Total arch replacement for thoracic aortic aneurysm via median sternotomy with or without left anterolateral thoracotomy

Total arch replacement via antero-lateral thoracotomy with partial sternotomy in patients with a tracheostoma: report of two cases

Midsternotomy in patients with a coexisting tracheostomy is associated with a risk of deep sternal wound infection (DSWI) or mediastinitis. We herein present two cases of total arch replacement using a surgical technique designed to avoid the danger of DSWI. Total arch replacement via an antero-lateral thoracotomy with partial sternotomy can be one of the options for patients with a tracheostoma or after laryngectomy, and can both protect organs and avoid DSWI.

Antero-lateral partial sternotomy for extensive thoracic aortic aneurysm

OBJECTIVES

Surgical strategies for patients with aortic arch aneurysm extending to the descending aorta remain controversial. The antero-lateral partial sternotomy (ALPS) approach has been developed as a less invasive alternative single-stage strategy for extensive thoracic arch aneurysm (ETAA).

METHODS

From September 2007 to April 2011, 18 patients underwent elective total arch replacement for ETAA by the ALPS approach (ALPS group). In this approach, a skin incision was made from the bottom of the xiphoid to the anterior axillary line at the third intercostal space with a convex curved line. The thorax was entered through the third intercostal space and a partial lower sternotomy was done. Surgical outcomes were compared with those of 22 patients with ETAA who underwent elective total arch replacement by median sternotomy alone (MS) with regard to the level of distal anastomosis, postoperative complications and mortality.

RESULTS

In the ALPS group, no hospital mortality occurred and one patient experienced pneumonia. No significant difference between the ALPS and MS groups was seen in operative time (384.1 ± 41.6 min vs 402.3 ± 85.3 min P = 0.423) and cardiopulmonary bypass time (220.8 ± 47.1 min vs 236.9 ± 45.4 min P = 0.286). In contrast, distal anastomosis was at a significantly lower vertebral level in the ALPS than in the MS group (5.5 ± 0.4 vs 4.3 ± 0.9, respectively: P < 0.0001).

CONCLUSIONS

The ALPS approach provides good surgical exposure for distal aortic arch aneurysms extending to the descending aorta and ensures the accurate reconstruction of the distal anastomosis without major complications.

Surgical treatment for aortic coarctation with chronic type B dissection: report of a case

The aim of this paper is to report a rare case of aortic coarctation with type B aortic dissection. A 37 year-old man had sudden, intense back pain. Enhanced computed tomography revealed aortic coarctation (CoA) at the proximal descending aorta and acute type B aortic dissection just distal to the CoA. The dissecting, descending aortic aneurysm had expanded to a maximal diameter of 52 mm. The aortic coarctation was resected and then the descending aorta was replaced with prosthetic grafts in an uneventful procedure. Surgical repair resulted in a good outcome.

Frozen elephant trunk procedure in a dextropositioned arch and descending aorta

PURPOSE

To describe the use of a hybrid frozen elephant trunk technique to treat a patient suffering from a multisegmentally diseased, dextropositioned aortic arch and right descending aorta.

TECHNIQUE

The technique is illustrated in a 58-year-old woman who was diagnosed with chronic type A aortic dissection in a right aortic arch and descending aorta; a lusoric left subclavian artery passed behind the esophagus. Aneurysmal dilatation of the arch and descending aorta required treatment. A frozen elephant trunk procedure was performed in a single stage via a median sternotomy using a hybrid Chavan-Haverich endograft, with complete surgical replacement of aortic arch. The stents for the endograft were placed in the descending aorta in an antegrade fashion through the opened aortic arch.

CONCLUSION

This case demonstrates the feasibility of treating complex pathologies of the thoracic aorta even in cases of aberrant anatomy. A conventional 2-stage approach for treatment of the complex pathology could have been complicated due to difficulties with exposure.

