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Ann Thorac Surg 2008;85:956-964. doi:10.1016/j.athoracsur.2007.11.014
© 2008 The Society of Thoracic Surgeons
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Original Articles: Cardiovascular

Hypothermic Circulatory Arrest: Safety and Efficacy in the Operative Treatment of Descending and Thoracoabdominal Aortic Aneurysms

Joseph S. Coselli, MD*, Jovan Bozinovski, MD, Catherine Cheung, Hons, BSc

The Texas Heart Institute, St. Luke’s Episcopal Hospital, and Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas

Accepted for publication November 2, 2007.

* Address correspondence to Dr Coselli, Baylor College of Medicine, One Baylor Plaza, BCM 390, Houston, TX 77030 (Email: jcoselli{at}bcm.edu).

Presented at the Fifty-third Annual Meeting of the Southern Thoracic Surgical Association, Tucson, AZ, Nov 8–11, 2006.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 References
 
Background: The safety and efficacy of hypothermic circulatory arrest in the operative treatment of descending thoracic aortic aneurysms and thoracoabdominal aortic aneurysms are not clearly established. We evaluated our experience with repair of descending thoracic and thoracoabdominal aortic aneurysms using hypothermic circulatory arrest.

Methods: In all, 111 patients with descending thoracic aortic aneurysms (83) or thoracoabdominal aortic aneurysms (28) underwent graft replacement of the involved aortic segments using hypothermic circulatory arrest. The technique was used when the location, extent, and severity of disease precluded placement of a proximal aortic clamp. Mean patient age was 61.4 ± 13.1 years and 81 (73%) were male. Nine patients (8%) presented with acute dissection; 74 (67%) had chronic dissection; 56 patients (51%) required emergency operations, including 16 (14%) with ruptured aneurysms. Mean circulatory arrest time was 39.7 ± 16.2 minutes.

Results: There were no intraoperative deaths. There were 31 operative deaths (28%), including 23 patients (21%) who died within 30 days. Operative mortality was 29% (30 of 102) for patients undergoing emergent or urgent operations and 1% (1 of 9) for all elective cases (p = 0.4). Postoperative paraplegia developed in 1 patient (1%) and 17 patients (15%) had postoperative renal failure. Cardiac complications occurred in 26 patients (23%), reoperation for bleeding in 6 (5%), tracheostomy was required in 24 (22%), and 10 (9%) sustained postoperative stroke.

Conclusions: When cross clamping the aorta is not feasible, hypothermic circulatory arrest can be performed but with an increased morbidity and mortality rate.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Discussion
 References
 
Cardiopulmonary bypass with profound hypothermic circulatory arrest (HCA) has proven to be an efficacious technique in the treatment of complex pathology involving the ascending aorta, transverse aortic arch, descending, and thoracoabdominal aorta, permitting safe intervals of circulatory arrest. As an adjunct for the protection of the central nervous system, it is well established [1]. It has been less frequently employed to protect the spinal cord and renal function [2, 3]. The latter is a consequence of the disadvantages of hypothermia, which include coagulopathy, cold injury to the lung, the inflammatory consequences of cardiopulmonary bypass, and retraction injury of the heparinized left lung. Although we have not employed hypothermic cardiopulmonary bypass for noncerebral organ protection on a routine basis, we have, however, encountered a group of patients whose anatomy and pathology either prevented clamping of the proximal aorta or necessitated replacement of all or part of the transverse aortic arch. The results of our treatment for this high-risk, complex cohort of patients forms the basis of this report.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Discussion
 References
 
Since 1986, perioperative data from all patients undergoing aortic repair in the clinic of the senior author (J.S.C.) have been collected and entered into a clinical database. Retrospective review of this database and waiver of informed consent were approved by the Institutional Review Board at Baylor College of Medicine.

