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Ann Thorac Surg 2007;83:S811-S814
© 2007 The Society of Thoracic Surgeons

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Supplement

Optimization of Aortic Arch Replacement With a One-Stage Approach

Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, St. Louis, Missouri

^_* Address correspondence to Dr Kouchoukos, Cardiac, Thoracic, and Vascular Surgery, Inc, 3009 N Ballas Rd, Suite 360C, St. Louis, MO 63131. (Email: ntkouch{at}aol.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: Staged procedures for extensive aneurysmal disease of the thoracic aorta are associated with a substantial cumulative mortality for the two procedures and death in the interval between, often from aortic rupture. We have used a one-stage approach for operative repair of most, or all, of the thoracic aorta.

METHODS: Sixty-nine patients were treated using a bilateral anterior thoracotomy with transverse sternotomy, hypothermic circulatory arrest, and reperfusion of the arch vessels first to minimize brain ischemia. Forty-two patients had chronic ascending aortic dissections (all but 1 had a previous operation), 24 had degenerative aneurysms, and 3 had chronic descending aortic dissections with proximal extension. The ascending aorta and aortic arch were replaced in all patients combined with resection of various lengths of descending aorta.

RESULTS: In-hospital mortality was 7.2% (5 patients). Morbidity included reoperation for bleeding (13%), mechanical ventilation for more than 72 hours (50%), temporary tracheostomy (13%), and temporary renal dialysis (9%). No patient sustained a stroke. There have been 9 late deaths unrelated to the aortic disease. Four patients have undergone successful reoperation on the aorta for false aneurysm in 1, endocarditis in 1, and progression of disease in 2. Survival at 5 years was 71%.

CONCLUSIONS: The one-stage arch-first technique is a safe and suitable alternative to the two-stage procedure for repair of extensive thoracic aortic disease.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
The optimal surgical technique for the treatment of extensive disease of the thoracic aorta is not clearly established. A staged approach has been favored by some surgical groups when the ascending aorta, the arch, and the descending thoracic or thoracoabdominal aorta are involved, and the elephant trunk technique has been widely used in this setting [1–4]. However, recent reports with the elephant trunk technique have documented a cumulative mortality exceeding 20%, which includes in-hospital mortality for the two procedures and death (commonly from aortic rupture) in the interval between them [3, 5]. Similarly, there is no clear consensus on the optimal method of brain protection for procedures that involve total replacement of the aortic arch.

We report here our experience with single-stage repair of extensive disease of the thoracic aorta using a bilateral anterior thoracotomy (clamshell) incision and performance of the arch anastomosis first during a period of hypothermic circulatory arrest to minimize the duration of brain ischemia.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
Patient Selection
During an 11-year interval ending in February 2006, 69 patients underwent one-stage repair of the ascending aorta, the aortic arch, and varying lengths of the descending thoracic aorta using a technique that has been previously reported [6]. The mean age of the patients was 61 years (range, 24 to 82 years), and 46 (69%) were men. Seven patients (10%) had Marfan syndrome, and 47 (68%) had undergone previous operations on the thoracic aorta, the aortic valve, or the coronary arteries.

Chronic ascending aortic dissection was the principal indication for use of this operative technique (Table 1). Of the 42 patients with this condition, 33 had undergone previous ascending aortic replacement, with or without aortic valve replacement or repair, for acute ascending aortic dissection with distal extension and had progressive enlargement of the remaining dissected aortic arch and varying lengths of the descending thoracic aorta. The other 9 patients presented with chronic ascending dissection after previous aortic valve replacement or repair in 4, coronary artery bypass grafting in 4, or without a previous operation in 1. Of the remaining 27 patients, 24 had extensive degenerative aneurysms and 3 had chronic descending dissections with proximal extension. Five of the 24 patients with degenerative aneurysms had previous operations on the thoracic aorta. Rupture of the aneurysm was present in 3 patients. The mean interval between the initial and the second procedure among the 47 patients undergoing reoperation was 71 months (range, 1 to 265 months).

