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Ann Thorac Surg 2007;83:S815-S818
© 2007 The Society of Thoracic Surgeons

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Supplement

Optimization of Aortic Arch Replacement: Two-Stage Approach

Department of Cardiothoracic and Vascular Surgery, The University of Texas at Houston Medical School, Memorial Hermann Heart and Vascular Institute, Houston, Texas

^_* Address correspondence to Dr Safi, Department of Cardiothoracic and Vascular Surgery, The University of Texas at Houston Medical School, 6410 Fannin St, Suite 450, Houston, TX 77030. (Email: hazim.j.safi{at}uth.tmc.edu).

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

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
BACKGROUND: Aneurysms of the aortic arch seldom occur alone. They usually involve the ascending aorta. Occasionally, the aneurysm also involves the descending thoracic or thoracoabdominal aorta. We advocate a staged approach for repair of these extensive aortic aneurysms, with the ascending and arch generally being repaired in the first stage and the descending thoracic or thoracoabdominal aorta being repaired in the second stage.

METHODS: Between February 1991 and December 2005, we repaired aneurysms of the ascending, arch, descending thoracic, and thoracoabdominal aorta in 2120 patients. Of these, 254 (12.0%) involved the ascending, arch, and descending aorta (extensive aortic aneurysm). A first-stage repair was done in 254 patients, and 115 returned for a second-stage repair for a total of 369 procedures performed.

RESULTS: First-stage 30-day mortality was 6.3% (16/254), with the glomerular filtration rate (GFR) exceeding 70 mL/min in 2.9% of patients and less than 70 mL/min in 10.5% (p < 0.03). Second-stage 30-day mortality was 9.6% (11/115), with GFR exceeding 70 mL/min in 4.9% and less than 70 mL/min in 9.8% (not significant). The incidence of postoperative stroke for the first stage was 2.0% (5/254), and the rate of neurologic deficit (paraplegia and paraparesis) was .9% (1/115) in the second stage. The mortality for the interval of 31 days to 6 weeks after the first-stage operation was 2.9% (7/238).

CONCLUSIONS: Aneurysms involving the transverse arch with extensive involvement of the ascending and descending thoracic or thoracoabdominal aorta can be effectively repaired using the two-stage technique with acceptable morbidity and mortality. GFR correlates to surgical outcome in the first-stage repair. After the first stage, prompt treatment of the remaining segment of aorta is crucial to success.

	Introduction

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Aneurysmal disease is rarely isolated solely in the transverse aortic arch. Frequently, the ascending aorta or aortic root is also affected, and occasionally, the descending thoracic or thoracoabdominal aorta will also be involved. The term extensive aortic aneurysm was coined to describe those aneurysms that involve all segments of the aorta. Repair of such aneurysms presents a great surgical challenge because the brain, heart, and spinal cord must all be protected. Graft replacement of the ascending aorta, arch, and descending thoracic aorta performed in a single operation can exaggerate potential hazards. The patient must undergo a lengthy procedure that requires multiple incisions, an increased number of protective surgical adjuncts, longer clamp times, and greater blood loss.

Before the introduction of the elephant trunk technique in 1983 [1], staged repair was also fraught with complications. Invariably, the pulmonary artery or descending thoracic aorta would be entered during dissection of the aorta, causing catastrophic and often fatal hemorrhage [2]. The elephant trunk technique permits the surgeon to avoid dissection of the proximal native descending thoracic aorta in the second stage and obviates the bleeding problem.

We have routinely used a modified version of the elephant trunk technique since 1991 [3]. The purpose of this study is to report our results with this technique for repair of extensive aortic aneurysms, with special attention paid to the morbidity from stroke in the first stage and from paraplegia and paraparesis in the second stage. We will also discuss our overall mortality rates as they relate to preoperative renal function.

	Patients and Methods

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The University of Texas Houston Medical School’s Committee for the Protection of Human Subjects approved data collection and analysis for this study.