Study Variables and Definitions
Among the preoperative variables, dissection was considered acute if patients underwent surgery within 14 days of the initial event; after 14 days, dissection was considered chronic. Acute presentations were defined as patients requiring emergent or urgent operation because of acute dissection, free or contained rupture, or acute symptoms [4]. Preoperative renal failure was defined as patients receiving dialysis. Intraoperative variables included extent of repair for thoracoabdominal aortic aneurysms (TAAA), which was based on Crawford’s original classification. For descending thoracic aortic aneurysms (DTAA), the extent of repair was classified based on the descending thoracic aortic segments that were replaced, namely the proximal one third (A), middle one third (B), distal one third (C), or any combination of these.

Regarding outcome variables, operative mortality was defined as death within 30 days of operation or during the initial hospitalization. Hospital-to-hospital transfer was not considered discharge; patients who died after being transferred were counted as operative deaths. Transfer to a nursing home or rehabilitation center was considered discharge, unless a patient died because of complications directly related to the operation [5]. All patients with postoperative neurological deficits involving the lower extremities were included in the paraplegia or paraparesis categories, regardless of whether the deficit was immediate, delayed, transient, or permanent. This included patients with unilateral lower-extremity deficits, unless an associated deficit involving the ipsilateral upper extremity—indicating a stroke—was present. Acute renal failure was defined as serum creatinine level being greater than 3.1 mg/dL, or if the patient required hemodialysis.

Cardiac complications were defined as myocardial infarction, atrial or ventricular arrhythmia requiring treatment, pericardial effusion requiring drainage, or cardiac failure requiring inotropic support greater than 48 hours, and the use of intra-aortic balloon counterpulsation or mechanical ventricular support. All cases of vocal cord paralysis were confirmed by direct laryngoscopy.

Statistical analysis was conducted with SPSS software (SPSS Institute, Chicago, Illinois). For comparative evaluations, Fisher’s exact tests were used for categorical variables and Student’s t tests were used for continuous variables.

Patients
Demographic and preoperative characteristics of these patients are presented in Table 1. Patients had mean age of 61.4 ± 13.1 years, and 81 (73%) of them were men. One hundred and two patients had acute presentations, and 81 patients had aortic dissections, of which 9 (8%) were acute and 74 (67%) were chronic. Two patients with chronic dissection presented with superimposed acute dissection. Rupture occurred in 16 patients (14%) and pseudoaneurysm in 9 (8%). Fifty patients (45%) had previous aortic repairs.


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  		Table 1 Clinical Characteristics of 111 Patients Who Underwent Surgical Repair of Descending Thoracic or Thoracoabdominal Aortic Aneurysms Using Hypothermic Circulatory Arrest
 
Operative Technique
After the induction of anesthesia, monitoring catheters, including a pulmonary artery catheter, are placed. Double-lumen endotracheal intubation is performed. Electroencephalographic monitoring with a 10-lead montage is applied. The descending thoracic aorta is exposed through a left posterolateral thoracotomy incision through either the fourth or fifth intercostal space without rib resection. For exposure of the entire thoracoabdominal aorta, the incision through the fifth or sixth intercostal space is carried across the costal margin to the level of the umbilicus. A combined abdominal and retroperitoneal approach is utilized along with circular division of the diaphragm and exposure of the abdominal aorta with anterior and right lateral reflection of the spleen, tail of the pancreas, and left kidney. The left common femoral vein or femoral artery or both are exposed through an incision along skin lines immediately distal to the groin. Heparin, 4 mg/kg, is administered intravenously. To establish venous drainage, a 28F to 32F long multiholed cannula is inserted through the femoral vein over a guidewire and positioned at the level of the right atrium, confirmed on transesophageal echocardiography. Vacuum-assisted venous drainage is utilized and flows of 1.8 to 2.4 L · min–1 · m–2 or 50 mL/kg are achieved. To control left ventricular filling, an angled cannula, 20F or 22F, is placed through the inferior pulmonary vein into the left atrium utilizing a Y-branch in the venous line. Alternatively, the left atrial appendage or the pulmonary artery may be used for this.