Operative Procedure
The ascending aorta, the entire aortic arch, and varying lengths of the descending thoracic aorta—most or all of the descending aorta in 40 patients (58%)—were resected and replaced in all patients. For patients with aortic dissection, the descending thoracic aorta was transected at a level at which the diameter did not exceed 3 to 3.5 cm. A portion of the septum between the true and false lumens was excised, and the graft was sutured to the outer circumference of the aorta. Concomitant procedures, including aortic valve or aortic root replacement, coronary artery bypass grafting, and mitral valve repair were performed in 36 patients (52%). Patients with aortic enlargement that extended below the diaphragm were managed with staged procedures.

Perfusion Data
Arterial return was established using a common femoral artery in 32 patients and the right axillary artery in 37 patients. The latter site is currently preferred. The mean durations of cooling, circulatory arrest, hypothermic arch perfusion, spinal cord and lower body ischemia, myocardial ischemia, rewarming, and cardiopulmonary bypass are summarized in Table 2. Among the 35 patients in whom a cuff of aorta was used to attach the brachiocephalic arteries to the aortic graft, the mean duration of circulatory arrest was 39 ± 9 minutes, exceeded 50 minutes in 4 patients, and did not exceed 60 minutes in any patient.

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
Early Death and Morbidity
There were five (7.2%) in-hospital deaths. Two patients died in the operating room of biventricular failure and respiratory failure. The other 3 patients died on postoperative days 5, 8, and 23 of multiple organ system failure in 2 and cardiac failure in 1. The patient who died on postoperative day 23 had paraplegia.

Reoperation for bleeding or for evacuation of clot from the left pleural space was required in 9 (13%) of the 67 operative survivors. In most, only exploration of the left pleural cavity was required to evacuate clot. The intraoperative mean transfusion requirements were 8 units of packed cells, 8 units of fresh frozen plasma, 5 units of platelets, and 7 units of cryoprecipitate. Mechanical ventilatory support for more than 72 hours was required in 34 (50%) of the 67 operative survivors, and 9 (13%) required tracheostomy. The mean duration of ventilatory support was 8.2 days (median, 4 days; range, 1 to 91 days). Permanent vocal cord paralysis occurred in 2 patients (3%).

Intraoperative insertion of a right ventricular assist device for right ventricular dysfunction was required in 3 patients, 2 of whom died in the hospital. The device was removed on the third postoperative day in the third patient, who had a full recovery and was discharged from the hospital. Renal failure requiring temporary ultrafiltration or hemodialysis occurred in 6 patients (9%), 2 of whom died in the hospital. In the remaining 4 patients, blood urea nitrogen and creatinine levels returned to baseline levels before discharge from the hospital.

No patient sustained a stroke. Transient neurologic dysfunction occurred in 6 (9%) of the 67 operative survivors and resolved completely in all of them. It was present in 5 (14%) of the 35 patients with the aortic cuff technique and in 1 (3%) of the 34 patients with the branched graft technique (p = 0.2). The mean duration of postoperative hospital stay was 22 days (median, 14 days; range, 5 to 118 days). There were no deep wound infections. One patient with a chronic ascending dissection required a femorofemoral artery bypass graft for postoperative occlusion of the left external iliac artery. One patient with Marfan syndrome required exploration of a groin incision for arterial bleeding and also a left thoracotomy to treat a persistent chylothorax.

Late Death
Nine patients have died during the follow-up interval, which extends to 100 months. These deaths occurred between 3 and 79 months postoperatively and resulted from cardiac failure in 3 patients, renal failure, stroke, metastatic cancer, and endocarditis in 1 patient each, and from an unknown cause in 2. The 3-year and 5-year product-limit survival estimates are 79% and 71%, respectively.