Aortic Replacement via Median Sternotomy with Left Anterolateral Thoracotomy

Prevention of cerebral injury is an important consideration during repair of aortic arch aneurysm, and the major goal of cerebral protection techniques. We describe our surgical strategy for treatment of extended thoracic aortic aneurysms. Between January 2001 and June 2008, 17 men and 6 women, with a mean age of 67.9 ± 8.3 years, underwent total replacement of the arch and descending aorta. Six (26.1%) patients required emergency surgery. A median sternotomy with a left anterolateral thoracotomy provided a good visual field, and bilateral axillary arteries were preferentially used for systemic as well as selective cerebral perfusion. Two (8.7%) patients died in hospital. Prolonged mechanical ventilation was required for 7.3 ± 8.4 days after surgery in 17 patients who all recovered uneventfully. Permanent neurological dysfunction developed in 1 (4.3%) patient who died of sepsis 2 years after the operation. Our results suggest that total arch replacement through a median sternotomy plus a left anterolateral thoracotomy is helpful for extended replacement of the thoracic aorta as well as distal reoperation for dissecting type A aortic aneurysm. Perfusion via bilateral axillary arteries may improve cerebral protection.

Vocal cord paralysis after aortic arch surgery: Predictors and clinical outcome

OBJECTIVE

This study is retrospective cohort study of data on vocal cord paralysis after aortic arch surgery collected during 14 years at a general hospital. We investigated factors in the development of vocal cord paralysis after aortic arch surgery and the effect of vocal cord paralysis on clinical course and outcome.

METHODS

We reviewed data for 182 patients who underwent aortic arch surgery for aortic arch aneurysm and aortic dissection between 1989 and 2003, of whom 58 patients had proximal aortic repair, 62 had distal arch repair, and 62 had total arch repair. We assessed factors associated with the development of vocal cord paralysis and examined in detail the clinical outcome of patients with vocal cord paralysis.

RESULTS

Postoperative vocal cord paralysis occurred in 40 patients. Multiple logistic regression analysis revealed the following risk factors with odds ratios (OR) for vocal cord paralysis: extension of procedures into distal arch (OR, 17.0), chronic dilatation of the aorta at the left subclavian artery (OR, 9.14), and total arch repair (OR, 4.24). Adoption of open-style stent-grafts reduced the incidence of vocal cord paralysis (OR, 0.031). The postoperative occurrence of vocal cord paralysis itself emerges as an independent predictor of pulmonary complications (OR, 4.12) and leads to a longer duration of hospital stay.

CONCLUSIONS

The risk of vocal cord paralysis after aortic arch surgery depends on surgical factors, such as aneurysmal involvement of the distal arch, or the application of newer, less invasive surgical procedures. Vocal cord paralysis after aortic arch surgery itself, under aggressive postoperative respiratory management, did not increase aspiration pneumonia but was associated with postoperative complications leading to higher hospital mortality and prolonged hospitalization.

Surgical Management of Distal Arch Aneurysm: Another Approach With Improved Results

BACKGROUND

Surgical treatment for distal arch aneurysm carries the risk of stroke. Although left thoracotomy has been used for repair of distal arch aneurysm as a standard approach, we have performed total arch replacement under deep hypothermia with circulatory arrest through a midsternotomy for this subset of aneurysms.

METHODS

From January 1998 to February 2003, 119 patients underwent elective total arch replacement (mean age, 72.3 +/- 6.0 years) for distal arch aneurysm under deep hypothermia with circulatory arrest. Antegrade selective cerebral perfusion was used for brain protection. Arch vessels were independently reconstructed using quadrifurcated grafts. Concomitant procedures included tricuspid annuloplasty in 1 patient, aortic valve operations in 2, sinotubular junction plication in 6, and coronary artery grafting in 22.

RESULTS

The early mortality rate was 0.84% (1 of 119). The mean duration of circulatory arrest was 67.1 +/- 19.7 minutes. Perioperative stroke rate was 0.84% (1 of 119). This stroke occurred 9 days postoperatively in an 81-year-old man with a history of cerebral infarction. Other complications were reexploration for bleeding in 1 patient (0.84%) and respiratory failure in 6 (5.0%).

CONCLUSIONS

This operative approach for distal arch aneurysm featured a low mortality rate and low risk of perioperative stroke. Concomitant cardiac surgery could be performed routinely in standard fashion. Distal arch aneurysms that do not involve a large segment of the descending thoracic aorta can thus be repaired with low mortality and few cerebral complications through a midsternotomy.