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Original Articles: Adult Cardiac

Arch Aneurysm Repair With Long Elephant Trunk: A 10-Year Experience in 111 Patients

^a Department of Cardiovascular Surgery, Japan Labor Health and Welfare Organization Osaka Rosai Hospital, Sakai, Japan
^b Department of Cardiovascular Surgery, Rinku General Medical Center, Izumisano, Japan
^c Department of Cardiovascular Surgery, National Hospital Organization, Osaka National Hospital, Osaka, Japan
^d Department of Cardiovascular Surgery, Takarazuka City Hospital, Takarazuka, Japan
^e Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan

Accepted for publication March 31, 2009.

^_* Address correspondence to Dr Toda, 1179-3, Nagasone-cho, Kita-ku, Sakai, Osaka, 565-0871, Japan (Email: ktoda2002{at}yahoo.co.jp).

Presented at the Poster Session of the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Background: We studied the long-term outcome of arch aneurysm repair with a long elephant trunk (LET) anastomosed at the base of brachiocephalic artery.

Methods: Between 1998 and 2008, 111 patients underwent arch aneurysm repair with LET. A 4-branched graft was sutured to the sinotubular junction, the distal ascending aorta transected, and a LET inserted into the aortic arch while selective cerebral perfusion was maintained. The graft distal end was anastomosed to the LET, incorporating the distal ascending aorta, and arch vessels were anastomosed to graft branches.

Results: Concomitantly, 33 patients (30%) underwent other cardiac procedures, including 11 aortic root replacements. Two patients died (1.8%) within 30 days and 7 died (6.3%) after 30 days. Perioperative morbidity included 2 (1.8%) with stroke, 3 (2.7%) with paraplegia, and 1 (0.9%) with paraparesis. Postoperative computed tomography scans revealed complete aneurysmal thrombosis around the LET in 88 patients (79%), who were monitored without a second-stage procedure. Among 23 patients with incomplete thrombosis, 19 underwent a second-stage procedure to complete distal fixation of the LET. Overall survival was 88%, 83%, and 75%, at 1, 3, and 5 years after aneurysm repair with the LET. No aneurysm rupture or reexpansion occurred in patients with complete thrombosis. Four patients with incomplete thrombosis died of rupture before the second-stage procedure.

Conclusions: Our results demonstrated safety and good durability of the LET technique and suggest that this technique is a simple and safe procedure that is applicable to a variety of arch aneurysms.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
An extensive aortic arch pathology involving the descending aorta remains a surgical challenge and an optimal technique remains controversial. A single-stage procedure with a bilateral anterior thoracotomy carries substantial morbidity due to respiratory complications, although it is an excellent procedure permitting access to the entire thoracic aorta [1]. A two-stage approach with an elephant trunk (ET) anastomosed in the distal aortic arch was introduced by Borst [2] as a less invasive procedure; however, the cumulative risk of two major procedures and the additional risk of rupture between the two procedures have been demonstrated [3].

In 1998 we introduced a total arch replacement (TAR) with a long elephant trunk (LET) anastomosed at the base of the brachiocephalic artery (BCA) [4]. This technique yields a secure and rapid anastomosis in the distal ascending aorta, where anastomosis and hemostasis can be performed without difficulties. Previous findings presented by our group suggest that the technique does not require subsequent distal anastomosis and could transform a two-stage ET procedure into a single-stage repair when complete aneurysmal thrombosis around the LET is achieved [5].

We have applied this technique for a wide variety of aortic pathologies, including acute type A [6] and chronic type B dissection [7], and have also combined this technique with aortic root replacement [8]. We review our experience with 111 patients during a 10-year period and analyze early outcome as well as the long-term safety and effectiveness of our arch aneurysm repair technique that uses an LET anastomosed at the base of BCA.

	Patients and Methods

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This retrospective review of the clinical records was approved by the appropriate Institutional Review Boards of the participating institutions, and informed consent was provided by each patient.

Patients
Between October 1998 and September 2008, 111 patients with an arch aneurysm underwent TAR with an LET in Osaka Rosai Hospital and affiliated institutions (Rinku General Medical Center, National Hospital Organization Osaka National Hospital, and Takarazuka City Hospital). The baseline patient clinical profiles including associated comorbidity are reported in Table 1. The mean patient age was 69 years, and 11 patients (10%) were older than 80 years at the time of the operation. Among 25 patients with significant coronary artery disease (CAD), 6 patients had a history of percutaneous coronary intervention and 9 received concomitant coronary artery bypass grafts (CABG). Three patients required hemodialysis because of chronic renal failure, and 3 patients had a poor left ventricular ejection fraction of less than 0.35.

