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Ann Thorac Surg 2007;83:1041-1046
© 2007 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Optimal End-Organ Protection for Thoracic and Thoracoabdominal Aortic Aneurysm Repair Using Deep Hypothermic Circulatory Arrest

John W. Fehrenbacher, MD, PhDa,*, David W. Hart, MDb, Erica Huddlestona, Harry Siderys, MDa, Camille Ricea

a Methodist Hospital and Clarian Health Systems, Indianapolis, Indiana
b Indiana University Hospital, Indianapolis, Indiana

Accepted for publication September 26, 2006.

* Address correspondence to Dr Fehrenbacher, CorVascMD’s PC, 1801 N. Senate Blvd, Indianapolis, IN 46202 (Email: jfehrenbacher{at}comcast.net).

Presented at the Poster Session of the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 1, 2006.


Dr Fehrenbacher discloses that he has a financial relationship with CryoLife, Inc.

 

   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: Despite the advent of numerous protective strategies, thoracic and thoracoabdominal aortic replacement remains a high risk. While mortality rates have improved over the last 15 years, the incidence of adverse outcomes (including stroke, renal failure, and paraplegia, as well as death) remains at 13% to 30% in all published series. The use of deep hypothermic cardiopulmonary bypass with circulatory arrest has been associated with high morbidity in the past; however, we report a single surgeon’s experience of improved end-organ protection with low morbidity and mortality utilizing this technique.

Methods: One hundred seventy-three consecutive patients with descending thoracic and thoracoabdominal aneurysms were operated on between April 1995 and March 2005. Hypothermic (15°C) cardiopulmonary bypass with circulatory arrest and open proximal anastomosis were utilized in all subjects. Visceral arteries were uniformly reimplanted as an island while additional renal artery bypasses were performed as required. Lower intercostals and lumbar arteries were aggressively reimplanted or preserved at the aortic anastomosis. No other adjuncts for spinal cord protection were routinely employed.

Results: Sixty-three patients with isolated descending thoracic aortic aneurysms and 27 patients with extent I, 49 with extent II, 20 with extent III, and 14 with extent IV thoracoabdominal aortic aneurysms underwent operative repair. Ninety percent of cases were elective while 10% were urgent or emergent. There were seven hospital deaths, and the hospital mortality was 4.0%. Operative complications included stroke in seven patients (4.1%), paraplegia in four (2.4%), including 0 of 62 ambulatory patients with isolated thoracic aneurysm repairs, and acute renal failure requiring dialysis in two of 168 operative survivors that were not dialysis-dependent before surgery.

Conclusions: Deep hypothermic circulatory arrest allows replacement of complex aortic pathology with low mortality. End-organ protection is excellent with lower incidences of dialysis-dependent renal failure and paraplegia than are reported with other currently used surgical techniques.

Resection of descending thoracic or thoracoabdominal aortic pathology remains high risk, with cumulative death, stroke, paraplegia, or dialysis-dependent renal failure rate between 13% and 30% in recently reported series [1–8]. For elective operations, mortality has decreased over the last 15 years at major aortic surgery centers and the bulk of the serious morbidity involves cerebral, spinal cord, and visceral injury. While complications such as paralysis, stroke, and renal dialysis may not be lethal, they do confer serious quality of life issues as well as long-term costs to patients, to their families, and to health care systems. Many strategies have been proposed to minimize these serious end-organ morbidities, but none have met with universal success or acceptance. Endovascular stent grafting shows promise in the treatment of thoracic aortic aneurysms; however, long-term durability is not yet proven and selection criteria will leave some patients with the need for surgery.