We have employed two separate sites for arterial cannulation on a routine basis. In younger patients with minimal intimal arterial atherosclerosis, the femoral artery is cannulated with a 20F or 22F straight cannula. In older patients with severe atherosclerosis or intraluminal thrombus within part or all of the aneurysm, a 22F angled cannula is placed within the lower descending thoracic aorta. A computed tomography or magnetic resonance angiography scan is used to determine an appropriate site with minimal thrombus. Additional alternatives for perfusion return include the left common carotid and or left axillary artery using direct cannulation or end-to-side anastomosis of an 8-mm Dacron graft (DuPont, Wilmington, DE). Immediately upon cannulation, and generally after exposure of the aortic pathology confirming the need for cardiopulmonary bypass and circulatory arrest, systemic cooling is initiated. For additional protection, we administer methylprednisolone (5 to 10 mg/kg), sodium thiopental (10 to 15 mg/kg), lidocaine (100 mg), and a short-acting β-blocker. Care is taken during retraction of the left lung to minimize manipulation and hemorrhagic parenchymal injury.

In this series, we have not employed cardioplegia, either antegrade or retrograde, for myocardial protection nor have we used retrograde cerebral perfusion. Cooling is carried out until the electroencephalogram is isoelectric. The nasopharyngeal temperature is monitored and is generally between 15°C to 18°C at the point of electrocerebral silence. Immediately before circulatory arrest, the head is packed circumferentially with bags containing crushed ice. The operative field is flooded with carbon dioxide to reduce the risk of air embolism when the aortic arch is opened. We have used cerebrospinal fluid drainage in selected cases in which the risk of spinal cord ischemia is considered significant, and there is sufficient time to implement this adjunct. Typically, we do not employ intrathecal papaverine, somatosensory or motor-evoked potential monitoring, selective spinal cord cooling, or intrathecal papaverine.

With the initiation of circulatory arrest, the patient is placed in the Trendelenburg position, and the left atrial venting catheter is clamped. When possible the aorta is cross clamped distal to the aortic pathology and flows maintained in the distal circulation are at 1 to 1.5 L/min, allowing for gentle back bleeding through the brachiocephalic vessels to reduce the risk of air embolism. Reconstruction at the level of the transverse aortic arch, namely, the proximal repair, generally takes one of three forms. In the simplest procedure, a saccular aneurysm is repaired with a patch under a single period of circulatory arrest. Dacron material is employed in patients with atherosclerotic saccular aneurysms, whereas in mycotic aneurysms homograft aortic material is utilized. Second, in patients in whom the pathology extends well into or involves the entire transverse thoracic aortic arch, an end-to-end proximal anastomosis is carried out to the ascending aorta followed by reattachment of the brachiocephalic vessels, either with collagen-impregnated (Hemashield; Meadox Medical, Oakland, New Jersey) or gelatin-sealed (Vascutek; Vascutek Terumo, Renfrewshire, Scotland) woven Dacron graft. Finally and most commonly, a single open proximal anastomosis in a beveled hemiarch fashion is carried out. For patients in whom the distal aortic reconstruction is either anticipated to be complex, extensive, or prolonged, a prefabricated side graft of 8-mm Dacron off the main aortic graft, immediately distal to the proximal anastomosis, is employed to reestablish flow to the heart and brachiocephalic vessels after the flushing of air and debris. Flushing is facilitated by temporarily increasing the flow into the distal circulation and volume loading. The aortic graft is then occluded distal to the 8-mm side graft, and arterial inflow is advanced to approximately 40% of the total calculated amount needed perfusion.

Rewarming using the proximal circulation is initiated. In the more extensive and complex Crawford extent II TAAA, rewarming is delayed until visceral arterial reattachment is completed. If the reconstruction is limited to the upper or mid descending thoracic aorta, a simple end-to-end distal anastomosis is carried out. Distal flows can be temporarily reestablished for the flushing of air and debris before releasing the clamp and restoring to full levels, and further rewarming. Cardiopulmonary bypass is only discontinued when the nasopharyngeal temperature has reached 36°C to 36.5°C. Excessive rewarming is avoided. In patients who require more extensive thoracoabdominal aortic aneurysm repair and reconstruction, under a period of 40% flow, the nasopharyngeal temperature is maintained between 20°C and 22°C. During this period, the aortic graft is used to reattach intercostal arteries as well as visceral, renal, and lumbar arteries after which full flow is reinitiated and rewarming completed. Eighty-seven patients (78%) in this series had no intercostal or lumbar arteries reattached as shown in Table 2. Two patients (2%) had one pair of segmental arteries reattached, 10 patients (9%) had 2 pairs reattached, 5 patients (5%) had 3 pairs, 5 patients (5%) had 4 pairs, and 2 patients (2%) had 5 pairs reattached. When anatomy permits, the proximal clamp is adjusted in a sequential fashion distally, allowing flow to the intercostal and visceral vessels before completion of the distal anastomosis.