While the patient is being cooled, the heart is arrested by antegrade and retrograde cold blood cardioplegia, after which a 4-branched arch graft (Hemashield Platinum, MAQUET Cardiovascular LLC, Wayne, NJ) is sutured into the sinotubular junction (Fig 1A). The size of the LET is determined by the size of the descending aorta in preoperative computed tomography (CT) scans. We measure the inner diameter of the nonaneurysmal descending aorta and choose a graft one size smaller for patients with a nondissecting aneurysm. In acute aortic dissection cases, we choose a LET that is two sizes smaller to reduce the friction between the graft and aortic wall.

View larger version (81K): [in this window] [in a new window]   Fig 1. Total arch replacement with a long elephant trunk (LET) anastomosed at the base of the brachiocephalic artery. (A) A 4-branched arch graft is sutured into the sinotubular junction under cardioplegic arrest. (B) After systemic perfusion is switched to selective cerebral perfusion using the Dacron grafts anastomosed to the right and left axillary arteries, and a small cannula in the left common carotid artery, the distal ascending aorta is transected and the LET is placed into the aortic arch by pulling the LET with a catching catheter. (C) A distal anastomosis is performed between the 4-branched arch graft and LET tube graft incorporating the distal ascending aorta. (D) After antegrade distal perfusion is resumed from the side branch of the graft, the patient is rewarmed, and the arch vessels are reconstructed.

A distal anastomosis is then performed between the 4-branched arch graft and LET tube graft incorporating the distal ascending aorta (Fig 1C). Before completing the distal anastomosis, we wash debris from the LET by perfusing the descending aorta through a small arterial cannula placed in the femoral artery. Antegrade distal perfusion is resumed from the side branch of the graft and the patient is rewarmed. During rewarming, the BCA and left common carotid artery are divided and anastomosed to the branches of the graft, and the most distal branch is anastomosed to the left axillary artery graft, which is introduced into the pericardial space through a retroclavicular tunnel. The proximal left subclavian artery is then closed with clipping or sutures (Fig 1D). Before closing the chest, the branched graft is entirely covered with an expanded polytetrafluoroethylene sheet.

Follow-Up
Patients who demonstrated complete thrombosis of the arch aneurysm in postoperative CT scan images were discharged and monitored as outpatients. Patients who did not demonstrate complete thrombosis required a second-stage procedure, which we have previously described [4]. Briefly, the descending aorta is exposed through an anterolateral left thoracotomy. The descending aorta is clamped under a normothermic femorofemoral venoarterial bypass, and the LET is pulled out and the distal end is anastomosed to the descending aorta. In those patients, preoperative variables were investigated by review of clinical records, and postoperative variables were investigated by a review of outpatient records. A cross-sectional follow-up examination was conducted in December 2008 by telephone interviews.

Data Analysis
Data were analyzed using StatView 5.0 software (SAS Institute, Cary, NC). Values are expressed as the mean ± standard deviation. Univariate analyses were conducted for patient demographics and considered perioperative risk factors, as summarized in Tables 2 and 3. The Fisher exact test was used for categoric variables and a Mann-Whitney U test was used to compare continuous variables. Survival curves were generated using Kaplan-Meier methods and compared using the log-rank test. A value of p < 0.05 was considered significant.

	Results

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

The LET was a mean length of 15.9 ± 3.1 cm (range, 10 to 22 cm) and had a diameter of 24 ± 2 mm (range, 18 to 30 mm). The distal end of the LET, which was marked with a metal clip, was confirmed in CT scan as located between the Th5 and Th10 levels (mean, 7.5 ± 1.2).

Thirty-three patients (30%) underwent 35 concomitant procedures, including aortic root replacements in 11, aortic valve replacements in 8, CABG in 9, reconstruction of the left vertebral artery in 5, aortic and mitral valve replacement in 1, and patch closure of an aortopulmonary artery fistula in 1. The mean duration values in minutes for operative details were aortic cross clamp time, 100 ± 45; CPB, 210 ± 58; hypothermic circulatory arrest of the lower body for open distal anastomosis, 27 ± 10; and antegrade SCP time 96 ± 29.

Two patients (1.8%) died in-hospital, at 4 and 7 days postoperatively, of a thoracoabdominal aortic aneurysm (TAAA). There were 7 (6.3%) postoperative hospital deaths, including 3 patients who died of pneumonia at 3 to 5 months, 2 who died of mediastinitis at 2 and 3 months, 1 who died of a TAAA rupture at 45 days, and 1 who died of sepsis due to cholecystitis at 2 months.

