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Norton EL, Orelaru F, Ahmad RA, Clemence J, Wu X, Kim KM, Fukuhara S, Patel HJ, Yang B. Hypothermic circulatory arrest versus aortic clamping in thoracic and thoracoabdominal aortic aneurysm repair. J Card Surg 2022; 37:4351-4358. [PMID: 36321695 PMCID: PMC9812898 DOI: 10.1111/jocs.17054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/29/2022] [Accepted: 08/25/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND To compare perioperative and midterm outcomes in thoracic and thoraco-abdominal aortic aneurysm (TAA and TAAA) repair using hypothermic circulatory arrest (HCA) or aortic clamping (AC) with mild hypothermia. METHODS From 2012 to 2021 there were 180 open repairs of a TAA or TAAA, of which 90 (50%) were done with HCA and 90 (50%) with aortic clamping with mild hypothermia. The indications for HCA were arch aneurysm, TAA from chronic aortic dissection, and inability to clamp the aorta for proximal anastomosis. RESULTS Compared to AC, the HCA group had less prior descending aorta replacement/repair (9.1% vs. 32%, p = 0.0001). Intraoperatively, the HCA group had more TAAs (70% vs. 20%, p < 0.0001) while the AC group had more TAAAs (80% vs. 30%, p < 0.0001). HCA group had longer cardiopulmonary bypass times (242 vs. 181 min, p < 0.0001) but shorter cross-clamp time (39 vs. 120 min, p < 0.0001) and lower temperatures (18°C vs. 34°C, p < 0.0001). Postoperatively, the HCA group had longer intubation times (31 vs. 26 h, p = 0.002), but all other postoperative outcomes including paralysis (2.2% vs. 8.9%, p = 0.08), and operative mortality (4.4% vs. 2.2%, p = 0.68) were similar between HCA and AC groups. Patient age was an independent risk factor for postoperative paralysis (OR 1.07, p = 0.03) while HCA was not significant (OR 0.37, p = 0.21). Five-year survival was similar between HCA and AC groups (85% vs. 80%, p = 0.36). CONCLUSIONS Postoperative outcomes and midterm survival were acceptable in thoracic and thoracoabdominal aneurysm patients after HCA or AC. Both HCA and AC with mild hypothermia were valid approaches in TAA/A repair.
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Affiliation(s)
- Elizabeth L Norton
- Department of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - Felix Orelaru
- Department of General Surgery, St. Joseph Mercy, Ann Arbor, Michigan
| | | | - Jeffrey Clemence
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Karen M Kim
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Shinichi Fukuhara
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Himanshu J Patel
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Bo Yang
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
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Tan SZ, Singh S, Austin NJ, Alfonso Palanca J, Jubouri M, Girardi LN, Chen EP, Bashir M. Duration of deep hypothermic circulatory arrest for aortic arch surgery: is it a myth, fiction, or scientific leap? THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:243-253. [PMID: 35238523 DOI: 10.23736/s0021-9509.22.12275-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The use of deep hypothermic circulatory arrest (DHCA) to provide aortic surgeons with a bloodless operative field while simultaneously protecting the brain and peripheries from ischemic damage revolutionized cardiac and aortic surgery, and is currently used in specialist centers across the globe. However, it is associated with manifold adverse outcomes, including neurocognitive dysfunction and mortality. This review seeks to analyze the relationship between DHCA duration and clinical outcome, and evaluate the controversies and limitations surrounding its use. EVIDENCE ACQUISITION We performed a review of available literature with statistical analysis to evaluate the relationship between DHCA duration (<40 min and >40 min) and key clinical outcomes, including mortality, permanent and temporary neurological deficit, renal damage, admission length, and reintervention rate. The controversies surrounding DHCA use and future directions for care are also explored. EVIDENCE SYNTHESIS Statistical analysis revealed no significant association (P>0.05) between DHCA duration and clinical outcomes (early and late mortality rates, neurological deficit, admission length, and reintervention rate), both with and without adjunctive perfusion techniques. CONCLUSIONS Available literature suggests that the relationships between DHCA duration (with and without adjunctive perfusion) and clinical outcomes are unclear, and at present not statistically significant. Alternative surgical and endovascular techniques have been identified as promising novel approaches not requiring DHCA, as have the use of biomarkers to enable early diagnosis and intervention for aortic pathologies.