Between February 1991 and December 2005, 2120 patients underwent repair of the ascending, descending, and thoracoabdominal aorta (935 ascending and arch; 1185 descending thoracic and thoracoabdominal). Of these, 254 (12.0%) underwent repair for extensive aortic aneurysm. A total of 369 elephant trunk procedures were performed in 254 patients. Their mean age was 68 years (range, 16 to 87); 129 (50.8%) were men and 125 (49.2%) were women.

Patients with stroke were identified by a thorough neurologic examination and computed tomography scan of the head. Aneurysms of 5 cm or more were considered for repair. Symptomatic aneurysms smaller than 5 cm ere also considered for intervention.

The traditional first-stage repair of the ascending aorta and arch repair was performed in 254 patients, and 115 patients underwent second-stage repair. Reasons that patients did not undergo a second-stage procedure after the first stage included awaiting the second-stage repair or they refused the procedure, prophylactic first stage (thoracic aneurysm between 4 and 5 cm), severe atheromatous plaque (grade III or IV) without aneurysm, lost to follow-up, and for technical reasons (Fig 1).

View larger version (23K): [in this window] [in a new window]   Fig 1. Flow chart shows staging and disposition of patients who underwent the first-stage elephant trunk procedure. Definitions: prophylactic refers to repair of descending or thoracoabdominal aortic aneurysms of less than 5 cm diameter; technical repair is one that did not involve an aneurysm, but the elephant trunk was performed for technical reasons; atheromatous refers to a procedure that did not involve an aneurysm but was done because of severe atheromatous disease in the proximal descending thoracic aorta; interval mortality refers to death occurring in the period after the first stage elephant trunk, between 31 days and 6 weeks. (ET = elephant trunk, LTF = lost to follow-up.)

Cardiopulmonary bypass, profound hypothermia, and circulatory arrest are used. Retrograde cerebral perfusion has been used in all cases since 1992 [5]. The patient’s nasopharyngeal temperature is lowered until the electroencephalograph is isoelectric and the pupils are fixed and dilated. To protect the heart, we use antegrade/retrograde blood cardioplegia, keeping the myocardial septal temperature below 20°C.

We place the patient in the head-down position and insert a Dacron graft (DuPont, Wilmington, DE), which has been inverted on itself, into descending thoracic aorta. We suture the inverted edge distal to left subclavian. Then we bring the inverted portion of the graft into operative field. We make an elliptical incision in the graft opposite the brachiocephalic arteries and suture with 3-0 polypropylene. Once this is done, we cannulate the ascending aorta either directly or with a specially manufactured graft with a sidearm.

We then start rewarming the viscera and the brain. As rewarming is begun, we turn our attention to the remainder of the ascending aorta. We evaluate the aortic root. If the valve is diseased, the aortic root is dilated, or both, we use a composite valved graft to replace the aortic root. We reattach both main coronary arteries using the button technique. Then the patient is warmed until nasopharyngeal temperature is 36°C. The patient is weaned from cardiopulmonary bypass and then decannulated and closed.

The patient will usually stay in the intensive care unit (ICU) for 1 to 2 days. After discharge from the hospital, the patient is advised to come back in 4 to 6 weeks for the second-stage repair.

Second-Stage Technique
The second stage of the elephant trunk technique is much like standard descending thoracic or thoracoabdominal aortic aneurysm repair [4]. Cerebrospinal fluid drainage is used. Distal aortic perfusion is established from the left atrial appendage or pulmonary vein to the left common femoral artery. With a clamp at the mid-descending thoracic aorta, the proximal third of the descending thoracic aorta is opened without proximal dissection. The elephant trunk portion of the graft, inserted in the descending thoracic aorta during the first stage is grasped and clamped. A new woven Dacron graft is sutured to the "elephant trunk."

The remainder of the operation follows our standard method of repair of descending thoracic and thoracoabdominal aortic aneurysms [6]. We use sequential clamping of the descending thoracic aorta to perform the reattachment of the intercostals arteries, the visceral arteries, and finally, the distal aortic anastomosis. Intercostals arteries T8–T12 are routinely reattached, except in cases of heavily calcified or occluded arteries or acute aortic dissection. The visceral arteries are perfused using cold blood, keeping the left renal temperature at less than 20°C, or with tepid blood while the anastomosis is performed using an inclusion technique.