Late Reoperations
Four patients have undergone successful reoperations that involved the aortic graft (n = 2) or the remaining aorta (n = 2). One required reoperation on the aortic root and the ascending aortic graft for presumed infection 15 months postoperatively. The aortic root was replaced with an aortic allograft, and the ascending portion of the previously inserted aortic graft was replaced with a new polyester graft. The second patient was reoperated upon for a false aneurysm surrounding the descending thoracic aortic segment of the aortic graft 40 months postoperatively. At operation, erosion of the graft resulting from compression against a rib was noted, and a segment of the graft was replaced. The third patient, who had a chronic descending aortic dissection, required replacement of the remaining contiguous thoracic and upper abdominal aorta for aneurysmal enlargement 34 months after the initial operation. The fourth patient required resection of a separate infradiaphragmatic degenerative aneurysm 31 months postoperatively.

All surviving patients have been monitored with serial computed tomography studies at 6-month to 12-month intervals. To date, no other patient has had sufficient enlargement of the remaining thoracic aorta to require reoperation.

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

 
Advantages of the Arch-First Technique
We implemented the arch-first technique for procedures that required total replacement of the aortic arch to minimize the duration of brain ischemia. The traditional method for total aortic arch replacement, described by Griepp and colleagues [7] and popularized by Crawford and colleagues [8] involves performance of the distal aortic anastomosis first, followed by the arch anastomosis, with both of these anastomoses being performed during an interval of hypothermic ischemic arrest. This technique continues to be widely used, particularly in combination with the elephant trunk modification.

Crawford and colleagues found that perioperative stroke with a focal neurologic deficit was related to the duration of circulatory arrest and to the presence of concurrent distal aortic disease [8]. The duration of circulatory arrest was also a predictor of early death [8]. Furthermore, because the duration of hypothermic circulatory arrest and increasing age are important predictors of temporary neurologic dysfunction and of the persistence of fine-motor and memory deficits after operations on the aortic arch, reducing the duration of circulatory arrest should reduce the prevalence of these complications as well, particularly in elderly patients [9, 10].

In our initial 35 patients, in whom a cuff of aorta surrounding the brachiocephalic arteries was sutured to the aortic graft, the duration of circulatory arrest averaged 39 minutes and did not exceed 60 minutes in any patient. In the more recent 34 patients, we used axillary artery cannulation for arterial return, a branched graft, and an interval of hypothermic brain perfusion from the right carotid and right vertebral arteries, during which the 3 brachiocephalic arteries were attached to the branches of the aortic graft, the mean duration of circulatory arrest was reduced to 9.8 minutes and exceeded 13 minutes in only 4 patients. No patient in the entire series sustained a stroke, and temporary neurologic dysfunction was observed in 14% of the patients with the aortic cuff technique and 3% of the patients with the branched graft technique, suggesting that this is a highly effective technique for brain protection. The arch-first technique has the additional advantages of providing arterial brain perfusion without the need for direct cannulation of the brachiocephalic arteries, a potential cause of embolization and stroke, or for a separate perfusion circuit for the brain.

When used in conjunction with a bilateral anterior thoracotomy, excellent exposure of the heart, the brachiocephalic arteries, both phrenic and the left vagus nerves, and the entire descending thoracic aorta is obtained. Injury to the dilated ascending aorta, which can occur with a median sternotomy incision during a reoperation, is avoided because the transverse thoracotomy incision is made below this level. The wide exposure of the left pleural cavity avoids excessive manipulation and compression of the left lung, which can result in intrapulmonary hemorrhage in a fully heparinized patient. If concomitant coronary artery bypass grafting is not required, mobilization of the heart from the pericardium is necessary only on the lateral surface of the right atrium and the adjacent interatrial groove. If coronary artery bypass grafting is necessary, exposure of the three major coronary arterial systems is easily accomplished. The right atrium and the interatrial groove are easily exposed if tricuspid or mitral valve procedures are required.

Use of a bilateral anterior thoracotomy also permits resection of the entire thoracic aorta. This eliminates the need for a two-stage procedure if the disease is confined to the thoracic aorta, the attendant mortality and morbidity associated with a second thoracic aortic procedure, and the mortality that occurs in the interval between the staged procedures [2, 3].

