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Ann Thorac Surg 2006;82:542-546
© 2006 The Society of Thoracic Surgeons
Department of Cardiovascular Surgery, Cardiovascular Institute and FuWai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
Accepted for publication March 3, 2006.
* Address correspondence to Dr Sun, Department of Cardiovascular Surgery, Cardiovascular Institute and FuWai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China (Email: huxp21{at}sohu.com).
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Abstract |
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METHODS: From February 2004 to October 2005, thirteen patients with Marfan syndrome underwent one-stage total or subtotal aortic replacement for aortic dissection or aortic aneurysms. Four patients received subtotal aortic replacement (ascending aorta to the abdominal aorta). Nine patients underwent total aortic replacement (ascending aorta to the aortic bifurcation). Operations were performed under circulatory arrest with profound hypothermia. Patients were opened with a mid-sternotomy and a thoracoabdominal incision. Extracorporeal circulation was instituted with two arterial cannulae and a single venous cannula in the right atrium. During cooling, the ascending aorta or aortic root was replaced. At the nasopharyngeal temperature of 20°C, the aortic arch was replaced with selective antegrade cerebral perfusion. After brain reperfusion, staged aortic occlusions allowed for replacement of descending thoracic and abdominal aorta. Intercostal, visceral, and renal arteries were anastomosed to the graft.
RESULTS: There was no operative or early postoperative death. One case of postoperative complication was noted for cerebral infarction secondary to embolism. Spinal neurologic deficits did not occur. At the last follow-up, ranging from 4 to 24 months postoperatively, all 13 patients were alive and had good functional status.
CONCLUSIONS: One-stage total or subtotal aortic replacement for treatment of extensive aortic disease is feasible with acceptable surgical risks and satisfactory results. It can eliminate the risk of remnant aortic aneurysm rupture in staged total aortic replacement.
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Introduction |
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TopAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Material and Methods |
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All patients underwent a complete preoperative investigation. Magnetic resonance imaging (MRI) or enhanced electron beam computed tomography (EBCT) and echocardiography were performed to obtain complete information for selecting the appropriate surgical technique (Fig 1). Special attention was paid to aortic valve insufficiency, location of the coronary ostia, and origin of the carotid-subclavian, visceral, renal, and iliac arteries to plan graft anastomoses.
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32x10 x 8 x 8 x10 mm) was used to substitute the diseased aorta. Patients were placed on the operating table in the right lateral decubitus position, with the lower body slightly tilted to the left to expose the abdomen and groin regions. The entire length of the aorta was exposed through two incisions. A median sternotomy was made to expose the aorta from the valve to the arch. Meanwhile, a second surgical team proceeded to make a left thoracoabdominal incision to expose the aorta from the arch to the bifurcation. The skin incision was drawn from between the left scapula and spinal processes in the fourth intercostal space, then brought downward along the paramedian abdominal line after crossing the costal margin and ending at the level of the pubis.
The left chest was entered through the fourth intercostal space. Occasionally, to gain better exposure of the distal aortic arch and proximal descending aorta, the fourth rib was cut. Once the costal margin was interrupted, the left hemidiaphragm was circumferentially incised along its parietal insertion. Then the peritoneal sac was detached from the abdominal wall; the abdominal viscera were moved to the right, and the thoracoabdominal aorta was completely exposed.
Extracorporeal circulation was instituted with two arterial return cannulae in the ascending aorta (first four cases used the right axillary artery) and in the left iliac artery. Venous drainage was effectuated with a single cannula into the right atrium (10 cases) or from the left iliac vein advancing to the right atrium (first 3 cases). The left heart was decompressed through the right superior pulmonary vein.
Bypass and cooling were started after opening the patient. During cooling time, the ascending aorta (proximal to the arterial cannula) was cross-clamped and the heart was stopped with the injection of a cold blood cardioplegic solution. In our most recent patient, the myocardium was cooled down with the whole body and no cardioplegic solution was used. Before the ascending aortic replacement, a Bentall or David operation was performed if indicated.
When the nasopharyngeal temperature was lowered to 20°C, the upper thoracic aorta, and the arch vessels were cross-clamped. Then upper body circulation was stopped and selective antegrade cerebral perfusion began at a flow rate of 5 to 10 mL · kg–1· minute–1 from the right axillary arterial cannula or by direct cannulation into the innominate artery. The ascending aortic incision was continued to the beginning of the descending aorta, taking care to avoid injury to the left recurrent laryngeal nerve. The aortic arch was reconstructed by anastomosing the carotid-subclavian orifices in a single button to the side of the graft.
Upon completion of this anastomosis, the clamp of the carotid trunks was removed and the graft was allowed to fill with blood. After evacuating the air, the graft was cross-clamped distally at the left subclavian artery, and the upper body was then perfused through the right axillary arterial cannula or an arterial cannula inserted into a 10 mm side branch attached to the graft.
Thereafter, the patient was rotated to the right. The lower thoracic aorta (at the diaphragm) was cross-clamped. The incision of the thoracic aorta continued distally. After removing intimal flaps, the first five intercostal orifices were sutured in the lumen of the aorta. The intercostal orifices from the sixth to the twelfth, which are considered a vital blood supply of the spinal cord, were directed into an approximately 2 cm diameter arterial tube and then anastomosed to an 8 mm side branch attached to the graft.
