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Ann Thorac Surg 2005;79:133-137
© 2005 The Society of Thoracic Surgeons

Original article: Cardiovascular

Does Cross-Clamping the Arch Increase the Risk of Descending Thoracic and Thoracoabdominal Aneurysm Repair?

Leonard N. Girardi, MD*, Karl H. Krieger, MD, Charles A. Mack, MD, Leonard Y. Lee, MD, Anthony J. Tortolani, MD, O. Wayne Isom, MD

Department of Cardiothoracic Surgery, Weill Medical College of Cornell University, New York, New York, USA

Accepted for publication June 25, 2004.

* Address reprint requests to Dr Girardi, Associate Professor of Cardiothoracic Surgery, Weill Medical College of Cornell University, 525 E 68th St, M-424, New York, NY 10021 (E-mail: lngirard{at}med.cornell.edu).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
BACKGROUND: Descending thoracic and thoracoabdominal aortic aneurysms may arise in the distal aortic arch. Repair of these aneurysms has been associated with increased morbidity and operative mortality. Complex surgical and endovascular techniques have reduced the risks for this cohort. We examined outcomes utilizing an approach based on simple cross-clamping of the arch.

METHODS: From July 1997 to January 2004, 272 consecutive patients had aneurysm repair through the left chest. Twenty-nine requiring profound hypothermic circulatory arrest (PHCA) were excluded. Two hundred and forty-three were divided into two groups: group I (n = 60) had distal arch involvement and required cross-clamping proximal to the left subclavian artery. Group II (n = 183) were cross-clamped distal to the subclavian. Adjuncts for neurologic and renal protection were utilized as needed.

RESULTS: In-hospital mortality for all 243 patients was 3.7%. There was no difference in mortality between groups (I, 3.3% vs II, 3.8%). Group I patients also had similar rates of paraplegia (I, 0% vs II, 2.2%), stroke (I, 1.2% vs II ,1.1%), and renal failure (I, 1.7% vs II, 5.5%). Group I patients had significantly more recurrent nerve palsies (I, 33% vs II, 4.9%) although this did not translate into a higher incidence of respiratory failure.

CONCLUSIONS: Repair of thoracic aneurysms arising in the distal arch can be repaired with a technique based on simple cross-clamping without an increase in mortality or major neurologic injury. Recurrent nerve palsy is much more common with this approach but is well-tolerated without increasing the need for tracheostomy.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
It is not uncommon for aneurysms of the descending thoracic and thoracoabdominal aorta to take origin in the distal aortic arch. This location presents the surgeon with unique anatomic and technical considerations that may complicate surgical repair. Extensive manipulation and clamping of the arch may increase the incidence of cerebral embolization and stroke. Gaining proximal control of the aorta between the great vessels can also be challenging, especially if the patient has had prior aortic reconstruction. Injury to adjacent structures such as the esophagus, bronchus, or pulmonary artery during these maneuvers can be catastrophic. Similarly, temporary occlusion of the left subclavian artery (LSA) can reduce anterior spinal artery blood flow and potentially increase the incidence of spinal cord dysfunction. These considerations have made repair of distal arch aneurysms a procedure with traditionally higher operative mortality, with increased rates of central nervous system injury, renal failure, and pulmonary complications [1, 2].

A variety of surgical approaches have been proposed to reduce the risk of operating on aneurysms in this region. Profound hypothermia and circulatory arrest eliminates the difficulties associated with obtaining proximal aortic control while providing excellent spinal cord protection [3, 4]. Others have abandoned an open approach altogether, instead opting for an endovascular stent graft for distal arch reconstruction [5–7]. These techniques are clearly appropriate for some patients with distal arch aneurysms. However, the complexity of their application may discourage a more liberal utilization regardless of outcomes. As such, a technique based on aortic cross-clamping may be more appealing in its simplicity. Kay and colleagues [8] reported their results in 32 patients having distal arch aneurysm repair with simple aortic cross-clamping between the innominate and left common carotid arteries. Without any additional methods of cerebral, renal, or spinal cord protection, the patients in this report had no cerebral injury, and a paraplegia and renal failure risk comparable to other reports of that era.