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  		Table 2 Operative Details Regarding 111 Patients Who Underwent Surgical Repair of Descending Thoracic or Thoracoabdominal Aortic Aneurysms Using Hypothermic Circulatory Arrest
 

   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Discussion
 References
 
There were no intraoperative deaths. Operative mortality rate was 28% (31), with 30-day death being 21% (23) as presented in Table 3. Thirty patients died in-hospital (27%); 24 of these deaths occurred at our hospital and 6 occurred after transfer to another institution. The dispositions of the 86 patients who were discharged or transferred from our hospital included 61 patients (71%) discharged home, 11 patients (13%) discharged to extended care facilities, 7 patients (8%) discharged to rehabilitation centers, and 7 patients (8%) transferred to another hospital. The average time between operation and discharge from our hospital was 24.2 ± 29.6 days (median, 15). Ten patients (9%) had strokes. Renal failure occurred in 17 patients (15%), with cardiac complications in 26 patients (23%). Vocal cord paralysis developed in 43 patients (39%).


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  		Table 3 Early Complications in 111 Patients Who Underwent Surgical Repair of Descending Thoracic or Thoracoabdominal Aortic Aneurysms Using Hypothermic Circulatory Arrest
 
One patient (1%) developed paraplegia. The patient was a 64-year-old man with Marfan syndrome, a history of congestive heart failure, and a chronic DeBakey type I aortic dissection. He presented with a superimposed acute dissection and a ruptured DTAA. The patient had a prior aortic valve and ascending aortic replacement and a repair of his extent IV TAAA. He underwent emergent replacement of his DTAA (extent ABC) without cerebrospinal fluid drainage or reattachment of intercostal arteries. The patient had immediate paraplegia and acute renal failure, and was on temporary hemodialysis. He was discharged to a long-term care facility on postoperative day 15, without hemodialysis. Four months later, he survived an emergent repair of a rupture of the visceral patch of his prior TAAA repair with a multibranch graft. At 3.5 years of follow-up, he remains well and in a wheelchair. He is currently without hemodialysis, but with permanent paraplegia.

Results from the univariate analyses comparing elective repairs versus emergent or urgent repairs are listed in Table 4. Patients undergoing elective repairs received fewer platelet transfusions during operation (p = 0.03). Otherwise, there were no significant differences in preoperative, intraoperative, or postoperative factors between the two groups. Results from the comparison of preoperative characteristics and intraoperative variables for the survival status of patients after surgical repair using hypothermic circulatory arrest are listed in Table 5. In particular, rupture is strongly associated with patient deaths with a p value of 0.001; cardiac complications (p < 0.001) and vocal cord paralysis are also strongly indicated in patient deaths (p < 0.001). Acute dissection is associated with patient deaths at p = 0.01, whereas diabetes mellitus is weakly associated (p = 0.04). For intraoperative variables, acuity of urgent and emergent operative nature displays a strong association with patient deaths (p = 0.005 and p = 0.001, respectively), in addition to the extents A and ABC of DTAA repair (p values 0.03 and 0.02, respectively). Cardiopulmonary bypass time (p = 0.03) and transfusion of packed red blood cells (p = 0.02) are also indicated. For the 17 acute renal failure patients (15%), there were 9 who died (53%) and 8 (47%) who survived. Of the 9 patients who died, 8 had been placed on hemodialysis. For the 8 survivors, 2 were on permanent dialysis, 5 were on temporary dialysis, and 1 did not require dialysis. Five of 17 patients who had acute renal failure were also cases of aortic rupture, 3 of whom later died and 2 of whom survived on temporary dialysis.


