Ann Thorac Surg 2003;76:1298-1301
© 2003 The Society of Thoracic Surgeons
Case report
Preoperative construction of an extracranial arterial shunt for resection of an aortic arch aneurysm with occluded left carotid artery
Hisato Takagi, MD, PhDa*,
Yoshio Mori, MD, PhDa,
Yukio Umeda, MD, PhDa,
Yukiomi Fukumoto, MD, PhDa,
Yoshimasa Mizuno, MDa,
Yasuhiko Kaku, MD, PhDb,
Noboru Sakai, MD, PhDb,
Hajime Hirose, MD, PhDa
a First Department of Surgery, Gifu University School of Medicine, Gifu Japan
b Department of Neurosurgery, Gifu University School of Medicine, Gifu, Japan
Accepted for publication February 21, 2003.
* Address reprint requests to Dr Takagi, First Department of Surgery, Gifu University School of Medicine, 40 Tsukasa, Gifu 500-8705, Japan
e-mail: h-takagi{at}cc.gifu-u.ac.jp
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Abstract
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A 68-year-old man with aortic arch aneurysm was referred to our department. Preoperative carotid echography and magnetic resonance angiography revealed occlusion of the left internal carotid artery. Single-photon emission computed tomography scanning indicated that cerebral blood flow was decreased and reactivity to acetazolamide was reduced in the left temporal lobe. A successful superficial temporal artery–middle cerebral artery anastomosis was first made by neurosurgeons. A postoperative single-photon emission computed tomography scan showed that cerebral blood flow and reactivity to acetazolamide were remarkably improved. Two months after the anastomosis, the aortic arch aneurysm was successfully repaired.
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Introduction
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Internal carotid artery disease occurs commonly in patients undergoing aortic reconstruction, and severe stenosis is less common in patients with aortic aneurysm than in those with aortoiliac occlusive disease [1]. Carotid artery endarterectomy is safe in selected patients who require abdominal aortic reconstruction for abdominal aortic aneurysm or aortoiliac occlusive disease, and it reduces perioperative stroke and may improve long-term survival when performed before abdominal aortic repair [2]. However, there have been no reports on repair of thoracic aortic aneurysm in combination with surgical treatment of concomitant carotid occlusive lesion. We describe a case of successful aortic arch aneurysm repair with prior superficial temporal artery–middle cerebral artery (STA-MCA) anastomosis for concurrent left internal carotid artery (ICA) occlusion.
A 68-year-old man with hoarseness from compression of the left recurrent laryngeal nerve as a result of thoracic aortic aneurysm was referred to our department. Both chest computed tomography scanning and aortography showed a saccular aneurysm located in the minor curvature of the aortic arch (Fig 1).
Although arterial pulsation was well palpable and no bruit was auscultated in the bilateral common carotid arteries, preoperative routine carotid echography as well as subsequent magnetic resonance angiography revealed occlusion of the left ICA. Single-photon emission computed tomography scanning indicated that cerebral blood flow (CBF) was decreased and reactivity to acetazolamide was reduced in the left temporal lobe (Figs 2, 3).
A successful STA-MCA anastomosis was
firstly performed by neurosurgeons. In a postoperative single-photon emission computed tomographic scan, CBF and reactivity to acetazolamide were remarkably improved (Figs 2, 3). Two months after the STA-MCA anastomosis, the patient undertook repair of the aortic arch aneurysm through a median sternotomy. Cardiopulmonary bypass was established with arterial cannulation into a prosthetic graft anastomosed to the right axillary artery because of remarkable arteriosclerotic lesions in the ascending aorta detected with periaortic echography. Antegrade selective cerebral perfusion was used for cerebral protection. The brachiocephalic artery was perfused through the graft anastomosed to the right axillary artery, and both left common carotid and left subclavian arteries were cannulated and perfused separately. During the selective cerebral perfusion, pressures of these three aortic branches were maintained at approximately 60, 60, and 40 mm Hg, respectively. Total aortic arch replacement with reconstruction of the brachiocephalic artery, the left common carotid artery, and the left subclavian artery was completed. The nadir rectal temperature during hypothermic arrest was 20.8°C. The patient became conscious and was extubated on the first postoperative day without any cerebral complications. He was discharged uneventfully on the 30th postoperative day and is now doing well 3 months after the aneurysm repair without transient ischemic attack or stroke.
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Fig 1. Both chest computed tomography scanning (upper panel) and aortography (lower panel) showed a saccular aneurysm located in the minor curvature of the aortic arch.
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Fig 2. Single-photon emission computed tomography scanning indicated that cerebral blood flow was decreased in the left temporal lobe (upper panel). A superficial temporal artery–middle cerebral artery (STA-MCA) anastomosis improved cerebral blood flow (lower panel). (Pre = before anastomosis; Post = after anastomosis.)
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Fig 3. Single-photon emission computed tomography shows that reactivity of cerebral blood flow to acetazolamide was reduced in the left temporal lobe (upper panel). It was improved by a superficial temporal artery–middle cerebral artery (STA-MCA) anastomosis (lower panel). (Pre = before anastomosis; Post = after anastomosis.)