Since the time of this report, the morbidity and mortality of thoracic aneurysm repair has been dramatically reduced by the addition of adjuncts for neurologic and renal protection [9–11]. We wished to examine a more contemporary experience repairing aneurysms arising in the distal arch, utilizing a technique based on simple cross-clamping proximal to the LSA. With the selective addition of cerebrospinal fluid (CSF) drainage, left heart bypass, and intercostal reimplantation, we sought to compare our outcomes to a number of more complex surgical techniques and define the role of our approach for patients with this high-risk anatomy.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Patients
Between July 1997 and January 2004, two hundred seventy-two consecutive patients underwent descending thoracic or thoracoabdominal aortic aneurysm (TAAA) repair through a posterolateral thoracotomy or thoracoabdominal incision. Twenty-nine had thoracic aneurysms with extensive proximal arch involvement or porcelain aortic arches that precluded safe application of a cross-clamp. These patients were repaired through the left chest with the assistance of profound hypothermic circulatory arrest (PHCA). They were excluded from this analysis. During this same period, an additional 337 patients had aortic arch reconstruction through a median sternotomy utilizing PHCA. These patients were also excluded. The remaining 243 patients were divided into two groups and analyzed retrospectively. Seventy-two of these patients had isolated descending aneurysms. The remaining 171 had TAAAs in the following distribution: extent I, n = 95; extent II, n = 41; extent III, n = 23: and extent IV, n = 12. The patients were then divided into two groups depending on where the proximal cross-clamp was applied. Group I (n = 60) consisted of patients undergoing thoracic aneurysm repair with cross-clamping proximal to the LSA. Group II (n = 183) patients had aneurysm repair with cross-clamping distal to the LSA.

There were 146 males and 97 females with a mean age of 63 years. Preoperative comorbidities are listed in Table 1. There were significantly more males in group I although the mean age between the groups was not markedly different. Chronic obstructive pulmonary disease (COPD) and chronic renal insufficiency were more prevalent in group II. The groups were otherwise comparable with respect to cerebrovascular disease, cardiac function, aneurysm size, and previous aneurysm repairs.


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  		Table 1. Patient Demographics
 
Operative Techniques
The surgical techniques we utilize and the rationale for their application have been previously described [12]. Figure 1 outlines our algorithm for determining safe cross-clamping proximal to the LSA and the use of adjuncts for neurologic and renal protection. Briefly, after establishing a right sided, upper extremity arterial line and right heart catheter, single lung ventilation is established with a bronchial blocker. A spinal drainage catheter is placed in the third or fourth lumbar space and after appropriate positioning a posterolateral thoracotomy or thoracoabdominal incision is created. For aneurysms requiring control proximal to the LSA, the ligamentum arteriosum is divided under direct vision with preservation of the left recurrent and phrenic nerves. The main trunk of the left vagus nerve is also dissected out to the apex of the chest and encircled with a vessel loop for positioning during the proximal anastomosis. Gentle digital dissection is then carried out to develop a plane around the aortic arch, creating space between the left common carotid and left subclavian arteries. A similar technique is used when control proximal to the left carotid artery is necessary. The pericardial reflection on the undersurface of the arch is often taken down for additional exposure. A 3 to 4 cm portion of proximal LSA is also dissected and encircled in preparation for occlusion during the proximal anastomosis. Heparin is administered at 1 mg/kg and a partial bypass circuit is inserted when necessary. A padded cross-clamp (Applied Medical, San Jose, CA) is placed and a second clamp is placed on the subclavian artery. Once the aneurysm is opened, the aorta is transected circumferentially and dissected off of the esophagus. The origin of the subclavian artery is inspected and a decision is made to either include this vessel in the proximal anastomosis or reattach it with a separate graft. We have not reimplanted the subclavian as a "button." After completing the proximal anastomosis, it is reinforced circumferentially with horizontal mattress sutures buttressed with Teflon felt pledgets. The clamp is then moved beyond the subclavian artery. Distal aortic reconstruction is then completed with reimplantation of intercostal, visceral, and renal vessels as indicated. If a left subclavian bypass is necessary, it is completed after flow is restored to the aorta. Protamine is administered and the patient is taken to the intensive care unit. During the cross-clamp period bladder temperature is maintained between 32 and 33°C and CSF pressure is kept at less than10 mm Hg. Postoperative mean arterial blood pressure is maintained near 90 Torr for the first 48 hours and CSF drainage is maintained for 72 hours.