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  		Table 4 Comparison of Preoperative Characteristics, Intraoperative Variables, and Early Outcomes in Patients Who Underwent Elective Versus Emergent or Urgent Surgical Repair Using Hypothermic Circulatory Arrest
 

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  		Table 5 Comparison of Preoperative Characteristics and Intraoperative Variables in Patients Who Survived Versus Died After Surgical Repair Using Hypothermic Circulatory Arrest
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Discussion
 References
 
Regarding the surgical management of pathologies involving the descending thoracic or thoracoabdominal aorta, well-established techniques have included simple aortic cross clamping or the use of distal perfusion with atriofemoral bypass. Cardiopulmonary bypass with deep HCA has been used less commonly. Proponents have justified the technique, citing benefits that include minimal circumferential dissection of the aorta, complete elimination of the need for proximal aortic cross clamping, access to the proximal aortic arch and even the ascending aorta, and a bloodless operative field. The intent and purpose of profound hypothermia has been to provide access to the distal ascending aorta and proximal transverse aortic arch, as well as providing protection to the brain, spinal cord, kidneys, and to a lesser extent the abdominal viscera.

Borst and associates [6] are credited with reporting the first successful use of HCA in the management of a complex aortic arch lesion approached through the left side of the chest. Crawford and associates [7] described the use of partial cardiopulmonary bypass, profound hypothermia, and circulatory arrest in the treatment of 25 patients exposed through left posterolateral incisions. The most frequent indications for use were complications during attempts at proximal exposition of the aorta for purposes of cross clamping or the inability to expose the distal arch secondary to fibrosis resulting from prior arch operations or proximal extent of the aneurysm. Twenty-one patients (84%) survived more than 30 days. There were 4 postoperative deaths: 2 from myocardial infarctions, one from pulmonary embolism, and one from bleeding. Twelve patients (48%) required prolonged respiratory support, and 9 (36%) with tracheostomy. Neurologic injury occurred in 20%, diffuse brain injury occurred in 1, localized stroke in 2, and paraplegia in 2. These authors noted the lack of assured spinal cord protection and an increase in complications, particularly pulmonary complications, and as a consequence thought these methods should not be used routinely, but rather in selected cases.

Kieffer and associates [8] employed a technique similar to Crawford in 15 patients and for similar indications. Their mortality rate was 27% (4 of 15); with 2 intraoperative and 2 postoperative deaths. Bleeding and left ventricular failure were the cause of the former, coagulopathy and aortic rupture of the latter. Two surviving patients (15%) required tracheostomy. In 1 (8%) of the 13 patients whose neurologic status could be evaluated postoperatively, paraplegia developed 4 hours after operation. Safi and associates [9] employed hypothermic circulatory arrest in 21 patients, and had a 30-day mortality rate of 29%, with a mortality rate of 50% among urgently operated patients. Overall, 67% had pulmonary complications, 13% had stroke, and 13% had spinal cord neurologic deficits. These authors believed the incidence of mortality and morbidity was comparable to their conventional methods but recommended the judicious application of circulatory arrest in rare instances when proximal control was not feasible or catastrophic intraoperative bleeding led to no other options. Okita and colleagues [10] reported outstanding results in 25 patients with no early mortality, 1 stroke, and 1 delayed-onset paraplegia. Their series was based on a select group of patients, none of whom had acute aortic dissection; all were operated upon on an entirely elective basis. No patient demonstrated postoperatively the need for hemodialysis. Prolonged mechanical ventilation (greater than 48 hours) was required in 5 patients (20%).