Techniques of open thoracic (TA) and thoracoabdominal (TAAA) aneurysm repair commonly utilized by cardiac surgeons include clamp-and-sew, left heart bypass (either staged or complete repair), and cardiopulmonary bypass with deep hypothermic circulatory arrest (DHCA) and open proximal anastomosis (as popularized by Kouchoukos and colleagues [5]). Many extent IV TAAAs are repaired by vascular surgeons using the clamp-and-sew technique, some with variable types of shunts to aid visceral perfusion while under aortic cross-clamp. Hypothermic cardiopulmonary bypass, with periods of deep hypothermic circulatory arrest, provides good cerebral protection during aortic arch procedures and ascending or proximal descending thoracic aortic procedures in which the aorta cannot be safely cross-clamped. This is a skill common in the armamentarium of most cardiac surgeons and recently has been applied successfully to TA and TAAA repair by several groups [5, 6, 9, 10]. Ten years ago, we also began using this technique in our practice with the premise that it would afford low mortality and excellent spinal cord and renal protection for replacement of thoracic and thoracoabdominal aortic pathology.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
The Institutional Review Board approved the study and waived the need for patient consent in this retrospective chart review. Data are presented as means ± standard deviations. Paired t tests were used to compare individual laboratory values before and after surgery. A z-test comparison of proportions was used to compare incidence of stroke before and after changing femoral bypass initiation technique and a Kaplan-Meier method was used to calculate 1, 3, and 5 year survival based on follow-up clinical data. A p value less than 0.05 was considered statistically significant.

All adult patients with aortic aneurysmal disease that involved the distal aortic arch, descending thoracic aorta, or thoracoabdominal aorta who underwent aortic replacement by the primary author (JWF) at The Methodist Hospital, Indianapolis, IN between April 1995 and March 2005 are included in this retrospective study. This institution is a large, urban, teaching hospital and a regional referral center for aortic pathology. All operations were performed by JWF, often assisted by the coauthors. The long-term mortality has been analyzed on 169 of the 173 patients that were available for follow-up. This follow-up was provided by chart review, phone communication, and state mortality record analysis as of June 2006.

Operative Technique
All 173 patients were operated on using the same technique. A left thoracoretroperitoneal incision was performed. After preliminary dissection for exposure, the patient was heparinized with 3 mg/kg of heparin. A long 33/30 Fr Carpentier bicaval cannula (Medtronic, Minneapolis, MN) was inserted into the left femoral vein and guided into the right heart by transesophageal echo. Arterial cannulation was generally performed using the left common femoral artery, or, in the case of severe aortoiliac disease, through the distal thoracic aorta. A 20 Fem-Flex cannula (Edwards Life Science, Irvine CA) was utilized. Cardiopulmonary bypass was begun slowly and the patient was cooled to a tympanic membrane temperature of 15°C. The left ventricle or the pulmonary vascular bed is routinely vented during ventricular fibrillation to maintain a pulmonary artery mean pressure of 20 mmHg or less. Although electroencephalogram, somatosensory-evoked potentials (SEPs), and motor-evoked potentials (MEPs) were not used in this study population, we currently monitor all three.

Circulatory arrest was instituted and the thoracic aneurysm was clamped just distal to the anticipated proximal anastomosis. Just prior to circulatory arrest, 40 to 60 mEq of potassium chloride, depending on body surface area and serum creatinine, was delivered into the cardiopulmonary circuit to obtain a diastolic cardiac arrest. The thoracic aorta was transected proximal to the cross-clamp with the patient in Trendelenburg. The open aorta was then carefully examined for atheromatous debris at the site of the aneurysm and proximal to the aneurysm for any significant intraluminal grumous material. The proximal anastomosis was accomplished at a nondiseased level. During this anastomosis, the distal aorta was perfused through the femoral cannula and the venous cannula was partially occluded to encourage retrograde bleeding from the proximal transected aorta.

After the anastomosis was completed, tested, and glued a perfusion cannula was introduced into a side arm of the graft and perfusion of the proximal aorta was begun through a second arterial line. BioGlue (Cryolife, Kennesaw, Georgia) was used in all cases except when resection was performed for infection. The remainder of the aneurysm was then opened and individual perfusion catheters (9 Fr. Pruitt Irrigation occlusion catheters, LeMaitre Vascular, St. Petersburg, FL) were introduced into the renal and visceral arteries. Patent intercostals and lumbar arteries from T10 to just before the celiac artery takeoff were implanted as an island or preserved at the aortic anastomosis. If none were patent from T10 to L2, then more proximal intercostals were reimplanted and, rarely, large infrarenal lumbar arteries. The renal and visceral arteries were evaluated for significant stenosis, and if stenosis was present individual bypass grafts were sewn to these arteries distal to the area of stenosis. The remainder of the operation consisted of attaching either the visceral artery islands or the individual bypass grafts to the main aortic graft, followed by revascularizing the distal aorta or iliac arteries.