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  		Fig 1. Management strategies for patients with descending thoracic or thoracoabdominal aneurysms requiring control of the aorta between the left common carotid and left subclavian arteries. ("complex" = extent II aneurysm, anticipated cross-clamp time greater than 30 minutes, severely reduced ventricular function, acute or chronic dissection; CSF = cerebrospinal fluid; PHCA = profound hypothermic circulatory arrest; (+) = yes; (–) = no.)

 
Statistical Analysis
Comparative statistical analysis of perioperative variables was performed using SPSS statistical package (SPSS, Chicago, IL). Group I and group II cohorts underwent univariate analysis with Fisher’s exact test. Statistical significance was defined by a p value less than or equal to 0.05.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Sixty patients required control of the aorta proximal to the LSA (group I) while 183 patients had the aorta clamped distal to the same artery (group II). The utilization of partial bypass, simple clamp and sew technique, and intercostal artery reimplantation was not significantly different between groups (Table 2). A greater percentage of patients in group II had CSF drainage catheters inserted (82% vs 99%, p < 0.001). The need for LSA reconstruction was significantly higher in group I (n = 8), when compared to group II (n = 3).


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  		Table 2. Techniques for Aortic Reconstruction
 
Sixty patients with aneurysms arising in the distal aortic arch (group I) had an in-hospital mortality of 3.3% (n = 2) (Table 3). This was not significantly different than the 3.8% in-hospital mortality rate (n = 7) seen for 183 patients requiring control distal to LSA (group II) (p > 0.6). The incidence of stroke or intracerebral hemorrhage in group I (n = 1, 1.7%) was similar to that in group II (n = 2, 1.1%) (p > 0.6). Similarly, there was no significant difference in the incidence of paraplegia or paraparesis between the two groups (I, n = 0, 0% vs II, n = 4, 2.2%), (p > 0.32).


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  		Table 3. Complications and Mortality
 
Ten patients (5.5%) developed renal failure requiring hemodialysis in group II while only 1 patient required postoperative hemodialysis in group I (1.7%) (p > 0.20). The incidence of left recurrent nerve injury or palsy was significantly higher in group I (n = 20, 33%) when compared to group II patients (n = 9, 4.9%) (p < 0.0001). This did not significantly increase the need for temporary tracheostomy in group I patients (n = 7, 11.7%) when compared to their group II counterparts (n = 13, 7.1%), (p > 0.20).

A greater, but insignificant (p < 0.2), percentage of patients in group I had aneurysm rupture at the time of presentation (n = 16, 27%) when compared to those with aneurysms requiring aortic control distal to the LSA (n = 35, 19%). Thirty-five (19%) patients in group II had extent III or extent IV aneurysms while there were, obviously, no such patients in group I. In addition, 111 patients in group II had the higher risk extent I or II TAAA while only 25 patients in group I had aneurysms with this degree of aortic involvement (62% vs 42%, p < 0.008). Despite this significant difference in the percentage of more extensive aneurysms, the mean cross-clamp time for patients in group II was 6.1 minutes shorter than for the first group.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
There are many options for reconstruction of aneurysms beginning in the distal aortic arch. One of the earliest reports on this complex subset of patients came from Cooley’s group in 1986 [8]. Their report on a simple clamp and sew technique in 32 patients with distal arch aneurysms is unique in its simplicity. Without adjuncts for neurologic or renal protection, they reported a 6% mortality and no strokes despite cross-clamping between the innominate and left common carotid arteries. A 9.4% paraplegia rate and two cases of permanent renal failure may have dissuaded others from adopting this technique that clearly relies on speed to achieve a successful outcome. The critical role of spinal ischemic time is clear. All three cases of permanent paraplegia occurred when the clamp time exceeded 30 minutes. The addition of CSF drainage, left heart bypass, intercostal reimplantation, and moderate hypothermia significantly reduces the morbidity and mortality for patients having thoracic aneurysm repair with cross-clamping of the arch. Despite a mean cross-clamp time of 40 minutes we had no patients with spinal cord injury and only one with renal failure. Exclusion of left subclavian and vertebral artery flow during the proximal anastomosis does not significantly increase the risk for neurologic injury, even when subclavian artery reconstruction is required. Furthermore, arch manipulation does not appear to increase the risk of cerebral embolization above that seen in patients where the aneurysm begins beyond the LSA. Our mortality of 3.3% in this high-risk cohort of 60 patients further validates simple cross-clamping as the foundation of a sound surgical approach.

