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Ann Thorac Surg 2007;83:S791-S795
© 2007 The Society of Thoracic Surgeons

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Supplement

Aortic Arch Replacement With a Trifurcated Graft

^a Section of Cardiothoracic Surgery, New York College of Medicine, Westchester Medical Center, Valhalla
^b Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, New York

^_* Address correspondence to Dr Spielvogel, Section of Cardiothoracic Surgery, Westchester Medical Center, Valhalla, NY 10595. (Email: spielvogeld{at}wcmc.com).

Presented at Aortic Surgery Symposium X, New York, NY, April 27–28, 2006.

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
BACKGROUND: The purpose of this study was to review the results of aortic arch replacement using a trifurcated arch graft in conjunction with hypothermic circulatory arrest (HCA) and selective antegrade cerebral perfusion (SCP).

METHODS: One hundred fifty consecutive patients (91 male; mean age, 63 ± 14 years; range, 20 to 87) had aortic arch replacement using a trifurcated arch graft and HCA/SCP from September 1999 to December 2005. The axillary artery was used for cannulation; a trifurcated graft was sewn to the arch vessels during a short interval of HCA; SCP was utilized through the trifurcation graft during the proximal and distal arch repair, and then the trifurcation graft was sewn to the arch graft. Fifty-five patients had chronic dissection; 48 had atherosclerotic and 29 had degenerative aneurysms; 74 had undergone previous cardiac surgery. Isolated arch reconstruction was undertaken in 38 patients: concomitant procedures included ascending aortic replacement in 74; ascending aorta and root replacement in 21; descending replacement in 4, and coronary artery bypass grafting in 36. An elephant trunk was used in 144, but distal to the left subclavian artery in only 87; in 34, it was distal to the left carotid, in 9, it was between the brachiocephalic and left carotid, and in 18, it was proximal to all arch branches. Mean HCA duration was 31.1 ± 6.5 minutes; SCP lasted 66.6 ± 21.0 minutes, at a mean temperature of 15.8 ± 2.1°C.

RESULTS: Adverse outcome occurred in 13 of 150 patients (8.7%): there were 7 hospital deaths and 6 permanent strokes. Temporary neurologic dysfunction was seen in only 7 patients, and renal failure was transient in 9 patients requiring dialysis.

CONCLUSIONS: The use of a trifurcated arch graft with HCA and SCP is a safe and versatile technique for repair of arch aneurysms.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
The strategy for neurologic protection is a critical part of the technique for aortic arch reconstruction, as prevention of global and focal brain injury is necessary to minimize morbidity and mortality. In this regard, combining intervals of antegrade, hypothermic selective cerebral perfusion (SCP) and deep hypothermic circulatory arrest (DHCA) continues to gain acceptance, as patients experience less temporary neurologic dysfunction, an indicator of subtle brain injury. However, the method of delivery remains controversial, particularly in patients with atherosclerotic disease of the arch [1, 2].

We have developed a technique utilizing a trifurcated graft that permits expeditious arch reconstruction and minimizes focal and global neurologic sequelae, while providing the flexibility to adapt to arch anomalies [3, 4] unanticipated intraoperative findings or complications. Herein we present our results using this technique.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
Patient Data Abstraction
From a prospectively compiled database approved by the Institutional Review Board of the Mount Sinai Hospital (Project 05-0952 001 01 CS X) including waiver of informed consent for chart review, we identified 150 consecutive patients (91 male, 59 female) who underwent nonemergent resection of arch aneurysms between September 1999 and December 2005, utilizing antegrade, hypothermic cerebral perfusion through direct axillary artery cannulation and a trifurcated graft, after an interval of DHCA.

The mean age was 63 ± 14 years (range, 20 to 87). The most frequent etiologies were chronic dissection (56 patients, 37.3%), atherosclerosis (48 patients, 32%), and degenerative change (29 patients, 19.3%); other etiologies are detailed in Table 1. As noted in Table 2, 68 patients (45.3%) had undergone previous cardiac surgery.

The mean maximal diameter of the aorta was 6.1 cm (range, 4.0 to 12). The extent of aortic replacement varied: isolated arch replacement was undertaken in 38 patients (25.3%), whereas a number of patients had concomitant ascending aortic replacement (74 patients, 49.3%), ascending and root replacement (21 patients, 14%), and descending aortic resection (4 patients, (2.7%). An elephant trunk was placed in 144 patients (96%): distal to the left subclavian artery in 87 (58%), distal to the left common carotid in 34 (22.7%), between the brachiocephalic and left carotid arteries in 9 (6%), and proximal to all arch branches in 18 (12%). Coronary artery bypass grafting was performed in 36 patients (24%).