Cerebrospinal fluid drainage was not used during these operations. However, three patients did have cerebrospinal fluid drains postoperatively for immediate or delayed spinal cord injury (two with resolution of delayed paraparesis).


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Demographics are shown in Table 1. The mean age was 66.1 ± 12.8 years and two-thirds of patients were males. Thirty-eight percent had undergone previous aortic surgery. Sixty-three patients (36%) had disease not extending below the diaphragm (designated TA; isolated thoracic aortic aneurysms). Twenty-seven patients (16%) had extent I TAAA, 49 patients (28%) had extent II TAAA, 20 patients (12%) had extent III TAAA, and 14 patients (8%) had extent IV TAAA. The arch or hemiarch was resected in TA (31 of 63, 49%) and TAAA (21 of 110, 19%). Atheromatous fragments were responsible for approximately half of these more proximal resections involving the arch. Etiologies and presentations are summarized in Table 2. Two-thirds were atherosclerotic-degenerative aneurysms and 10% were taken to the operating room in urgent or emergent settings. Mean operating time was 390 ± 111 minutes, total cardiopulmonary bypass time was 210 ± 78 minutes, and circulatory arrest time was 32 ± 9.3 minutes.


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  		Table 1 Demographics
 

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  		Table 2 Etiology and Presentation
 
Mortality
The hospital mortality rate was 4.0% (seven patients) all within the first nine postoperative days. Two of 155 patients taken to the operating room in an elective setting died (1.3%), while five of 18 patients undergoing operations in urgent or emergent settings died (28%). The mortality rate for patients with atherosclerotic aneurysms was 5.2% (six patients) and 0% for patients with acute or chronic dissections. Two patients with isolated descending thoracic aneurysms died (both with emergent, ruptured aneurysms), and there were four deaths among 49 patients with extent II TAAAs and one death among 20 patients with extent III TAAAs. There were no deaths among 85 patients undergoing elective operation for isolated thoracic aneurysms or extent I TAAAs.

The 1-year, 3-year, and 5-year survivals were 82%, 72%, and 62%, respectively (Fig 1). Long-term survival according to age groups is also shown within this graph.


Figure 1
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  		Fig 1. The 1-year, 3-year, and 5-year Kaplan-Meier survival by age group. (Numbers in parentheses = number of patients.)

 
Neurologic Injury
Stroke with a resulting focal neurologic deficit occurred in seven patients (4.1% of operative survivors). Early in this series, full flow was initiated immediately upon starting cardiopulmonary bypass through the femoral cannulas. Since 1998, we have routinely begun bypass with the venous cannula partially occluded and maintained pulsatile flow for the first five minutes (as recommended by Griepp and colleagues [11]). Two strokes occurred in the initial 19 patients initiating full femoral bypass (10.5%), while five strokes have occurred in the last 154 patients since routinely starting femoral bypass slowly (3.2%; p = 0.41 by z-test comparison of proportions). Six of seven strokes occurred when the proximal descending thoracic aorta was involved. The seven were as follows: two isolated TAs, two extent I TAAAs, two extent II TAAA, one extent III, and no strokes in extent IV. The extent III aneurysm had severe atheromatous disease involving the proximal descending thoracic aorta but was not resected due to the emergent nature of this procedure. All seven patients who had strokes underwent femoral cannulation, as did the vast majority of cases (170 femoral, three descending thoracic aorta). Two stroke patients died, one with severe neurologic compromise. Four of the seven strokes were discharged without any residual neurologic defects.