A recent review of patients with traumatic aortic transection further supports the notion that cross-clamping the arch proximal to the LSA is safe [13]. In 91 patients undergoing surgical reconstruction for traumatic aortic injury, there was no difference in the incidence of paraplegia when clamping proximal (12%) or distal to the LSA (10%). Again, however, the importance of speed is highlighted. The mean clamp time for patients with neurologic injury was 16 minutes longer than a group without injury where the mean clamp time was 30.3 minutes. Aortic reconstruction high in the left chest is technically demanding and more time consuming when the distal arch is involved. In addition to limited exposure, precious minutes may be added to a time sensitive procedure during attempts at recurrent nerve preservation and suture line reinforcement to ensure hemostasis. Our experience supports this notion as the mean clamp time in group I was 6 minutes longer than group II despite having significantly fewer complex extent I and II TAAAs. If one can extend the safe period of aortic occlusion with modern methods of neurologic and renal protection, and if one reserves cross-clamping without adjuncts for those procedures anticipated to take less than 30 minutes, is it necessary to increase the complexity and duration of the operation to avoid perioperative complications and deaths?

Because the complexity of aneurysm repair in this area often mandates longer periods of cross-clamping, many have espoused alternative techniques of reconstruction including PHCA. Kouchoukos and colleagues [3] reported their experience with PHCA in 192 consecutive patients requiring thoracoabdominal and descending aneurysm repair. Only 2.7% of patients developed postoperative paraplegia or paraparesis while an additional 2% had a cerebrovascular accident. The utility of profound hypothermia for end organ protection is further highlighted by the 2.2% incidence of renal failure. However, the use of this modality is not risk free. Nearly 10% of patients required prolonged inotropic support postbypass while 9% required tracheostomy for respiratory failure. The 30-day mortality was 6.8% with an in-hospital mortality of 12.5%. These results suggest that the outstanding neurologic and renal protection provided by profound hypothermia is associated with a substantial systemic insult. For some patients this risk is justified. Patients with porcelain aortic arch, extensive aneurysmal involvement of the proximal arch, contained high proximal aortic rupture, and reoperations where the aneurysm is densely adherent to adjacent structures, clearly benefit from PHCA. Twenty-nine of our patients required PHCA for aneurysm repair for the previously mentioned reasons. The utility of hypothermia for spinal cord protection was confirmed by a zero percent incidence of paraplegia or paraparesis. However, the incidence of stroke in this high-risk cohort was 10.3% with a mortality of 17%. Three of the 5 deaths were secondary to permanent, irreversible cerebral injury. While these results are clearly biased against PHCA, we believe that this method is mandatory in the surgical arsenal of surgeons performing complex aortic reconstruction. We, however, suggest that comparable outcomes can be achieved utilizing a foundation of simple clamp and sew reconstruction with selective application of adjuncts for end organ protection [9–12].

Endovascular stent grafting for aneurysms arising in the distal arch was first described in 1996 [5]. Over the last 8 years the techniques have evolved. The most promising approach is through a mediasternotomy with stent graft delivery through an arch aortotomy under hypothermic circulatory arrest and selective cerebral perfusion [6]. In a small cohort of 23 patients having distal arch aneurysm repair, the operative mortality was 4.3% with a similarly low risk of stroke or paraplegia. The incidence of a significant endoleak was 8.6% with one patient demonstrating aneurysm growth over the first postoperative year. These results compare favorably with our experience and may be the preferred approach for patients with significant cardiac pathology requiring concomitant repair. A majority of the aneurysms will shrink after stent placement [6], although a 14% incidence of stent failure and 6% chance of late aneurysm rupture mandates lifelong radiographic follow-up [14]. This technique has also not been examined in patients with TAAAs or chronic dissections, a cohort that constitutes a large percentage of patients in our series. A transaortic approach through the proximal arch may also be appropriate for patients with extensive proximal arch pathology where our experience with PHCA through the left chest has met with substantial morbidity and mortality. We continue to espouse open repair as the gold standard for distal arch aneurysms. We await longer follow-up with these less invasive methods before recommending this technique as the standard of care.