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Affiliation(s)
- Sven Z Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sidhant Singh
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Natasha J Austin
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Joaquin Alfonso Palanca
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Health and Education Improvement Wales, Nantgarw, UK -
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Sickeler RA, Kertai MD. Risk Assessment and Perioperative Renal Dysfunction. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00008-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Abstract
The conduct of partial left heart bypass or partial car diopulmonary bypass (CPB) during surgery involving the descending thoracic aorta or thoracoabdominal aorta is one of the most unappreciated and misunder stood extracorporeal circulation procedures in cardio vascular surgery. It is different from conventional CPB, and although some uninitiated practitioners consider it simpler, it is in fact more complicated than conven tional CPB and involves different concepts. It requires expertise and skill in regulating the flow, pressure, and oxygenation of blood going to both the proximal and distal parts of the body and management of the special bypass or shunt procedures used, specialized monitor ing, and knowledge about the protection and preserva tion of organs both proximal and distal to the aortic clamping. It demands exquisite communication and un derstanding of the unique problems faced by the sur geon, anesthesiologist, and perfusionist.
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Affiliation(s)
- Eugene A. Hessel
- Department of Anesthesiology, College of Medicine, Chandler Medical Center, University of Kentucky, Louisville, KY
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Shimizu H, Mori A, Yoshitake A, Yamada T, Morisaki H, Okano H, Yozu R. Thoracic and thoracoabdominal aortic repair under regional spinal cord hypothermia. Eur J Cardiothorac Surg 2013; 46:40-3. [DOI: 10.1093/ejcts/ezt574] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Awad H, Elgharably H, Popovich PG. Role of induced hypothermia in thoracoabdominal aortic aneurysm surgery. Ther Hypothermia Temp Manag 2012; 2:119-37. [PMID: 24716449 DOI: 10.1089/ther.2012.0009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
For more than 50 years, hypothermia has been used in aortic surgery as a tool for neuroprotection. Hypothermia has been introduced into thoracoabdominal aortic aneurysm (TAAA) surgery by many cardiovascular centers to protect the body's organs, including the spinal cord. Numerous publications have shown that hypothermia can prevent immediate and delayed motor dysfunction after aortic cross-clamping. Here, we reviewed the historical application of hypothermia in aortic surgery, role of hypothermia in preclinical studies, cellular and molecular mechanisms by which hypothermia confers neuroprotection, and the role of systemic and regional hypothermia in clinical protocols to reduce and/or eliminate the devastating consequences of ischemic spinal cord injury after TAAA repair.
