Right axillary arterial perfusion for descending thoracic or thoracoabdominal aortic aneurysm repair with open proximal anastomosis through left thoracotomy

Two-stage repair of DeBakey type IIIb aneurysm, using total arch replacement

Background

Open repair for chronic DeBakey type IIIb dissecting aortic aneurysm is an invasive procedure involving open proximal anastomosis under hypothermic cardiac arrest, with significant morbidity in high-risk patients. We adopted a two-stage repair strategy using total arch replacement with the elephant trunk technique, which enables aortic crossclamping and avoids open proximal anastomosis at the second-stage graft replacement through a left thoracotomy.

Methods

From January 2008 to October 2018, we performed DeBakey type IIIb dissecting aortic aneurysm repair in 76 cases, and compared the results of two-stage repair (group 1, 25 cases) and single-stage repair using graft replacement with open proximal anastomosis through a left thoracotomy (group 2, 31 cases).

Results

In group 1, the elephant trunk technique was successful in all cases. The second intervention included endovascular repair (13 cases) and graft replacement through a left thoracotomy (7 cases). Five cases were followed up conservatively because the false lumen was thrombosed after the elephant trunk technique. Aorta-related adverse events were seen in 5 cases in group 1 (1 re-dissection, 1 rupture, 2 stent-graft-induced new entries, 1 stent-graft migration) and 6 in group 2 (1 additional thoracic endovascular aortic repair, 1 rupture, 4 acute type A aortic dissections). There were no statistical differences between the two groups regarding aorta-related adverse events and death. The postoperative course was acceptable in both groups.

Conclusions

Single-stage repair with open proximal anastomosis is an option in patients not at high risk for invasive surgery, while two-stage repair is recommended for high-risk patients.

Transapical aortic perfusion using a deep hypothermic procedure during descending thoracic or thoracoabdominal aortic surgery

BACKGROUND

In descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) surgery, though proximal anastomosis using deep hypothermic circulatory arrest (DHCA) is often selected, there are issues surrounding brain and heart protection. In this study, the usefulness of concomitant upper body perfusion via transapical aortic cannulation during deep hypothermic surgery was examined.

METHODS

Between October 2014 and May 2019, 5 patients (Crawford extent II chronic dissection, N.=3; extent IV aneurysms, N.=1; DTAA, N.=1) underwent DTAA/TAAA repair under deep hypothermia using transapical aortic perfusion. A proximal anastomosis and artery of Adamkiewicz (AKA) reconstruction were performed under continuous perfusion of the upper and lower body at 20 °C.

RESULTS

The time from aortic cross-clamping to proximal anastomosis was 69±33 minutes, and it took 86±47 minutes to AKA reperfusion. There was no spinal cord ischemic injury or brain or heart complications. One patient required tracheostomy, and the average postoperative intubation time for the other patients was 57±52 hours. All patients were discharged, and the average postoperative hospital stay was 25.6±8.1 days.

CONCLUSIONS

Concomitant upper body perfusion by the transapical aortic approach contributes to avoidance of brain and heart complications and maintaining spinal cord circulation under deep hypothermic DTAA/TAAA surgery.

Selective Cerebral Perfusion with the Open Proximal Technique during Descending Thoracic or Thoracoabdominal Aortic Repair: An Option of Choice to Reduce Neurologic Complications

PURPOSE

Selective cerebral perfusion with the open proximal technique for thoracoabdominal aortic repair has not been conclusively validated because of its procedural complexity and unreliability. We report the clinical outcomes, particularly the cerebroneurological complications, of an open proximal procedure using selective cerebral perfusion.

METHODS

A retrospective chart review identified 30 patients between 2007 and 2015 who underwent aortic repair through left lateral thoracotomy with selective cerebral perfusion, established through endoluminal brachiocephalic and left carotid artery and retrograde left axillary artery.

RESULTS

The mean durations of the open proximal procedure and cerebral ischemia (the duration of the open proximal procedure minus the duration of selective cerebral perfusion) were 110.3 ± 40.1 min and 24.8 ± 13.0 min, respectively. There were two cases (7%) of permanent neurologic dysfunction (PND) but no in-hospital deaths. Multivariate analysis identified the duration of cerebral ischemia as an independent risk factor for neurologic complications including temporary neurologic dysfunction (TND; odds ratio (OR): 1.13; p = 0.007), but no correlation was found between selective cerebral perfusion duration and neurologic complications.

CONCLUSION

Despite the relatively long duration of the open proximal procedure, selective cerebral perfusion has a potential to protect against cerebral complications during thoracic aortic repair through a left lateral thoracotomy.

Transapical aortic perfusion using a deep hypothermic procedure to prevent dissecting lung injury during re-do thoracoabdominal aortic aneurysm surgery

BACKGROUND

Avoiding various complications is a challenge during re-do thoracoabdominal aneurysm surgery.

CASE PRESENTATION

A 56-year-old man had undergone surgery for type I aortic dissection four times. The residual thoracoabdominal aortic aneurysm that had severe adhesions to lung parenchyma was resected. Since the proximal anastomotic site was buried in lung parenchyma, deep hypothermia was essential to avoid lung dissection and to protect the spinal cord during the proximal anastomosis. The deep hypothermia was induced with bilateral infusion of cardiopulmonary bypass by femoral artery cannulation for the lower body and by transapical cannulation for the upper body because of easy access. There was no hemorrhagic tendency after deep hypothermic bypass. The patient was discharged uneventfully.

CONCLUSIONS

For upper body perfusion, transapical aortic cannulation was a simple and effective procedure during left thoracotomy.