Kouchoukos and associates [11, 12] have employed HCA on a routine basis and focus on the advantages of cerebrospinal cord and organ protection. Their series included 192 patients yielding a 30-day mortality of 6.8% (13 patients). Their 90-day mortality rate was 12.5% (24 patients), and it was 40% for 20 patients who required an emergent operation. Paraplegia occurred in 4 and paraparesis in 1 of 186 operative survivors (2.7%). Renal dialysis was required in 4 patients (2.2%), mechanical ventilation (≥48 hours) in 64 patients (34%), and tracheostomy in 17 patients (9%). They concluded that hypothermia substantially increases the tolerable duration of spinal cord ischemia, thus allowing a safe interval for attachment of intercostal and lumbar arteries while providing satisfactory protection of the heart, brain, kidneys, and abdominal viscera without the need for additional adjuncts. Additionally, they found that the duration of aortic clamping, duration of spinal cord ischemia and the extent of aorta replaced were not identified as risk factors for the development of paraplegia or paraparesis.

When the indications for the use of HCA are limited to technical considerations and emergent conditions, an harsh reality is that the morbidity and mortality are challenging at best—Crawford 16%, Kieffer 27%, Kouchoukos 40%, Safi 29% to 50%, and this report 29% [7–9, 12]. Spinal cord ischemic complications are infamously multifactorial, and the failure to revascularize, effectively or in a timely fashion, critical intercostals and lumbar arteries remains a potential etiology. Regardless, the protective impact of hypothermia on this most devastating complication is confirmed by the work of Kouchoukos and coworkers [12] with an incidence of only 2.7% in 186 survivors, and reaffirmed in this series with a spinal cord deficit rate of only 1 in 111 patients (<1%), an incidence too low for meaningful statistical analysis.

Control of bleeding during HCA remains problematic. Our approach, when protamine sulfate is clinically inadequate, is to primarily use blood products, such as platelets, fresh frozen plasma, and in particular, cryoprecipitate. Additional products, when necessary, include aprotinin and factor VII. Adequate patient rewarming cannot be understated in its influence upon this particular complication. Additionally, the blood product usage in this series of patients is included in Tables 2, 4, and 5. The incidence of paraplegia in this series (1%) was surprisingly low (as noted in Table 3). It compares very favorably with our previously reported incidence of paraplegia in patients undergoing descending thoracic aortic replacement (2.3% to 4%) and in TAAA (3.8%) [13,14].

In recent years, many of the patients with aortic pathology treated through the left side of the chest using HCA have been considered for surgical management using alternative approaches. These have included replacement of the transverse arch through a median sternotomy, with an elephant trunk technique, and either staged or same-procedure exclusion of the descending thoracic aorta with endovascular stent grafting. Another approach is the debranching of the brachiocephalic arteries through a sternotomy without the use of cardiopulmonary bypass or HCA, with or followed by stent grafting of the arch and descending thoracic aorta. Only further use and evaluation will determine the ideal technique for individual patients.

For surgeons who routinely use either left heart bypass or partial cardiopulmonary bypass, it should be within their armamentarium to switch to HCA in cases of complex pathology or when faced with intraoperative complications prohibiting proximal cross clamping. Hypothermic circulatory arrest will continue to play an important role in organ protection, primarily as applies to the spinal cord, in patients at extreme risk of ischemic complications such as those with Crawford extent II aneurysms.


   Discussion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
References
 
DR IRVING KRON (Charlottesville, VA): Joe, I enjoyed this thoughtful and honest paper, and your results are clearly thought provoking. There was a 30% mortality, 10% stroke rate and 16% renal failure, and it takes forever to rewarm. So if Coselli is having these kinds of results, I would not do this on every case like other people are talking about. We certainly share your bias toward avoiding circulatory arrest. I have two questions for you.

How frequently do you know preoperatively you must do this and does this give you an advantage in how you set up the case? The second question is much more intriguing. Clearly you have an advantage in terms of prevention of paraplegia. This is a very low paraplegia rate for extensive aneurysms. Is hypothermia alone that good? I would like your thoughts about it. Thank you for the opportunity to discuss this.