Disadvantages of the Arch-First Technique
To permit performance of the arch anastomosis first, wide exposure of the entire aortic arch is necessary, and this is best accomplished with a bilateral anterior thoracotomy approach, which requires sacrifice of both internal thoracic arteries. No major wound complications have occurred, however.

Concern has also been expressed about a high prevalence of pulmonary complications with this approach. The prevalence of major pulmonary complications in our series does not, however, exceed that reported for the first stage of a two-stage approach for treatment of extensive thoracic aortic disease in which a median sternotomy incision is used for the first stage [2]. A low prevalence of pulmonary complications with a bilateral anterior thoracotomy for extensive thoracic aortic resections has been observed by other groups [11, 12]. Furthermore, this incision has been widely and successfully used for bilateral lung transplantation in patients with severely impaired pulmonary function, mediastinal and bilateral pulmonary tumors, and complex congenital heart disease. Injury to the phrenic nerves must be avoided, however.

Indications
Our experience with the arch-first technique indicates that it is a safe and suitable alternative to other methods of brain protection during procedures that involve total replacement of the aortic arch. It is of particular value in patients requiring reoperation for chronic ascending aortic dissection who have substantial dilatation of the proximal descending thoracic aorta, which can preclude safe suturing of an aortic graft to this segment. It is also a satisfactory alternative to the two-stage procedure for treatment of extensive degenerative aortic disease that is confined to the thoracic aorta.

Our current and preferred technique for brain protection using axillary artery cannulation, a brief period of circulatory arrest, subsequent hypothermic antegrade brain perfusion, and a branched graft, has substantially reduced the duration of circulatory arrest of the brain. It eliminates the need for cannulation of the brachiocephalic arteries and the attendant risk of embolization and is safe, as evidenced by the absence of stroke and a low prevalence of temporary neurologic dysfunction.

	References

Top Abstract Introduction Patients and Methods Results Comment References

 

1. Heinemann MK, Buehner B, Jurmann MJ, Borst H-G. Use of the "elephant trunk technique" in aortic surgery Ann Thorac Surg 1995;60:2-7.[Abstract/Free Full Text]
2. Safi HJ, Miller III CC, Estrera AL, et al. Staged repair of extensive aortic aneurysmsMorbidity and mortality in the elephant trunk technique. Circulation 2001;104:2938-2942.[Abstract/Free Full Text]
3. Schepens MA, Dossche KM, Morshuis WJ, van den Barselaar PJ, Heijmen RH, Vermeulen FE. The elephant trunk technique: operative results in 100 consecutive patients Eur J Cardiothorac Surg 2002;21:276-281.[Abstract/Free Full Text]
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5. Estrera AL, Miller III CC, Porat EE, Huynh TT, Winnerkvist A, Safi HJ. Staged repair of extensive aortic aneurysms Ann Thorac Surg 2002;74:S1803-S1805.[Abstract/Free Full Text]
6. Kouchoukos NT, Mauney MC, Masetti P, Castner CF. Single-stage repair of extensive thoracic aortic aneurysms: experience with arch-first technique and bilateral anterior thoracotomy J Thorac Cardiovasc Surg 2004;128:669-676.[Abstract/Free Full Text]
7. Griepp RB, Stinson EB, Hollingsworth JF, Buehler D. Prosthetic replacement of the aortic arch J Thorac Cardiovasc Surg 1975;70:1051-1063.[Abstract]
8. Svensson LG, Crawford ES, Hess KR, et al. Deep hypothermia with circulatory arrest: determinants of stroke and early mortality in 656 patients J Thorac Cardiovasc Surg 1993;106:19-31.[Abstract]
9. Ergin MA, Galla JD, Lansman SL, Quintana C, Bodian C, Griepp RB. Hypothermic circulatory arrest in operations on the thoracic aorta J Thorac Cardiovasc Surg 1994;107:788-799.[Abstract/Free Full Text]
10. Reich DL, Uysal S, Sliwinski M, et al. Cardiopulmonary support and physiology J Thorac Cardiovasc Surg 1999;117:156-163.[Abstract/Free Full Text]
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