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Ann Thorac Surg 2006;81:789-790
© 2006 The Society of Thoracic Surgeons
Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido 060-8556, 060-8543 Japan
(Email: kmori{at}sapmed.ac.jp).
We read with great interest the article on cross clamping of the arch by Girardi and coworkers [1]. The authors achieved a low stroke rate despite arch clamping. In general, cross clamping proximal to the left subclavian artery is believed to be associated with a high incidence of stroke in patients with degenerative aneurysms. We presented a series of 81 patients who underwent proximal cross-clamping between the left common carotid artery and the left subclavian artery for descending thoracic aortic aneurysm repair [2]. In our series, 6 of 25 patients (25%) with degenerative aneurysms suffered from stroke, whereas only 2 of 56 patients (4%) with aortic dissections experienced stroke. The result of our study indicated that degenerative aneurysm caused stroke more often than aortic dissection did. Considering this finding, we speculate that two key factors contributed to the low stroke rate in the series of Girardi and colleagues [1].
One factor is the cause. Because patients with degenerative thoracic aortic aneurysm are likely to have mobile atheromas on the arch wall, clamping of the aortic arch in such patients should increase the stroke rate. Although no baseline data on the cause of the aneurysms were given in the report of Girardi and colleagues [1], most patients may have had aortic dissection. A third of their patients who required cross clamping proximal to the left subclavian artery suffered left recurrent laryngeal nerve palsy, indicating that a usual arch manipulation was performed. If aneurysms had been degenerative, such manipulation would have increased the stroke rate because of the presence of debris or thrombus on the aortic wall. Thus it is important to distinguish between degenerative aneurysm and aortic dissection in their series.
The other factor is evaluation of the aortic arch. As Mitchell [3] pointed out, use of the epi-aortic ultrasound may play an important role in selecting high-risk patients for stroke. Their strategy is based on information on aortic calcification. Patients at high risk for stroke underwent profound hypothermic circulatory arrest to avoid arch clamping. The others underwent cross clamping of the thoracic aorta under passive hypothermia. According to this strategy, the incidence of stroke in low-risk patients in the series of Girardi and colleagues [1] was only 1%. They regarded extensive proximal arch involvement or a porcelain aortic arch as a high-risk factor. Generally, there is a variety of graded lesions on the aortic aorta, because the atherosclerotic process is a slow inflammatory disease. This raises the question of how they dealt with a moderate lesion. For example, did they clamp the calcified but localized aortic arch? What thickness and what extent of aortic atherosclerosis required hypothermic circulatory arrest? What is the definition of severe or extensive disease? It is important to answer these questions for facilitating management decisions.
The authors stated that repair of thoracic aneurysms arising in the distal arch can be performed using a simple cross-clamping technique without an increase in stroke rate. Therefore, we would like them to answer our questions so that we can follow their experiences.
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  L. N. Girardi, K. H. Krieger, C. A. Mack, L. Y. Lee, A. J. Tortolani, and O. W. Isom Reply Ann. Thorac. Surg., February 1, 2006; 81(2): 790 - 790. [Full Text] [PDF]
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