DR COSELLI: There is absolutely no question that to have the opportunity to evaluate patients preoperatively, and alter the risk factors as part of that opportunity, favorably impacts the outcome. From the standpoint of the analysis of our data here, it is not possible to statistically demonstrate that fact, which is intuitively obvious. I, too, was struck by the low paraplegia rate in this cohort of patients. There are two ways to look at this issue. With hypothermic circulatory arrest, you may be trading off a higher mortality rate for a lower incidence of paraplegia. I am not certain that this is the most appropriate thing to do. If, however, you approach the situation from the standpoint of using hypothermia as a routine approach in all extensive thoracoabdominal aortic aneurysms for organ protection, the results may be entirely different and reflect the work of Nick Kouchoukos.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 References
 

  1. Griepp RB, Stinson EB, Hollingsworth JF, Buehler D. Prosthetic replacement of the aortic arch J Thorac Cardiovasc Surg 1975;70:1051-1063.[Abstract]
  2. Rokkas CK, Kouchoukos NT. Profound hypothermia for spinal cord protection in operations on the descending thoracic and thoracoabdominal aorta Semin Thorac Cardiovasc Surg 1998;10:57-60.[Medline]
  3. Kouchoukos NT, Rokkas CK. Hypothermic cardiopulmonary bypass for spinal cord protection: rationale and clinical results Ann Thorac Surg 1999;67:1940-1942.[Abstract/Free Full Text]
  4. LeMaire SA, Rice DC, Schmittling ZC, Coselli JS. Emergency surgery for thoracoabdominal aortic aneurysms with acute presentation J Vasc Surg 2002;35:1171-1178.[Medline]
  5. Edmunds LH, Clark RE, Cohn LH, Grunkemeier GL, Miller DC, Weisel RD. Guidelines for reporting morbidity and mortality after cardiac valvular operations Ann Thorac Surg 1996;62:932-935.[Abstract/Free Full Text]
  6. Borst HG, Schaudig A, Rudoph W. Arteriovenous fistula of the aortic arch: repair during deep hypothermia and circulatory arrest J Thorac Cardiovasc Surg 1964;48:443-447.[Medline]
  7. Crawford ES, Coselli JS, Safi HJ. Partial cardiopulmonary bypass, hypothermic circulatory arrest, and posterolateral exposure for thoracic aortic aneurysm operation J Thorac Cardiovasc Surg 1987;94:824-827.[Abstract]
  8. Kieffer E, Koskas F, Walden R, et al. Hypothermic circulatory arrest for thoracic aneurysmectomy through left-sided thoracotomy J Vasc Surg 1994;19:457-464.[Medline]
  9. Safi HJ, Miller III CC, Subramaniam MH, et al. Thoracic and thoracoabdominal aortic aneurysm repair using cardiopulmonary bypass, profound hypothermia, and circulatory arrest through left side of the chest incision J Vasc Surg 1998;28:591-598.[Medline]
  10. Okita Y, Takamoto S, Ando M, et al. Repair for aneurysms of the entire descending thoracic aorta or thoracoabdominal aorta using a deep hypothermia Eur J Cardiothorac Surg 1997;12:120-126.[Abstract]
  11. Kouchoukos NT, Masetti P, Rokkas CK, Murphy SF, Blackstone EH. Safety and efficacy of hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta Ann Thorac Surg 2001;72:699-708.[Abstract/Free Full Text]
  12. Kouchoukos NT, Masetti P, Rokkas CK, Murphy SF. Hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta Ann Thorac Surg 2002;74:1885-1887.
  13. Coselli JS, LeMaire SA, Conklin LD, Adams GJ. Left heart bypass during descending thoracic aortic aneurysm repair does not reduce the incidence of paraplegia Ann Thorac Surg 2004;77:1298-1303.[Abstract/Free Full Text]
  14. Coselli JS, Bozinovski J, LeMaire S. Open surgical repair of 2286 thoracoabdominal aortic aneurysms Ann Thorac Surg 2007;83(Suppl):862-864.



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C. K. Rokkas and N. T. Kouchoukos
Hypothermic Circulatory Arrest in the Treatment of Descending Thoracic and Thoracoabdominal Aortic Disease
Ann. Thorac. Surg., October 1, 2008; 86(4): 1399 - 1400.
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