No phrenic nerve palsy or new recurrent nerve palsy developed. Extubation occurred within 24 hours after the procedure in 69% of the patients. Postoperative morbidity included 2 strokes (1.8%), and permanent spinal cord ischemia (SCI) was documented in 4 patients, including 3 with paraplegia and 1 with paraparesis. SCI was transient in 5 patients, and resolved within 24 hours after cerebrospinal fluid drainage and administration of naloxone (Table 4). Univariate analyses of the influence of perioperative factors on postoperative SCI identified a significant association between the level of the distal end of the LET and SCI (Table 2).

The remaining 6 patients with incomplete thrombosis each underwent a second-stage procedure after follow-up CT scans revealed expansion of a descending or TAAA. The mean duration between the first and second procedures was 511 ± 336 days. Three received an anastomosis between the distal end of the LET and descending aorta through a left thoracotomy, and the other 3 underwent TAAA repair using the branched graft.

The average follow-up was 33 ± 26 months (range, 4 days to 94 months), and overall survival was 88%, 83%, and 75% at 1, 3, and 5 years after aneurysm repair with the LET. Rupture or reexpansion of the aneurysm was not encountered in those with complete thrombosis, but 4 of the 23 patients with incomplete thrombosis died of a ruptured aneurysm before undergoing a second-stage procedure (Table 5). One patient who refused the operation and died after discharge was considered as a late death. Aside from this patient, no other late death resulted from rupture of a treated aortic arch aneurysm (Table 6).

View larger version (21K): [in this window] [in a new window]   Fig 2. Kaplan-Meier survival curves after total arch replacement with a long elephant trunk (LET) in patients with complete thromboexclusion of arch aneurysm by LET (solid line), with incomplete thromboexclusion who underwent the second-stage procedure (dotted line), and with incomplete thromboexclusion who could not accomplish the second-stage procedure (dashed line).

	Comment

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
A direct surgical approach to treat pathologic conditions of the aortic arch has become an established procedure, with satisfactory results and durability [10]. However, performing anastomosis and hemostasis in the deep mediastinum beyond the left subclavian artery is not always straightforward because the tissues are fragile and visualization is poor. The depth of a distal anastomosis is a risk factor for prolonged distal anastomosis [11]. To overcome these difficulties, we modified Borst's ET technique [2], and introduced TAR with an LET anastomosed at the base of the BCA as a less invasive procedure. In the present retrospective study of 111 patients, we found that our LET technique could be applied for a variety of aortic arch pathologies with low rates of operative mortality (1.8%) and stroke (1.8%) compared with recent reports from other large series [10–13].

Neurologic injury is the principal cause of serious morbidity and a significant risk factor for in-hospital death after conventional total arch replacement [14]. We used antegrade SCP in which several different techniques, including direct balloon catheter perfusion of the BCA and the left carotid artery [14], as well as right axillary cannulation with balloon catheters in the left carotid and left subclavian arteries [13] have been proposed. We avoid insertion of a balloon catheter into the BCA, because malposition of a balloon catheter in that artery is not rare [15]. Instead we use bilateral axillary artery grafts and a small cannula in the left carotid artery for SCP.

We choose direct cannulation into the left carotid artery, except in patients with acute aortic dissection. With our technique, the cannula is placed in the left carotid artery at 5 cm distal from the aortic arch to avoid manipulation of atheromatous plaque near the orifice of arch vessels. To avoid a cerebral embolism associated with cannulation in the left carotid artery, cannulation is performed after establishing SCP from right and left axillary arteries, so that plaque possibly dislodged by cannulation can be flushed to the aortic arch by collateral back flow.

For additional safety in regard to cerebral circulation, we use near infrared spectroscopy to monitor cerebral oxygen saturation. When a difference in cerebral oxygen saturation is found between the left and right hemispheres, we check flow in the left and right carotid arteries by a transesophageal echocardiography (TEE), as well as left and right radial artery pressure, to rule out problems with the SCP circuit and cannulation.

In our technique, the branch grafts to the arch vessels are longer than 8 cm because the aortic arch is left in place and grafts branch off the main tube graft, which is anastomosed at sinotubular junction. We anastomose the 4-branched graft to the sinotubular junction in such a manner that 3 of the grafts branch off from the great curvature of the main tube graft, by which they lay on the ventral side of the SVC and innominate vein. No kinking or occlusion of the grafts to arch vessels ocurred, except for a patient in which occlusion of the graft to the left subclavian artery was found in a CT angiogram 3 years after the operation. Spielvogel and colleagues [12] reported use of a trifurcated graft for total arch replacement. Their graft was as long as ours, and they found no kinking or thrombosis of the graft in a series of 109 patients.

