Ann Thorac Surg 2001;71:29-32
© 2001 The Society of Thoracic Surgeons
Original article: cardiovascular
Thoracic and thoracoabdominal aneurysm repair under deep hypothermia using subclavian arterial perfusion
Yukinori Moriyama, MDa,
Yoshifumi Iguro, MDa,
Koichi Hisatomi, MDa,
Goichi Yotsumoto, MDa,
Hiroyuki Yamamoto, MDa,
Riichiro Toda, MDa
a Second Department of Surgery, Kagoshima University, Faculty of Medicine, Kagoshima, Japan
Accepted for publication May 31, 2000.
Address reprint requests to Dr Moriyama, Division of Cardiovascular Surgery, National Takasaki Hospital, Takasakicho 36, Gunma, Japan
e-mail: moriyama{at}med6.kufm.kagoshima-u.ac.jp
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Abstract
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Background. Hypothermic circulatory arrest is a valuable adjunct for thoracic and thoracoabdominal aortic aneurysm repair. Retrograde aortic perfusion through the femoral artery, however, carries a risk of cerebral embolism or malperfusion. To avoid these complications we adopted antegrade aortic perfusion through a prosthetic graft attached to the left subclavian artery through a left thoracotomy.
Methods. Ten patients had repair of descending thoracic and thoracoabdominal aortic aneurysm under deep hypothermia with antegrade aortic perfusion through the left subclavian artery. Hypothermic circulatory arrest was used because proximal aortic control was hazardous due to rupture or intraluminal disease, or for spinal cord protection.
Results. There was no brain injury and one hospital death. The cause of death was massive bleeding from the gastrointestinal tract not related to deep hypothermia or the perfusion method. All 9 survivors were alive and well after a mean follow-up period of 9 months.
Conclusions. Using the left subclavian artery as a site of aortic perfusion can avoid retrograde aortic perfusion, hence reducing the potential for brain injury due to embolic stroke or malperfusion through a dissected thoracoabdominal aorta.
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Introduction
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Retrograde aortic perfusion through the femoral artery with deep hypothermic circulatory arrest (HCA) is a valuable adjunct for thoracic and thoracoabdominal aneurysm repair [1–6]. However, retrograde perfusion of the brain through an atheromatous or dissected aorta carries the risk of cerebral embolism or malperfusion [6–9]. To avoid these fatal complications we have recently adopted proximal aortic perfusion through a prosthetic graft attached to the left subclavian artery by a left thoracotomy. We report here our experience with aneurysm repair in the descending thoracic and thoracoabdominal aorta under deep hypothermia using our antegrade aortic perfusion technique.
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Material and methods
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Between January 1994 and December 1999, a total of 45 patients underwent aneurysm repair in the descending thoracic or thoracoabdominal aorta. Ten of the 45 patients had aneurysm repairs under HCA using a left subclavian artery as the site of proximal aortic perfusion. The patient details are summarized in Table 1. There were 9 men and 1 woman, aged between 50 and 74 years (mean, 65 years). The aortic pathology for operation included aortic dissection in 7 patients, atherosclerotic aneurysm in 2, and traumatic rupture in 1. The decision to use HCA was made in 6 patients because proximal aortic control could not be performed safely due to aortic rupture or intraluminal disease. In the remaining 4 patients, HCA was used because the aortic disease requiring graft replacement involved most or all of the entire descending thoracic aorta or the thoracoabdominal aorta with high risk of spinal cord ischemic injury.
Operative technique
All patients had placement of a double-lumen endotracheal tube and were placed in a right lateral decubitus position. A pulmonary artery catheter and right radial and right femoral arterial lines were inserted. Transesophageal echocardiography was carried out in all 10 patients. The descending thoracic aorta was exposed through a posterolateral thoracotomy incision through the fourth intercostal space, and the incision was extended obliquely across the costal margin to the left pararectal line when necessary. The diaphragm was incised circumferentially and the abdominal aorta was exposed through an extraperitoneal approach. The left femoral artery and vein were exposed through an oblique incision, and a 28F long cannula was inserted and positioned in the right atrium. When a cannula of this size could not be inserted, the pulmonary artery was also cannulated and flows of greater than 2.2 L · min-1 · m-2 were accomplished.
During the period of cooling all 10 patients underwent an antegrade aortic perfusion through a prosthetic graft attached to the left subclavian artery. For this purpose the proximal segment of the left subclavian artery was gently mobilized for about 2 cm and encircled with umbilical tape. After heparinization the artery was clamped proximally and distally, and an 8-mm, sealed, woven Dacron (C. R. Bard, Haverhill, PA) graft was attached to it by end-to-side fashion using a 5-0 polypropylene suture (Fig 1). The graft was secured anteriorly in the wound, away from the main operative field. The left lung was collapsed and gently retracted anteriorly to minimize manipulation injury. After initiation of cardiopulmonary bypass, a sump-tipped venting catheter was placed in the left ventricle through the left superior pulmonary vein, and cooling was continued until the esophageal temperature reached 18°C and the rectal temperature dropped below 22°C. This required a mean perfusion time of 42 minutes (range, 30 to 55 minutes). At this stage the circulation was arrested.
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Fig 1. Left subclavian artery cannulation technique. After proximal and distal control of the left subclavian artery (LSA) a woven Dacron graft is anastomosed to it, followed by cannulation with a polyvinyl arch cannula. Venous drainage is completed through the main pulmonary artery or femoral vein. (CPB = cardiopulmonary bypass; FA = femoral artery.)