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Affiliation(s)
- Hamdy Awad
- 1 Department of Anesthesiology, Wexner Medical Center at The Ohio State University , Columbus, Ohio
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7
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Current strategies for spinal cord protection during thoracic and thoracoabdominal aortic aneurysm repair. Gen Thorac Cardiovasc Surg 2011; 59:155-63. [DOI: 10.1007/s11748-010-0705-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 08/30/2010] [Indexed: 11/26/2022]
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Fehrenbacher JW, Siderys H, Terry C, Kuhn J, Corvera JS. Early and late results of descending thoracic and thoracoabdominal aortic aneurysm open repair with deep hypothermia and circulatory arrest. J Thorac Cardiovasc Surg 2010; 140:S154-60; discussion S185-S190. [DOI: 10.1016/j.jtcvs.2010.08.054] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Revised: 08/10/2010] [Accepted: 08/23/2010] [Indexed: 10/18/2022]
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Juvonen T, Biancari F, Rimpiläinen J, Satta J, Rainio P, Kiviluoma K. Strategies for Spinal Cord Protection during Descending Thoracic and Thoracoabdominal Aortic Surgery: Up-to-date Experimental and Clinical Results - A review. SCAND CARDIOVASC J 2009. [DOI: 10.1080/cdv.36.3.136.160] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Karmy-Jones R, Simeone A, Meissner M, Granvall B, Nicholls S. Descending thoracic aortic dissections. Surg Clin North Am 2007; 87:1047-86, viii-ix. [PMID: 17936475 DOI: 10.1016/j.suc.2007.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Type B dissection has traditionally been managed medically if uncomplicated and surgically if associated with complications. This practice has resulted in most centers reporting significant morbidity and mortality if open repair is required. In the setting of malperfusion, operative repair has been conjoined with fenestration or visceral stenting to improve outcomes. Endovascular stent grafts seem to offer an attractive alternative in the acute complicated type B dissection, with reduced mortality and morbidity, particularly paralysis, compared with open repair. It is reasonable to consider endovascular stent grafts as another tool in managing dissection, but to recognize that open surgical repair still plays an important role, and that the data that define indications and outcomes are still emerging.
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Affiliation(s)
- Riyad Karmy-Jones
- Division of Thoracic Surgery, Heart and Vascular Institute, Southwest Washington Medical Center, P.O. Box 1600 Vancouver, WA 98668, USA.
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Vural H, Türk T, Göncü T, Yalçinkaya S, Yavuz S, Ozyazicioğlu A. Giant size abdominal aortic aneurysm repair using open proximal anastomosis under hypothermic circulatory arrest: A report of two cases. J Vasc Surg 2007; 46:363-5. [PMID: 17664112 DOI: 10.1016/j.jvs.2007.03.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2006] [Accepted: 03/09/2007] [Indexed: 11/26/2022]
Abstract
Hypothermic total circulatory arrest and open proximal anastomosis techniques are not commonly used in abdominal or juxtarenal abdominal aortic aneurysm repair. Proximal aortic clamping is usually adequate for surgical repair of abdominal aortic pathologies. We present two cases of giant-sized abdominal aortic aneurysms, one was juxtarenal and one was a Crawford type IV thoracoabdominal aneurysm, that were repaired by using open proximal anastomosis under hypothermic total circulatory arrest and a transabdominal approach. This technique may be useful for both thoracoabdominal and large abdominal aortic aneurysms because it offers the opportunity to not clamp the aorta and operate in bloodless surgical field.
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Affiliation(s)
- Hakan Vural
- Department of Cardiovascular Surgery, Bursa Yüksek Ihtisas Education and Research Hospital, Bursa, Turkey.
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Patel HJ, Shillingford MS, Mihalik S, Proctor MC, Deeb GM. Resection of the Descending Thoracic Aorta: Outcomes After Use of Hypothermic Circulatory Arrest. Ann Thorac Surg 2006; 82:90-5; discussion 95-6. [PMID: 16798196 DOI: 10.1016/j.athoracsur.2006.02.055] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2005] [Revised: 02/07/2006] [Accepted: 02/13/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND Use of hypothermic circulatory arrest (HCA) for operations on the descending thoracic aorta is controversial. While deep hypothermia may provide better end-organ and spinal cord function, prolonged cardiopulmonary bypass and circulatory arrest may increase morbidity. This study assessed outcomes after use of HCA for descending thoracic aortic resection in a large cohort of consecutive patients. METHODS Hypothermic circulatory arrest was utilized if arch or extensive descending thoracic aortic resection was required, or if aortic pathology precluded cross-clamping. One hundred thirty-two patients (mean age, 61.3 years) were identified. Diagnosis included fusiform (41.2%) or saccular aneurysm (10.7%) and acute (4.6%) or chronic (38.9%) dissection. Twenty-one patients presented with rupture. Arch resection (distal arch 100, total arch 11) was required in 111 patients (84.1%). The extent of descending thoracic aortic resection (required in 94%) included proximal third in 41 patients, proximal two-thirds in 6, and complete thoracic aorta in 77. The proximal anastomosis was performed with total body HCA while the distal anastomosis was constructed with lower body HCA only (duration upper body HCA 33.7 +/- 8.0 minutes; total duration lower body HCA 71.3 +/- 24.2 minutes). RESULTS Thirty-day mortality was 6.0%. Neurologic events included stroke (6.8%) and permanent lower extremity paralysis-paresis (4.5%). Temporary dialysis was needed in 7 (5.3%), though only 2 patients required permanent dialysis (1.9%). Independent predictors of a composite endpoint of death, stroke, permanent paralysis, or dialysis included duration of lower body HCA (p = 0.03) and major postoperative infection (p = 0.003). CONCLUSIONS Adjunctive use of deep hypothermic circulatory arrest for descending thoracic aortic resection affords excellent preservation of end-organ and spinal cord function with acceptable rates of mortality and significant morbidity.