Operative Technique
The surgical technique in detail has been previously described [3, 5]. Briefly, reconstruction is approached through a median sternotomy but can be performed using a bilateral anterior thoracotomy. Perfusing through direct axillary artery cannulation (Fig 1), the proximal aortic root reconstruction is performed while cooling, slowly lowering core temperature toward 15°C. The ascending aorta crossclamp is applied if significant aortic valve insufficiency is present or if direct epiaortic scanning (12 MHz) confirms minimal intraluminal clot or atheroma. If a jugular bulb catheter is available, a saturation greater than 95% indicates maximum cerebral metabolic suppression. A custom trifurcated graft may be constructed or a commercially prepared graft is utilized (Boston Scientific, Natick, Massachusetts). During circulatory arrest, the brachiocephalic vessels are transected approximately 1 cm beyond their origins (Fig 2A); the presence of macroscopic atherosclerotic disease may warrant further resection. The arch vessels are serially anastomosed with 5-0 polypropylene sutures (Fig 2B). Typically the left subclavian artery is attached first, followed by the left common carotid and innominate arteries. Each limb is gently aspirated and, clamping the main limb of the trifurcated graft, axillary perfusion is resumed, providing hypothermic SCP to the head and upper extremities. The perfusate temperature is allowed to drift upward during the remaining arch repair; no active rewarming is begun until full systemic flow is resumed.

View larger version (59K): [in this window] [in a new window]   Fig 1. Aortic arch aneurysm depicting direct cannulation of the right axillary artery.

View larger version (49K): [in this window] [in a new window]   Fig 2. (A) During deep hypothermic circulatory arrest, the brachiocephalic vessels are divided approximately 1 cm distal to their origin, where they are generally free of disease, and a trifurcated graft is appropriately trimmed. (B) The brachiocephalic anastomoses are completed.

A graft-to-graft anastomosis is constructed between the elephant trunk graft and the proximal repair, and these grafts are distended to facilitate choosing the ideal site for anastomosing the trifurcated graft (Fig 3). An opening is fashioned with ophthalmic electrocautery, and the beveled end of the trifurcated graft is anastomosed without interrupting cerebral circulation. With the grafts deaired, whole-body perfusion is restored and rewarming is begun.

View larger version (46K): [in this window] [in a new window]   Fig 3. With the main limb of the trifurcated graft clamped, antegrade selective cerebral perfusion is initiated through the axillary artery. During selective cerebral perfusion, the elephant trunk technique is used to reconstruct the arch and that graft is anastomosed to the proximal repair. The trifurcated graft is then anastomosed to the reconstructed aorta.

Transient neurologic dysfunction was assessed in patients not experiencing a stroke and was defined as postoperative confusion, agitation, or delirium. These patients had no evidence of new focal lesions on computed tomography or magnetic resonance imaging scans when studies were available.

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
All arch reconstructions were completed utilizing the trifurcated graft technique during a single period of HCA followed by SCP, with the following measurements: mean HCA 31.1 ± 6.5 minutes (range, 17 to 48); mean SCP 66.6 ± 21.0 minutes (range, 21 to 125); mean SCP temperature 15.8 ± 2.1°C (range, 12.0 to 22.1°C); mean cardiopulmonary bypass time 239 ± 53.1 minutes (range, 157 to 390).

Survival
Kaplan-Meier survival (Fig 4) at 1, 3, and 5 years was 75%, 73% and 61%, respectively.

View larger version (13K): [in this window] [in a new window]   Fig 4. Kaplan-Meier survival function (solid line). (Cum = cumulative; crosses = censored.)

Complications
The most frequent complication was prolonged intubation (>48 hours), necessary in 24 patients (16%). Transient neurologic dysfunction developed in 7 patients (4.7%), return to the operating room for bleeding was required in 7 patients (4.7%), and temporary renal support was needed in 9 patients (6%), but none required permanent dialysis. Median intensive care unit stay was 3 days (range, 1 to 108) and median hospital stay was 10 days (range, 4 to 108).

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

 
A strategy for neurologic protection must be an integral part of a technique for aortic arch replacement and should address two key areas: minimizing cerebral injury during global ischemia and avoiding particulate atheroemboli, which, with an aging population, has become even more important. Antegrade SCP has become recognized as an important tool for arch replacement and can be performed in several different ways: right axillary artery cannulation with balloon catheter in the left common carotid artery [6], direct balloon catheter perfusion of the innominate and left common carotid arteries [7–10], unilateral cerebral perfusion through the right axillary artery [11] or the right brachial artery [12], and even direct, bilateral cannulation of the carotid arteries outside the thorax [13].