If the patient is asymptomatic, we prefer to repair the ascending and arch first since the recovery period after this surgery is quicker than that of thoracoabdominal repair. However, if one portion of the extensive aneurysm is symptomatic, that portion takes precedence. We use the reverse elephant trunk technique if descending aorta requires immediate repair.

	Results

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The 30-day mortality was 6.3% (16/254) in first-stage repair, with a glomerular filtration rate (GFR) exceeding 70 mL/min in 2.9% of patients and less than 70 mL/min in 10.5% (p < 0.03), and 8.7% (10/115) in the second-stage repair, with the GFR exceeding 70 mL/min in 4.9% and less than 70 mL/min in 9.8% (not significant). During the interval of 31 days to 6 weeks after the first-stage repair, mortality was 2.9% (7/238). The interval mortality of patients who did not return was 16% (7/45; Fig 1). Postoperative stroke occurred in 5 (2.0%) of 254 first-stage patients. Adjunct retrograde cerebral perfusion was used in 235 patients undergoing first-stage repairs, with a stroke rate of 3 (1.3%), and 19 patients underwent repair without retrograde cerebral perfusion, with a stroke rate of 2 (10.5%), for an odds ratio of 0.11 (p < 0.006).

Second stage 30-day mortality was 9.6% (11/115). Although there were 28 (24.4%) type II and 47 (40.8%) type I thoracoabdominal aortic aneurysms, spinal cord dysfunction occurred in only 1 second-stage patient (0.9%).

Median hospital length of stay for stage one was 16 days (range, 0 to 256 days). Median ICU length of stay for stage one was 6 days (range, 0 to 95 days). Median hospital length of stay for stage 2 was 15 days (range, 1 to 115 days), and the median ICU length of stay was 4 days (range, 0 to 81 days). Median time between stage one and stage two was 64 days (range, 5 to 2527 days).

	Comment

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
In our experience, we rarely encounter disease of the transverse arch without involvement of some other portion of the aorta, usually of the ascending portion. We also occasionally see involvement of the descending thoracic or thoracoabdominal aorta. Staged repair has been the method of choice for repair of such aneurysms; however, before the advent of the elephant trunk technique, introduced by Hans Borst and colleagues in 1983 [1], the second stage was fraught with a high risk of catastrophic bleeding. The Borst technique allows the surgeon to open the transverse arch and descending thoracic aorta without dissection, obviating this risk.

Since our adoption of this technique in 1991, we have seen excellent results for morbidity and mortality. The 30-day mortality after the first-stage repair of the ascending aorta was 6.3%. We found that GFR was significantly associated with early death after the first-stage repair. For those that returned for the second-stage repair of the descending thoracic or thoracoabdominal aorta, 30-day mortality was 8.7%, with the GFR exceeding 70 mL/min in 4.9% and less than 70 mL/min in 9.8%. Although GFR was not significantly associated with mortality in this group of patients, we have previously shown that preoperative GFR is an excellent predictor of postoperative mortality for patients undergoing repair of the descending thoracic or thoracoabdominal aortic aneurysms [7].

Our most vexing concern is with the 2.9% mortality in the interval of 31 days to 6 weeks after the first-stage repair. A total of 139 patients were discharged from the hospital after the first-stage elephant trunk procedure. It is clarified in Fig 1 that not all of these were intended to have the second-stage procedure performed. Specifically, 45 patients who were expected to return for a second-stage procedure failed to return either because of refusal of a second-stage procedure or the patient was lost to follow-up. As such, we are diligent in asking our patients to return for the second-stage repair as soon as possible, although the patient’s clinical status after the first stage must taken into consideration. Staged repair using the elephant trunk technique is an effective treatment for extensive aortic aneurysms; however, surgery of just one portion of an extensive aortic aneurysm does very little to reduce the likelihood of aneurysm rupture and death.