Paraplegia occurred in four of 169 operative survivors (2.4%; one operative survivor had been paralyzed 10 years prior during operation for acute type B aortic dissection). Paraparesis occurred in four patients as well (2.4%). Six of these spinal cord injuries were diagnosed immediately after the patients awakened; two patients had delayed deficits (one after going into hemorrhagic shock due to a splenic rupture unrecognized at the initial operation; the other had brief hypotension presumably due to sedation, but this cause was not clearly elucidated). Three of the eight spinal cord injuries, two cases of immediate paraparesis and one case of delayed paraparesis, resolved with therapeutic maneuvers in the intensive care unit (ICU) (one with dopamine to increase systemic blood pressure and the other two with dopamine and immediate cerebrospinal fluid drainage). These three were ambulating at discharge. In all, there were five patients with permanent spinal cord injuries (3.0%); two of 26 patients operated on for extent I TAAAs and three of 48 patients operated on for extent II TAAAs.

Renal Dysfunction
Sixteen patients had preoperative diagnoses of chronic renal insufficiency (all had serum creatinine 1.8 or greater at the time of operation). Two died intraoperatively. Figure 2 shows the preoperative and postoperative serum creatinine levels of the 14 surviving patients (postoperative levels were measured five to seven days after surgery). The net change was only +2.8% (p = 0.81 by paired t test). Of 168 survivors who were not on chronic dialysis before surgery, only two required dialysis postoperatively (1.2%). None of the elective patients with preoperative renal insufficiency died. None of 33 operative survivors with extent III or IV TAAAs required new renal dialysis.


Figure 2
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  		Fig 2. Serum creatinine in 14 patients with preoperative renal insufficiency; excluding patients with preoperative dialysis.

 
Pulmonary Complications
Intubation and mechanical ventilation prolonged greater than 24 hours was required in 13 patients (7.6%). Four patients required tracheotomies. There was one case each of adult respiratory distress syndrome and pneumonia. Nine of 13 cases of prolonged ventilation were for patients with neurologic problems (stroke, paraplegia, confusion).

Other Morbidity
Ten of 170 operative survivors underwent reexploration for bleeding (5.9%). Three were diagnosed with acute myocardial infarction (1.8%). There were three major wound infections (two superficial and one deep, involving the graft). The mean transfusion requirement was 3.9 ± 3.6 units packed red blood cells. The mean ICU length of stay was 4.6 ± 4.0 days and the mean hospital stay was 10.9 ± 8.5 days.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
The natural history of untreated descending thoracic and thoracoabdominal aneurysms is poor; the reported 5-year survival estimates range from 18% to 46% [12, 13]. The operative mortality for thoracoabdominal aneurysms has improved from the pioneering experience of Svensson and colleagues [14] but remains approximately 8% [15]. The incidence of severe complications is also significant with permanent spinal cord injury reported from 4.5% [2] to 15% [14] and acute renal failure up to 20% [16] at high-volume centers.

Hypothermic cardiopulmonary bypass with circulatory arrest has been used by many surgeons for a variety of aortic pathologic states. Originally popularized by Griepp and colleagues [17] for aortic arch pathology, it has been recently applied to descending thoracic and thoracoabdominal aortic aneurysms by Kouchoukos and colleagues [5, 6]. Kouchoukos and Rokkas [18] have reported decreased susceptibility of spinal cord tissue to ischemic damage and, in a large clinical series, a very low spinal cord ischemic injury rate of 3.0% [5]. This exceptionally low paraplegia and paraparesis rate has been recently reproduced by groups also using hypothermic cardiopulmonary bypass with circulatory arrest in Los Angeles [9], Ann Arbor [10], and now Indianapolis by both academic leaders and experienced private-practice surgeons. It is a technique with which most cardiac surgeons are familiar, and it can be applied very successfully once the nuances of this fairly complex pump management are mastered. Additional techniques designed to minimize neurologic morbidity have also been used by other groups. Although in our series, cerebral spinal fluid drainage was not used preoperatively because of the concern of intraspinal bleeding in fully anticoagulated patients, it was used postoperatively for paraparesis and paraplegia. We recently (August 2005) began monitoring SEPs and MEPs and we are now placing spinal fluid drains prior to leaving the operating room if increasing blood pressure or cardiac output alone does not result in return of MEP.