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Comment
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The cumulative stroke or death rates are 24% at 2 years and 50% at 6 years in patients with symptomatic 75% or greater stenosis of the cervical ICA who have no endarterectomy and receive only medical therapy because of surgical risks [3]. The cumulative freedom from symptoms, that from stroke, and cumulative survival at 4 years are 83%, 91%, and 65%, respectively, in patients with either aortic aneurysm or peripheral arterial disease with at least unilateral 50% stenosis of either common or internal carotid arteries despite no history of cerebrovascular symptoms [4]. Patients with symptomatic or asymptomatic significant carotid stenosis have a high risk of stroke. Internal carotid artery stenosis of 50% or greater and 70% or greater occur in 17% and 9%, respectively, of patients undergoing reconstruction for aortic aneurysm[1]. On the other hand, abdominal aortic aneurysm of 3.0 cm or greater and 4.0 cm or greater are present in 18.2% and 8.3%, respectively, of patients with a 50% or greater carotid stenosis [5]. The incidence of carotid disease in patients with thoracic aortic aneurysm has been unclear. Stroke, which may be caused by carotid stenosis or occlusion, is one of the serious complications in repair of thoracic aortic aneurysm, especially aortic arch aneurysm. The presence of asymptomatic carotid artery stenosis or occlusion is significantly associated with hemispheric stroke in patients undergoing cardiopulmonary bypass [6].
Bower and colleagues [2] have analyzed patients undergoing both carotid endarterectomy and abdominal aortic reconstruction within 1 year. Perioperative stroke occurred in 2% of patients who undertook endarterectomy first, and in 14% of those who did abdominal aortic reconstruction first. Overall 5-year survival was significantly greater in the former group (77%) compared with the latter (51%). It has been concluded that carotid artery endarterectomy was safe in selected patients who required abdominal aortic reconstruction. When carotid artery endarterectomy was performed before abdominal aortic repair, it reduced perioperative stroke and might improve long-term survival.
In the present case, a STA-MCA anastomosis for left ICA occlusion was first performed to improve CBF of the left temporal lobe and secure the brain from ischemia related to hypotension during cardiopulmonary bypass. In repair of aortic arch aneurysm, we have been routinely using antegrade selective cerebral perfusion in which both the brachiocephalic artery and the left common carotid artery, except the left subclavian artery, were perfused. Although CBF had been improved with the prior STA-MCA anastomosis, the left subclavian artery also was perfused with anticipation of blood flow through the left vertebral artery. Consequently, total aortic arch replacement could be successfully performed without any perioperative cerebral complications. If the collateral circulation to the ICA functions as a compensatory source of CBF when the vessel diameter is reduced greater than 70%, maintenance of perfusion pressure at a level more than 70 mm Hg may counteract the decrease in CBF associated with stenotic lesions [7]. Even though the ICA is occluded, maintenance of high perfusion pressure may be effective when the collateral circulation functions. Decreased CBF and reduced reactivity to acetazolamide in a single-photon emission computed tomographic scan, however, mean a poorly developed collateral system. In this case, other strategies rather than maintenance of high perfusion pressure, such as a prior STA-MCA anastomosis, are required. In aortic arch aneurysm with ICA occlusion and decreased CBF, a STA-MCA anastomosis before aneurysm repair is effective to avoid perioperative cerebral ischemia. Retrograde cerebral perfusion rather than antegrade selective cerebral perfusion may be theoretically more advantageous for brain protection in repair of aortic arch aneurysm with cerebrovascular occlusive disease. However, decrease of CBF as a result of hypotension during systemic cardiopulmonary bypass before applying antegrade selective or retrograde cerebral perfusion cannot be avoided when occlusion or severe stenosis of the carotid artery is present.
Routine screening of the carotid artery may be justified in patients with aortoiliac aneurysmal and occlusive disease, provided there is a high prevalence of clinically significant lesions and sufficient predictive values or duplex scanning are obtained [8]. In repair of aortic arch aneurysm requiring special methods of cerebral protection, such as antegrade selective or retrograde cerebral perfusion or hypothermic circulatory arrest, concomitant cerebrovascular lesion may cause serious cerebral complications. Recently in elective surgery of thoracic aortic aneurysm, we have performed routine echography of the carotid artery to screen asymptomatic cerebrovascular disease. If stenosis is 50% or greater in a carotid echogram, single-photon emission computed tomography scanning including acetazolamide test is added to evaluate CBF. In concurrent carotid severe stenosis or occlusion, single-photon emission computed tomography scanning is useful to estimate CBF before aneurysm repair.
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References
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- Cahan M.A., Killewich L.A., Kolodner L., et al. The prevalence of carotid artery stenosis in patients undergoing aortic reconstruction. Am J Surg 1999;178:194-196.[Medline]
- Bower T.C., Merrell S.W., Cherry K.J., Jr, et al. Advanced carotid disease in patients requiring aortic reconstruction. Am J Surg 1993;166:146-151.[Medline]
- Bogousslavsky J., Despland P.A., Regli F. Prognosis of high-risk patients with nonoperated symptomatic extracranial carotid tight stenosis. Stroke 1988;19:108-111.[Abstract/Free Full Text]
- Ellis M.R., Franks P.J., Cuming R., Powell J.T., Greenhalgh R.M. Prevalence, progression and natural history of asymptomatic carotid stenosis: is there a place for carotid endarterectomy?. Eur J Vasc Surg 1992;6:172-177.[Medline]
- Kang S.S., Littooy F.N., Gupta S.R., et al. Higher prevalence of abdominal aortic aneurysms in patients with carotid stenosis but without diabetes. Surgery 1999;126:687-692.[Medline]
- Schwartz L.B., Bridgman A.H., Kieffer R.W., et al. Asymptomatic carotid artery stenosis and stroke in patients undergoing cardiopulmonary bypass. J Vasc Surg 1995;21:146-153.[Medline]
- Jones E.L., Hodakowski G.T. Combined coronary and carotid artery disease. In: Baue A.E., ed. Glenn’s thoracic cardiovascular surgery. Stamford: Appleton & Lange, 1996:2095-2101.
- Miralles M., Corominas A., Cotillas J., Castro F., Clara A., Vidal-Barraquer F. Screening for carotid and renal artery stenoses in patients with aortoiliac disease. Ann Vasc Surg 1998;12:17-22.[Medline]
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Abstract
Introduction