We have had good results in repair of the ascending aorta and arch using the technique of cardiopulmonary bypass, profound hypothermia, and circulatory arrest, along with the introduction in recent years of the adjunct retrograde cerebral perfusion, used to extend the brain’s tolerance to ischemia. In our experience, stroke rate has been reduced to 2.0%. We practice extreme diligence in cannulating the ascending aorta or femoral or axillary artery, tapering to the needs of the patient. Special care must be taken in the patient who has atheromatous plaques in the ascending aorta, transverse arch, or descending aorta, necessitating the use of the axillary artery. Retrograde cerebral perfusion also offers protection by flushing away all debris and impurities. Our findings that retrograde cerebral perfusion is significant with regard to stroke shows that this is an important modality.

Some have suggested an advantage for repair of extensive aortic aneurysms in a single operation because the patient does not have to return for a second-stage repair, thus avoiding the risk of mortality from rupture during the interval between the two stages [8]. Although this risk of rupture between stages is tangible in the elephant trunk technique, in our experience we have found that the risks and associated morbidity and mortality of the single-stage repair are greater. Furthermore, the limitation of the bilateral anterolateral thoracotomy approach advocated in the single-stage repair limits the surgeon to the thoracic aorta. In 65% of our patients undergoing repair for an extensive aortic aneurysm, aneurysmal disease extends into the thoracoabdominal aorta, which would be inaccessible in the advocated single-stage incision.

Aneurysms involving the transverse arch usually involve the ascending, descending, and thoracoabdominal aorta. The elephant trunk technique provides acceptable morbidity and mortality in these extensive aortic aneurysm repairs. Renal function correlates with surgical outcome of these patients in the first stage. However, because of the risk of rupture during the interval between operations, we recommend timely repair of the involved segment of the aorta to prevent rupture and death.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
We thank Kirk Soodhalter for his editorial assistance and for preparation of this manuscript and Chris Akers for his artistic assistance.

	References

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

1. Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using "elephant trunk" prosthesis Thorac Cardiovasc Surg 1983;31:37-40.[Medline]
2. Crawford ES, Svensson LG, Coselli JS, Safi HJ, Hess KR. Surgical treatment of aneurysm and/or dissection of the ascending aorta, transverse aortic arch, and ascending aorta and transverse aortic archFactors influencing survival in 717 patients. J Thorac Cardiovasc Surg 1989;98:659-673discussion 73–4.[Abstract]
3. Safi HJ, Miller 3rd CC, Iliopoulos DC, Letsou GV, Baldwin JC. Staged repair of extensive aortic aneurysm: improved neurologic outcome Ann Surg 1997;226:599-605.[Medline]
4. Safi HJ, Miller 3rd CC, Estrera AL, et al. Staged repair of extensive aortic aneurysms: long-term experience with the elephant trunk technique Ann Surg 2004;240:677-684discussion 84–5.[Medline]
5. Safi HJ, Brien HW, Winter JN, et al. Brain protection via cerebral retrograde perfusion during aortic arch aneurysm repair[see comments] Ann Thorac Surg 1993;56:270-276.[Abstract/Free Full Text]
6. Safi HJ, Estrera AL, Miller CC, et al. Evolution of risk for neurologic deficit after descending and thoracoabdominal aortic repair Ann Thorac Surg 2005;80:2173-2179discussion 179.[Abstract/Free Full Text]
7. Huynh TT, van Eps RG, Miller 3rd CC, et al. Glomerular filtration rate is superior to serum creatinine for prediction of mortality after thoracoabdominal aortic surgery J Vasc Surg 2005;42:206-212.[Medline]
8. Kouchoukos NT, Mauney MC, Masetti P, Castner CF. Single-stage repair of extensive thoracic aortic aneurysms: experience with the arch-first technique and bilateral anterior thoracotomy J Thorac Cardiovasc Surg 2004;128:669-676.[Abstract/Free Full Text]

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