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Ann Thorac Surg 2002;74:S1885-S1887
© 2002 The Society of Thoracic Surgeons
a Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, St. Louis, Missouri, USA
Accepted for publication July 30, 2002.
* Address reprint requests to Dr. Kouchoukos, Cardiac, Thoracic and Vascular Surgery, Inc., 3009 North Ballas Rd, Suite 266C, St. Louis, MO 63348, USA.
e-mail: ntkouch{at}aol.com
Presented at the Aortic Surgery Symposium VIII, May 2–3, 2002, New York, NY.
Abstract
BACKGROUND: Hypothermic cardiopulmonary bypass with circulatory arrest is an important adjunct for operations on the distal aortic arch, the descending thoracic, and the thoracoabdominal aorta. The safety and efficacy of this technique when compared with other adjuncts (ie, simple aortic clamping, partial cardiopulmonary bypass, regional hypothermia) is not clearly established.
METHODS: One hundred and ninety-two patients (age range, 20 to 83 years) with descending thoracic or thoracoabdominal aortic disease had resection and graft replacement of the involved aortic segments using hypothermic cardiopulmonary bypass and intervals of circulatory arrest (mean, 38 minutes). The technique was used when the location and severity of disease precluded placement of clamps on the proximal aorta (31 patients) or (in 161 patients) when extensive thoracic (47) or thoracoabdominal (114) aortic disease was present, and the risk for development of spinal cord ischemic injury was judged to be increased. Lower intercostal and lumbar arteries were attached separately to the aortic graft in 101 of the 161 patients (63%) who had extensive aortic replacement. No other adjuncts for spinal cord protection were used.
RESULTS: The 30-day mortality was 6.8% (13 patients). It was 40% (8 of 20) for patients having emergent operations (acute aortic dissection or rupture) and 2.9% (5 of 172) for all others (p < 0.001). The 90-day mortality was 12.5% (24 patients). Paraplegia occurred in 4 and paraparesis in 1 (full recovery) of the 186 operative survivors whose lower limb function could be assessed postoperatively (2.7%). Among the 109 survivors with thoracoabdominal aortic disease, early paraplegia occurred in 1 of 36 with Crawford extent I, 0 of 42 with extent II, and 2 of 31 with extent III disease. One patient (extent II) developed paraplegia on the 9th postoperative day after a hypotensive episode. None of the 47 patients with aortic dissection developed paralysis. Among the 186 operative survivors, renal dialysis was required in 4 patients (2.2%), prolonged inotropic support in 18 (10%), reoperation for bleeding in 9 (5%), mechanical ventilation (
48 hours) in 64 (34%), and tracheostomy in 17 (9%). Four patients (2%) sustained a stroke.
CONCLUSIONS: Hypothermic cardiopulmonary bypass with circulatory arrest provides safe and substantial protection against paralysis and renal, cardiac, and visceral organ system failure that equals or exceeds that of other currently used techniques but without the need of other adjuncts.
Elective hypothermic cardiopulmonary bypass (CPB) with intervals of circulatory arrest has been successfully used for the treatment of complex disease that involves the descending thoracic and thoracoabdominal aorta [1–3]. In our practice, this technique is used when the presence of proximal aortic disease makes clamping of the proximal aorta unsafe or mandates graft replacement of the arch, and when extensive thoracic or thoracoabdominal aortic disease is present, and the risk of developing paralysis is judged to be increased. The rationale for use of hypothermic CPB with periods of profound hypothermic circulatory arrest and low flow is to increase the tolerable duration of spinal cord ischemia while resection and graft replacement of the involved aortic segment and reimplantation of critical intercostal and lumbar arteries are being performed, and to provide protection for other organs.
Material and methods
Between January 1986 and February 2002, 192 patients with aortic disease involving the distal aortic arch, the descending thoracic aorta, or the thoracoabdominal aorta underwent resection and graft replacement of the diseased aortic segments using elective hypothermic CPB, usually in combination with a period of circulatory arrest. The patients ranged in age from 20 to 83 years (mean, 62 years) and 111 (58%) were male. Twenty-three patients (12%) had the clinical stigmata of Marfan’s syndrome. One hundred and fourteen patents (59%) had symptoms associated with their aortic disease. The remaining patients had aneurysms that were more than twice the size of the adjacent normal aorta, or had evidence of progressive enlargement of the aorta. Acute or chronic dissection was present in 54 patients (28%). One hundred and fourteen patients (59%) had Crawford type I, II, or III thoracoabdominal aneurysms. Twenty patients (10%) underwent emergent operations for rupture of the aneurysm or because of acute dissection. Forty-six patients (24%) had one or more previous operations on the thoracic or thoracoabdominal aorta, and 35 (18%) had undergone repair of an infrarenal abdominal aortic aneurysm.