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The proximal aorta was transected at the appropriate level, and the anastomosis of the Dacron graft to the proximal aorta was completed using 3-0 polypropylene sutures, buttressed with a strip of polyester felt (C.R. Bard, Inc, Woburn, MA). Cardioplegic solution was not used when a period of circulatory arrest was less than 40 minutes in this series. Flow through the left subclavian artery then was reestablished to restore antegrade cerebral and coronary circulation. A variety of segments of the thoracoabdominal aorta were replaced without time constraint. In case of chronic aortic dissection an elephant trunk procedure was applied: a free floating graft was inserted into the distal aorta after resection of the intimal flap. For the repair of an extensive thoracoabdominal aortic aneurysm the intercostal arteries and visceral branches were reconstructed under sequential clamping method after completion of the proximal anastomosis (Fig 2). Throughout the procedure electroencephalographic monitoring was used. The redox states of hemoglobin and cytochrome oxidase in the brain were also monitored continuously by near-infrared spectroscopy (OM-110, Shimazu, Tokyo, Japan). However, somatosensory or motor-evoked potentials were not monitored.
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Fig 2. Drawing of replacement of the proximal descending thoracic or thoracoabdominal aorta. (A) An open proximal anastomosis is made. (B) Antegrade perfusion is carried out through the left subclavian artery during the distal anastomosis. (C) In case of chronic dissection an elephant trunk procedure is applied. (D) For the repair of a thoracoabdominal aortic aneurysm the intercostal arteries and visceral branches are reconstructed in a sequential clamping method.
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Two patients with extensive atherosclerotic aneurysms had their entire thoracoabdominal aorta replaced. One patient who had traumatic rupture of the isthmus underwent proximal descending thoracic replacement. For patients who had aortic dissection, the enlarged proximal dissected segment including the intimal tear was resected, along with the descending thoracic aorta. One patient with chronic type B dissection, who had a history of aortic root reconstruction for acute type A dissection 5 years before, underwent replacement of the entire thoracoabdominal aorta and reconstruction of the intercostal arteries plus visceral branches. The other patient with chronic type B dissection and fusiform abdominal aortic aneurysm required concomitant replacements of the proximal descending thoracic aorta and infrarenal abdominal aorta. Perfusion data are summarized in Table 2.
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Results
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There was no stroke but one hospital death. The patient who died was a 69-year-old woman with preexisting chronic obstructive pulmonary disease; she had a Crawford type II thoracoabdominal aortic aneurysm and had her entire thoracoabdominal aorta replaced. She showed an uneventful initial recovery from the operation with no neurologic deficit and was extubated on the second postoperative day. However, she developed severe respiratory failure after pneumonia and finally succumbed to massive gastrointestinal bleeding on the 25th day after the operation. The remaining 9 patients recovered satisfactorily with no complications related to deep hypothermia or our antegrade aortic perfusion technique. One male patient with a preexisting nephrotic syndrome had a transient elevation of serum creatinine (up to 3.0 mg/dL) greater than preoperative levels, but he maintained a normal urinary output and did not require dialysis. The mean duration of postoperative hospital stay was 22 days (range, 14 to 52 days). All 9 hospital survivors were alive and well after a mean follow-up period of 9 months (range, 0.2 to 1.7 years).
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Comment
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Despite advances in anesthetic management and surgical techniques, cerebrovascular accident is a devastating complication following cardiac or aortic surgery [6–10]. The general causes of stroke during and early after aortic surgery include systemic hypotension caused by bleeding, embolization of particles or air, malperfusion syndromes in aortic dissection, and inadequate brain protection during HCA. At our institution HCA has been used for descending thoracic and thoracoabdominal aneurysm repair to ensure spinal cord protection or when the safe proximal aortic control would have been hazardous due to the presence of aortic rupture or intraluminal disease. Retrograde aortic perfusion through the femoral artery is a simple and convenient method, but can be complicated by obstructive arteriosclerotic disease and fragile atheroma or thrombus in the thoracoabdominal aorta [9, 11]. In our limited experience HCA has been reasonably safe with only one death, which was not related to deep hypothermia or the perfusion technique.
The left subclavian artery that was accessed easily through a thoracotomy has been used for a systemic-to-pulmonary arterial shunt using a prosthetic graft in neonates or small infants [12]. In addition, the axillary artery, a distal segment to the subclavian artery, is also well known as an alternative site for proximal arterial perfusion for cardiopulmonary bypass with good results in patients with severe atherosclerotic or aneurysmal disease [8, 9]. In this report we presented the antegrade aortic perfusion technique through the left subclavian artery. Although few patients have undergone this technique, we found that no patient had cerebral complication. In view of our favorable results, we believe our antegrade aortic perfusion technique may be safe and may effectively prevent embolic stroke caused by retrograde perfusion of the diseased thoracoabdominal aorta. In addition, a prosthetic graft used for arterial perfusion is available for later reconstruction of the left subclavian artery system when necessary.
Westaby and Katsumata [11] proposed a proximal aortic perfusion through the ascending aorta or aortic arch by an extended left thoracotomy for the treatment of complex arch and descending aortic disease. However, there is still some possibility that cerebral emboli may be produced even by simple external manipulation of an atheromatous aorta or aneurysm itself. The method we describe, however, is advantageous for several reasons, mostly owing to its simplicity and feasibility under a "no-touch" technique on an atheromatous aorta or aneurysm. Our technique avoids retrograde aortic perfusion to the brain at any time during the operative procedure, hence reducing the potential for cerebral injury due to embolization from the distal atherosclerotic aorta or malperfusion through the dissected thoracoabdominal aorta. We present this strategy as an useful adjunct to be added to the armamentarium of cardiovascular surgeons working in this field.
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References
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Abstract
Introduction