Two surgical approaches using a combination of deep hypothermia and SCP have emerged to minimize neurologic risks: the integrated, four-branched arch graft technique of Kazui and others [7–9] and, more recently, the independent, trifurcated graft technique [14]. Both permit shorter durations of DHCA by utilizing bilateral, antegrade SCP, while isolating the brachiocephalic vessels during arch repair, which reduces the chance for cerebral atheroembolization [15].

The trifurcated technique, which achieves SCP through axillary cannulation, offers a number of advantages over the four-branched arch graft technique, which employs direct cannulation of the brachiocephalic vessels with balloon catheters: instrumentation of the brachiocephalic vessels is avoided, an important point when atherosclerotic disease is present in the brachiocephalic vessels; similarly, in the event of acute or chronic dissection cannulation of the arch vessels may be difficult and malperfusion is possible; it is possible for perfusion cannulae can become dislodged or displaced during SCP [16]; perfusion cannulae in the limited space of the mediastinum may obscure the operative field during arch replacement; and lastly, the fact that the branches of the four-branched graft are fixed in their position on the arch graft limits the versatility of the technique for accommodating arch anomalies and similarly, since the elephant trunk is constructed before the brachiocephalic anastomoses with this technique, the position of the branch grafts are fixed in relation to the brachiocephalic vessels, which may lead to kinking. A disadvantage of the trifurcated graft technique is that lower core temperatures and longer DHCA intervals may be required depending on the operative strategy, although these are well within the accepted safe limits.

Unilateral cerebral perfusion through the axillary or brachial artery has been used by several groups with excellent results [12]. However, one relies on collateral circulation through the circle of Willis to ensure adequate left cerebral flow, which may be inadequate in certain individuals. The use of cerebral oximetry [17] or transcranial Doppler may identify those at risk [18].

A slight modification of the trifurcation graft method permits even shorter DHCA intervals, in the range of 15 to 20 minutes. During a single period of DHCA, the left subclavian artery is anastomosed to a limb of the trifurcated graft, followed by the innominate artery. Partial SCP at 400 to 500 mL/min is begun with the middle limb of the trifurcated graft clamped, back-flushing the open left common carotid through collaterals; the left common carotid is then gently occluded with a soft clamp, restoring cerebral circulation. Next, under partial SCP, the left carotid artery is attached and deaired, and SCP flow is increased to 10 mL · kg^–1 · min^–1. The remaining arch reconstruction proceeds as usual.

Large arch aneurysms may displace the left subclavian artery laterally and cephalad. In such cases, a preoperative left subclavian to left common carotid bypass facilitates the arch reconstruction, wherein a bifurcated graft is implanted during a short interval of DHCA.

The optimum application of SCP continues to be investigated, but certain aspects have been elucidated. Overperfusion has been shown to be as detrimental as underperfusion in a canine model [19]. Laboratory studies support the use of low temperatures for prolonged SCP [20], although some surgeons continue to feel that moderate, hypothermic SCP is adequate. Although controversial, the use of alpha-stat management for SCP in adult patients may be beneficial by helping to maintain metabolic suppression and by preserving cerebral autoregulation, which helps reduce the risk of cerebral embolization [21]. However, experimental studies indicate that areas of cerebral injury are more susceptible to ischemia during SCP [22] and the use of pH-stat management may be marginally beneficial in the subset of patients with previous strokes [23].

Our technique for SCP is alpha-stat management, a perfusate temperature between 15°C and 20°C, hematocrit of 25% to 30%, flows of 10 mL · kg^–1 · min^–1 with a mean arterial pressure of 40 to 60 mm Hg.

Finally, in patients with anomalies of the aortic arch, aberrant right subclavian artery or direct exit of the left vertebral from the aortic arch, simple modifications of the trifurcated technique permit safe arch repair [14]. In the case of an aberrant right subclavian artery, transposition of the right subclavian artery to the right common carotid artery facilitates a standard trifurcated graft reconstruction. With aberrant left vertebral arteries, a preoperative duplex ultrasound study should document the patency and flow of the right vertebral artery, as this will alter intraoperative strategy. A small left vertebral artery, less than 2 mm, with a patent right vertebral, may be ligated. A larger left vertebral artery should be preserved; it may be directly implanted into the left common carotid artery or extended with a portion of saphenous vein and implanted into the arch graft or trifurcated graft (Fig 5). We repaired 8 anomalous arch vessels in this fashion, 1 anomalous right subclavian arteries and 7 aberrant left vertebral arteries, and postoperative imaging revealed patency of all reconstructed vessels.

View larger version (90K): [in this window] [in a new window]   Fig 5. Aberrant vertebral arteries originating from the aortic arch have been reconstructed by direct implantation into the left common carotid artery or, with an interposed segment of saphenous vein, by implantation into the arch graft or trifurcated graft.

	References

Top Abstract Introduction Patients and Methods Results Comment References

 

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