The graft clamp was removed from the postsubclavian area and was placed under this anastomosis, allowing spinal cord perfusion to be resumed. The clamp of the lower thoracic aorta was released and placed on the iliac arterial cannula, thus producing abdominal ischemia. The incision of the thoracic aorta continued downward to the abdominal aneurysm.
Finally, the distal anastomosis was accomplished. Usually, orifices of celiac, superior mesenteric, and right renal arteries were joined at a single button anastomosing to the distal main graft. The left renal, inferior mesenteric, and bilateral iliac arteries were connected to the branches of the graft, respectively. In four subtotal aortic replacement cases, whose abdominal aorta was normal, the graft was directly anastomosed at the level of the celiac artery distally. The clamp of the iliac arterial cannula was released slowly and air was evacuated from the graft. When all anastomoses were completed, total circulation was reestablished, and rewarming was started (Fig 2; 3).
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Follow-Up
The EBCT and echocardiography were performed before discharge, three months after surgery, and then annually to evaluate condition of the graft. Follow-up ranged from 4 to 24 months (mean, 14 months). All 13 patients were alive and had good functional status.
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Results |
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Ten patients were extubated between first and fourth postoperative days. One patient had a right hemiparesis due to embolism after operation. Another two patients had pulmonary insufficiency and secondary pulmonary infection. These three patients underwent tracheotomy. Two patients had chylothorax. Four patients were reopened because of bleeding. One patient underwent lienectomy because of nontraumatic rupture of the spleen postoperatively. The patient with WPW syndrome received radio-frequency ablation because of recurrent supraventricular tachycardia after operation. No spinal neurologic deficits were observed. All 13 patients were discharged from the hospital between 14 and 50 postoperative days.
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Comment |
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Crawford's team performed total aortic replacement in a staged approach. Borst and colleagues [4] developed the "elephant trunk" technique to facilitate extended and total replacement in a staged operation. Most patients with extensive aneurysms of the aorta can be treated by a two-stage elephant trunk procedure with a relatively low operative risk. But several deaths occurred during the interval between staged operations due to rupture of residual aneurysms, refusal of second operation, or deterioration of general conditions [1, 2]. Thus, in some high-risk patients, the one-stage total aortic replacement should be considered.
Massimo and colleagues [7] reported simultaneous aortic replacement from the aortic valve to the bifurcation in 34 patients with a 30-day mortality of 14.7%. These observations confirmed that total aortic replacement may be appropriate in selected patients.
One-stage total aortic replacement prevents loss of patients during the interval between staged operations and avoids the physical suffering of a second operation. Moreover, it is more economical than a staged operation. This is very important in poor patients.
The one-stage total aortic replacement is the most complex operation in aortic surgery. To minimize circulatory arrest time and ischemic time of the brain, spinal cord, and viscera are key points for success of the operation.
Surgery on the aortic root could be completed during cooling and rewarming time. When reconstructing the carotid-subclavian, intercostal, and visceral arteries, the technical principle is to include as many vascular orifices into a single anastomosis as possible. Using these methods, the CPB and operating times were sensibly reduced. The extracorporeal circulation, with double arterial return cannulae, was an effective method in reducing cooling and rewarming time by allowing early resumption of cerebral, spinal, and visceral perfusion.
Cerebral protection performed with profound hypothermia and selective antegrade cerebral perfusion has proved completely effective by the absence of permanent central neurologic deficits except for cerebral infarction secondary to embolism in one patient. The embolism was presumedly due to the inadequate evacuation of the air during the operation. The carotid occlusion time ranging from 8 to 53 minutes proved to be safe.
Spinal and visceral protection was ensured by profound hypothermia during circulatory interruption and early resumption of perfusion. With a staged descending aortic occlusion technique, the ischemic time of spinal cord and viscera were reduced. No visceral failure and paraplegia arose in our series.
Myocardial protection was effective for arrest times of up to 235 minutes. The protection was provided by profound hypothermia and possibly with a single dose of crystalloid injected at the moment of aortic cross-clamping. After the patient was weaned from bypass, cardiac function proved to be sufficient in sustaining circulation without mechanical assistance.
Prolonged respiratory assistance and positive end-expiratory pressure ventilation were required in three patients due to postoperative pulmonary insufficiency. This complication was attributed to intraoperative pulmonary handling, unilateral lung ventilation, and injury caused by CPB.
Postoperative bleeding caused four patients to return to the operating room. Coagulation disturbance was attributed to the impairment of liver, endothelial and platelet dysfunction after deep hypothermia and prolonged extracorporeal circulation. To help bring bleeding under control, coagulation factors were administered at the moment of the weaning off of the CPB. Keeping patients warm was very important as well.
In conclusion, one-stage total or subtotal aortic replacement prevents loss of patients during the interval between staged operations, allows for better early results, and assures a favorable long-term survival. One-stage replacement of the entire aorta is feasible with acceptable surgical risks.
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L. Svensson Invited commentary Ann. Thorac. Surg., August 1, 2006; 82(2): 546 - 547. [Full Text] [PDF]
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