtre R., Murith N., Delay D., Kalonji T. Surgical management of hemorrhage from rupture of the aortic arch. Ann Thorac Surg 1998;65:1291-1295.[Abstract/Free Full Text]
2. Sogawa M., Yamamoto K., Haga M., et al. Successful surgery for an acute type A aortic dissection following repair of a descending thoracic aortic aneurysm. Nippon Kyobu Geka Gakkai Zaishi 1998;46:253-256.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Moro, H. Articles by Sogawa, M. Search for Related Content PubMed PubMed Citation Articles by Moro, H. Articles by Sogawa, M. Related Collections Related Article