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Ann Thorac Surg 2005;79:137-138
© 2005 The Society of Thoracic Surgeons

INVITED COMMENTARY

Department of Cardiothoracic Surgery, Stanford University Medical Center, Falk CVRC, 300 Pasteur Dr, Stanford, CA, 94305

This excellent review of a 7-year experience by Girardi and colleagues focuses on the management of distal arch disease in patients surgically treated for descending thoracic and type I and II thoraco-abdominal aneurysms. Excluded from this analysis are 29 patients managed with profound hypothermic circulatory arrest whose arch was deemed unclampable (extensive arch calcification, extensive proximal arch aneurysm, with or without rupture). Significantly, intraoperative epiaortic ultrasound and arch palpation were used to further define that group requiring PHCA. This partially explains, but by no means diminishes, the admirably low stroke rate (1.2%), a most feared complication of arch clamping in these degenerative aneurysms. If confirmatory studies are forthcoming, use of epiaortic ultrasound may develop as a powerful tool to assess the transverse arch, facilitating management decisions just as it has in the ascending aorta.

Paraplegia rates were also admirably low, reflecting excellent spinal cord protection with adjuncts of distal perfusion and cerebral spinal fluid drainage. No difference was noted between those clamped proximal and distal to the left subclavian artery, perhaps suggesting that with sequential clamping techniques, cord perfusion from two of three sources (namely, left vertebral artery, low thoracic intercostal arteries, and hypogastric arteries) provided adequate collateral blood supply to the cord during clamp exclusion of the third. Although speed of the proximal anastamosis is emphasized, distal perfusion techniques may decrease its importance. This experience will serve as a benchmark against which other surgical and endovascular techniques will be measured.

Related Article

Does Cross-Clamping the Arch Increase the Risk of Descending Thoracic and Thoracoabdominal Aneurysm Repair?

Leonard N. Girardi, Karl H. Krieger, Charles A. Mack, Leonard Y. Lee, Anthony J. Tortolani, and O. Wayne Isom
Ann. Thorac. Surg. 2005 79: 133-137. [Abstract] [Full Text] [PDF]

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				K. Morishita, N. Kawaharada, J. Fukada, and T. Abe Does Arch Clamping Increase Stroke Rates? Ann. Thorac. Surg., February 1, 2006; 81(2): 789 - 790. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mitchell, R. S. Search for Related Content PubMed Articles by Mitchell, R. S. Related Collections Great vessels Related Article