Upon awaking from anesthesia, 9 (8.1%) patients had paraplegia or paraparesis and were treated by increasing mean arterial pressure up to 100 mm Hg, spinal drainage, and naloxone administration. Five recovered completely within 24 hours, but paraparesis developed in 1 patient and paraplegia in 3. No delayed paraplegia developed. A relatively high incidence of paraplegia has been reported to be associated with a frozen ET procedure [16], although the mechanism of SCI appears to be multifactorial and remains poorly defined. Our analysis of the associations between patient risk factors and SCI revealed that the distal end of the LET was significantly deeper in patients with SCI (Table 2). The concept of collateral network circulation in the spinal cord has been proposed, and the importance of inputs into this network, including the subclavian arteries, hypogastric arteries, and segmental vessels, has been recognized [17].

To maintain collateral network circulation, we perfused the left subclavian artery when lower body circulation was stopped for open distal anastomosis. In addition to the importance of maintaining stable hemodynamics during and after LET placement to maintain sufficient collateral network circulation, extensive deployment of an LET should be avoided. Recently, in addition to using CT angiogram findings to determine the precise length of the LET in each patient, we use intraoperative TEE to confirm that the end of the LET is not placed beyond the level of Th 8. We also place the suture onto the lesser curvature of the LET beforehand to fix its length and prevent over-stretching when the graft is pulled down to the aortic arch. By following these technical refinements, we have not had a patient with postoperative SCI.

Overall survival was 88%, 83%, and 75% at 1, 3, and 5 years after aneurysm repair with the LET, which is comparable with other large series of total arch replacement [1, 3, 10, 13]. We found no significant difference in survival between patients with complete aneurysmal thrombosis without a second-stage procedure and those without complete thrombosis who underwent a second-stage procedure. Furthermore, we did not encounter rupture or reexpansion of the aneurysm in patients with complete aneurysmal thrombosis. Although the mean follow-up period may not be adequate for firm conclusions, this result suggests that our technique does not require a second-stage procedure when the LET results in thrombus exclusion of the arch aneurysm.

On the other hand, 4 patients without complete aneurysmal thrombosis who could not accomplish a second procedure had poor survival, and 3 died of ruptured aneurysm early after the first-stage procedure (Table 5). We speculate that early rupture might be related to localized aortic wall weakening due to hypoxia, which could be induced by incomplete thrombosis [18]. We consider that incomplete aneurysmal thrombosis is mainly attributable to incomplete distal sealing of the trunk, because complete thrombosis around the LET was seen in patients who underwent distal fixation of the LET without ligating the intercostal arteries during the second-stage procedure. Univariate analysis (Table 3) demonstrates that complete thromboexclusion of the arch aneurysm is less likely with an LET alone when the maximum diameter of the aneurysm exceeds 7 cm or the aneurysm extends beyond the level of the carina. Therefore it is necessary to confirm the thromboexclusion of the aneurysm early after the LET procedure in the patients with a large and extensive aneurysm.

When thromboexclusion is not anticipated, a rapid two-stage procedure [4] or replacement of the entire thoracic aorta or entire aorta using both mediastinal and thoracoabdominal incisions [19] may be necessary. In this series, 7 patients underwent distal fixation of the LET at the descending aorta through a left thoracotomy as a rapid two-stage procedure within 1 to 7 days after the first procedure. Distal fixation of the LET could be accomplished by transcatheter placement of an endovascular stent graft [20], as the LET could serve as a useful proximal landing zone for stent graft placement. Considering the progress in endovascular technology, this combined procedure may play an important role in treatment of extensive thoracic aneurysm with a suitable anatomy.

In conclusion, our results demonstrated safety and good durability of LET technique and suggest that this technique is a simple and safe procedure that is uniformly applicable for qualified patients with a wide variety of aortic arch aneurysm.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
This work was supported by research funds to promote the hospital functions of Japan Labour Health and Welfare Organization. We thank Kiyoshi Yoshida, CE, from the Perfusion Technology Section, Japan Labor Health and Welfare Organization Osaka Rosai Hospital, Sakai, Japan, for his contributions to this study.

	References

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Koichi Toda Kazuhiro Taniguchi Takafumi Masai Toshiki Takahashi Yoshiki Sawa Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Toda, K. Search for Related Content PubMed PubMed Citation Articles by Toda, K. Related Collections Great vessels Related Article