Operative technique
Our current technique has recently been reported [1]. Routine hemodynamic monitoring and double-lumen endotracheal intubation are performed. Electroencephalographic monitoring is used. The left common femoral artery and vein are exposed, and a 28F to 32F long cannula is inserted into the vein and positioned in the right atrium. Proper placement is verified with intraoperative transesophageal echocardiography. The femoral artery is cannulated with a 20F or 22F short cannula. The descending thoracic aorta is exposed using a left posterolateral thoracotomy incision through the bed of the unresected fifth or sixth rib. If necessary, the incision is extended into the abdomen, and the diaphragm is incised radially or circumferentially. CPB is established immediately after the chest is entered, and the patient is cooled until electroencephalographic silence is achieved, and nasopharyngeal temperatures of 12°C to 15°C and bladder temperatures of 15°C to 19°C are reached. Methylprednisone (7 mg/kg) and thiopental (10 to 15 mg/kg) are given during the period of cooling. The left lung is collapsed, and the heart is vented through the apex of the left ventricle or through the left inferior pulmonary vein. The aorta distal to the diseased segment is isolated circumferentially. The remainder of the aorta is not dissected. When required, circulatory arrest is established, the distal aorta is occluded, 1,000 to 1,500 mL of blood is drained into the venous reservoir, and the intracardiac vent is occluded.
For procedures confined to the distal aortic arch and proximal descending aorta, resection and graft replacement are usually performed during a single period of circulatory arrest without placement of clamps proximally. Collagen-impregnated woven polyester grafts are used. Distally, the aorta is clamped or occluded intraluminally to minimize blood loss. After the proximal anastomosis has been completed, retrograde venous perfusion is briefly established to assist with deairing. As the distal anastomosis is being completed, the graft is clamped near the proximal anastomosis and arterial perfusion is reestablished through the femoral artery to evacuate air. After completion of this anastomosis, the graft is deaired with an 18-gauge needle, the clamp is removed, and CPB and rewarming are initiated.
For procedures on the distal descending and the thoracoabdominal aorta, circulatory arrest is established, the distal aorta is occluded, and the proximal aorta is transected at the appropriate level. After completion of the proximal anastomosis, a second arterial cannula is inserted into the graft and connected to a second arterial perfusion line. Alternatively, a 10-mm polyester graft that has been sutured to the aortic graft can be connected to the second arterial line. Retrograde venous perfusion is also used to assist in deairing. The aortic graft is then occluded distal to the proximal arterial perfusion line, and flow into the upper aorta is reestablished. One-third of the total arterial flow is directed through the proximal arterial line, and two-thirds through the distal line. During the subsequent period of hypothermic low flow with the perfusate maintained at 20°C, the anastomoses between the aortic graft and the lower intercostal, lumbar, visceral, and renal arteries, and the distal aorta are completed. An attempt is made to reimplant all patent intercostal and lumbar arteries below the level of the sixth or seventh intercostal space. This was accomplished in 101 (63%) of the 161 patients who had extensive aortic replacement. Whenever possible, the clamp on the aortic graft is repositioned below the intercostal artery-to-graft anastomosis before the more distal anastomoses are performed, in order to permit early perfusion of the implanted intercostal arteries. Rewarming is initiated as the lowest intercostal or lumbar arteries are being attached to the graft. During rewarming, spontaneous defibrillation usually occurs when the nasopharyngeal temperature reaches 26°C to 28°C. When normothermia is reached, the left ventricular venting catheter is removed and CPB is discontinued.
Apart from the use of hypothermia, methylprednisone, and thiopental, no other adjuncts for spinal cord protection were employed.
Results
Mortality
The 30-day mortality was 6.8% (13 patients). It was 40% for 20 patients who required emergent operation for aortic rupture or acute dissection and 2.9% for the remaining 172 patients (p <0.001). The 90-day mortality was 12.5% (24 patients). The 30-day mortality according to the extent of aorta replaced is shown in Table 1.
In a multivariate analysis with bootstrap bagging of the first 161 patients, the most reliably identified risk factor for 30-day mortality was the presence of acute dissection or aortic rupture [1]. The presence of Crawford type II disease was also associated with a higher mortality (Table 1). However, among the 39 patients with Crawford type II disease without aortic rupture or acute dissection and without the administration of aprotinin [1], the 30-day mortality was 5.1% (2 patients).
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48 hours) in 64 (34%), and tracheostomy in 17 (9%). Comment
For the management of diseases of the descending thoracic or thoracoabdominal aorta, we believe that hypothermic circulatory arrest offers certain advantages over other techniques, such as simple aortic clamping or use of normothermic or mildly hypothermic distal perfusion with atriofemoral or femoral-femoral bypass. These include the need for only minimal dissection of the aorta, elimination of the need for proximal and sequential aortic clamping, easy access to the proximal aortic arch and ascending aorta, a bloodless field, and return of the majority of shed blood into the perfusion circuit. The profound hypothermia provides effective protection of the brain, spinal cord, kidneys, and the abdominal viscera. Furthermore, use of other adjunctive measures, such as monitoring of cerebrospinal fluid pressure, cerebrospinal fluid drainage, monitoring of evoked potentials, separate perfusion of the renal and visceral arteries, and insertion of epidural catheters, is not necessary.
In summary, our extended experience with hypothermic CPB and circulatory arrest confirms the safety of this technique for operations on the distal aortic arch, the descending thoracic aorta, and the thoracoabdominal aorta. It is particularly useful in patients at highest risk for development of paraplegia: those with Crawford type I and II disease and aneurysms associated with dissection. Hypothermia substantially increases the tolerable duration of spinal cord ischemia, thus allowing a safe interval for attachment of intercostal and lumbar arteries. It also provides satisfactory protection of the heart, brain, kidneys, and the abdominal viscera without the need for other adjuncts.
References
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