Recurrent laryngeal nerve palsy occurs in 9% to 12% of patients following thoracic aneurysm repair [15, 16]. Nerve contusion, rather than transection, is the usual mechanism of injury and may occur secondary to a cross-clamp injury or retraction of the nerve away from the site of the proximal anastomosis. Recurrent nerve palsy may also occur as the ligamentum arteriosum is divided in order to obtain adequate proximal control on the arch. A majority of patients will recover nerve function without the need for cord medialization. However, approximately 27% may need more urgent intervention because of severe dysphonia, glottic incompetence, or poor pulmonary toilet [16]. A majority of patients are hoarse immediately following extubation after aneurysm repair. If they have an effective cough and can swallow without aspiration, we avoid medialization during the same hospitalization even if the patient has a dramatic change in phonation. If it is difficult for them to clear secretions or if their caloric intake is restricted because of pharyngeal dysfunction, Teflon injection is performed. Utilizing this approach, only 5 of 29 patients with recurrent nerve palsy required medialization on the same hospitalization as aneurysm repair. This conservative approach does not increase the incidence of respiratory failure and allows the patient adequate time for the perioperative edema and contusion to resolve.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Crawford ES, Coselli JS, Safi HJ. Partial cardiopulmonary bypass, hypothermic circulatory arrest and posterolateral exposure for thoracic aortic aneurysm operation J Thorac Cardiovasc Surg 1987;94:824-827.[Abstract]
  2. Kieffer E, Koskas F, Walden R, et al. Hypothermic circulatory arrest for thoracic aneurysmectomy through left-sided thoracotomy J Vasc Surg 1994;19:457-464.[Medline]
  3. Kouchoukos NT, Masetti P, Rokkas CK, et al. Hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta Ann Thorac Surg 2002;74:S1885-1887.[Abstract/Free Full Text]
  4. Yamashita C, Okada M, Yoshimura T, et al. Impact of retrograde cerebral perfusion with posterolateral thoracotomy on distal arch aneurysm repair Ann Thorac Surg 1998;65:955-960.[Abstract/Free Full Text]
  5. Kato M, Ohnishi K, Kaneko M, et al. New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft Circulation 1996;94(suppl):II188-193.
  6. Sueda T, Orihashi K, Okada K, et al. Fate of aneurysms of the distal arch and proximal descending thoracic aorta after transaortic endovascular stent-grafting Ann Thorac Surg 2003;76:84-89.[Abstract/Free Full Text]
  7. Watari M, Sueda T, Ishii O, et al. Shrinkage of excluded aneurysmal spaces: the excellent results of endovascular stent grafting through the aortic arch for distal arch aneurysm J Thorac Cardiovasc Surg 2001;122:829-832.[Free Full Text]
  8. Kay GL, Cooley DA, Livesay JJ, et al. Surgical repair of aneurysms involving the distal aortic arch J Thorac Cardiovasc Surg 1986;91:397-404.[Abstract]
  9. Coselli JS, LeMaire SA, Conklin LD, et al. Morbidity and mortality after extent II thoracoabdominal aortic aneurysm repair Ann Thorac Surg 2002;73:1107-1116.[Abstract/Free Full Text]
  10. Koskoy C, LeMaire SA, Curling PE, et al. Renal perfusion during thoracoabdominal aortic operations: cold crystalloid is superior to normothermic blood Ann Thorac Surg 2002;73:730-738.[Abstract/Free Full Text]
  11. Safi HJ, Miller III CC, Huynh TT, et al. Distal aortic perfusion and cerebrospinal fluid drainage for thoracoabdominal and descending thoracic aortic repair: ten years of organ protection Ann Surg 2003;238:372-380.[Medline]
  12. Girardi LN, Krieger KH, Altorki NK, et al. Ruptured descending and thoracoabdominal aortic aneurysms Ann Thorac Surg 2002;74:1066-1070.[Abstract/Free Full Text]
  13. Carter Y, Meissner M, Bulger E, et al. Anatomical considerations in the surgical management of blunt thoracic aortic injury J Vasc Surg 2001;34:628-633.[Medline]
  14. Ellozy SH, Carroccio A, Minor M, et al. Challenges of endovascular tube graft repair of thoracic aortic aneurysm: midterm follow-up and lessons learned J Vasc Surg 2003;38:676-683.[Medline]
  15. Safi H, Hess K, Randel M, et al. Cerebrospinal fluid drainage and distal aortic perfusion: reducing neurologic complications in repair of thoracoabdominal aortic aneurysm types I and II J Vasc Surg 1996;23:223-229.[Medline]
  16. Teixido MT, Leonetti P. Recurrent laryngeal nerve paralysis associated with thoracic aortic aneurysm Otolaryngol Head Neck Surg 1990;102:140-144.[Medline]

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