"All comers" mortality is difficult to compare between various reported series and repair techniques. It is heavily influenced by the percentage of cases done urgently or emergently for rupture, contained rupture, thrombosis, or acute end-organ failure. Indeed, we found a greater than 20-fold increase in mortality in our patients operated on in nonelective settings compared with those operated on in an elective situation. Our elective in-hospital mortality rate of 1.3% stands well among reports from other high-volume centers. Of note, the mortality for elective isolated descending thoracic and extent I TAAAs combined was 0% (0 of 85). This number is not yet being replicated by endoluminal stent grafting in the elective setting [19, 20].

A recent study reporting State of California data revealed 30-day mortality of 19% and a one-year mortality of 31% in all elective TAAA repairs from 1991 to 2002 among 1,010 patients [21]. Although the elective surgical technique was not described in these 1,010 patients performed at 166 separate institutions, it is safe to assume that all cases were not performed using DHCA or at high-volume institutions. Our elective 30-day mortality of 1.3% and all-case one-year mortality of 13% provide favorable support for the technique of DHCA regionalization to high-volume institutions. It is, however, important to point out that comparing results from a multiinstitutional state registry to the results of a single institution could be a factor in mortality differences.

Most surgeons who deal with type III and IV TAAA are vascular surgeons who do not use cardiopulmonary bypass or left heart bypass, but rather use the clamp-and-sew technique. A few use innovative vascular bypasses or shunts during the procedure to support the viscera [22, 23]. Reasons commonly offered for avoiding cardiopulmonary bypass include the desire to avoid the complexity of bypass, those complications specifically related to retrograde aortic flow (ie, embolization), and bleeding associated with heparinization and bypass [16, 24]. These potential negatives are balanced by the benefits of cardiopulmonary bypass; primarily avoidance of ischemia of the dependent organs, and thus, the complications of renal failure, paraplegia, and the bleeding diathesis that is associated with visceral ischemia [25–32]. Obviously, only surgeons familiar with both techniques can adequately judge their merit and benefits. Among our patients with type III and IV TAAAs, there was only one stroke (extent III) and no new postoperative renal failure.

There are several major technical advantages we have noted using hypothermic cardiopulmonary bypass with circulatory arrest. The first is the opportunity to do an open proximal anastomosis. This simplifies the operation (especially in redo aortic replacement as less dissection is required). In addition, the open anastomosis allows a view of the interior of the aorta and any atheromatous debris is easily identified, and the aorta is resected further proximally until there is normal, nondiseased intima if possible. We believe this decreases the cerebral, visceral, or peripheral embolic potential as no residual atheromatous debris remains. Another advantage is that the viscera are cooled and almost continuously perfused for maximal protection. While blood utilization with this technique is greater than with routine infrarenal abdominal aortic surgery, our average utilization was approximately four units of packed cells with no incidents of unmanageable bleeding diathesis.

Most series of extent III and IV TAAAs report an operative mortality near 10%, acute renal failure in greater than 10% of patients, and permanent spinal cord ischemic damage in greater than 10% of patients [14, 23]. Our experience includes one death in 34 patients with extent III and IV TAAAs (a 65 year old female with a known extent III TAAA who was taken to the operating room emergently for acute mesenteric ischemia and profound metabolic acidosis; she was found to have a critical ostial stenosis of the superior mesenteric artery and an occluded inferior mesenteric artery). One of these patients was already end-stage renal disease on dialysis while six of the 34 had preoperative chronic renal insufficiency not requiring dialysis; in five of the six with chronic renal insufficiency the postoperative serum creatinine was lower but not statistically significant than the preoperative level.

The presence of preoperative renal insufficiency or failure is felt to increase the risk of surgery in all TAAA patients, and it has been recently suggested that renal failure or insufficiency should be considered a relative contraindication for surgery [33]. We have not found this to be the case in the 155 elective patients. In fact, with the use of hypothermic bypass and DHCA, the net change from baseline in the serum creatinine of 14 patients with chronic renal insufficiency (mean Cr 3.2 ± 1.8 mg/dL) was less than 3%.

Although the use of cardiopulmonary bypass with hypothermia and circulatory arrest adds to the complexity of caring for these patients in the operating room, we feel the resulting end-organ protection improves overall results.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

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