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Affiliation(s)
- Himanshu J Patel
- Section of Cardiac Surgery, Department of Surgery, University of Michigan Hospitals, Ann Arbor, Michigan 48109-0348, USA.
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Isaka M, Kumagai H, Sugawara Y, Okada K, Orihashi K, Ohtaki M, Sueda T. Cold spinoplegia and transvertebral cooling pad reduce spinal cord injury during thoracoabdominal aortic surgery. J Vasc Surg 2006; 43:1257-62. [PMID: 16765250 DOI: 10.1016/j.jvs.2006.02.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2005] [Accepted: 02/09/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE We examined the protective effects of the new selective spinal cord cooling by using cold saline infusion into the cross-clamped aorta and a transvertebral cooling pad placed over the lumbar vertebral column from paraplegia caused by ischemic spinal cord injury on thoracoabdominal aortic surgery. METHODS Eighteen rabbits were divided into three groups: groups I, II, and III (n = 6 for each group). In group I (37 degrees C; 5 mL) and group II (3 degrees C; 5 mL), saline was infused into the isolated aortic segment twice, at 0 and 5 minutes after aortic cross clamping. In group III, a 3 degrees C saline solution plus cooling pads placed just after cross clamping were combined. The infrarenal aorta was then isolated proximally and distally by vascular clamps for 12 minutes. In our preliminary study, only the abdominal aorta just distal to the left renal artery was clamped. At 48 hours after reperfusion, the groups clamped for 12 and 15 minutes were all paraplegic. The time of clamping the aorta was set at 12 minutes as the critical point when paraplegia occurred upon simple clamping of the infrarenal aorta only. The spinal cord temperature was monitored at the L4 level continuously during the procedures in all three groups. At 8, 24, and 48 hours after the operation, hind limb function was estimated by using the Tarlov score, which is often used for evaluating motor function in animals. A histopathologic study using hematoxylin and eosin stains was also performed. RESULTS At 48 hours after the operation, the Tarlov scores in groups I, II, and III were 0 +/- 0, 2.0 +/- 1.9, and 4.0 +/- 0 (mean +/- SD), respectively. The Tarlov score and histopathologic analysis in group III were significantly superior to those of groups I (P < .01) and II (P < .05). The spinal cord temperature in groups II and III decreased by -1.8 degrees C and -4.3 degrees C at its minimum. The rabbits in group III were also protected from paraplegia. CONCLUSIONS Selective spinal cord cooling with cold saline infusion into the isolated aortic segment and transvertebral regional cooling can reduce the neurologic damage of spinal cord ischemia.
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Affiliation(s)
- Mitsuhiro Isaka
- Department of Surgery, Division of Clinical Medical Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan.
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Nishi H, Miyamoto S, Minamimura H, Ishikawa T, Kato Y, Arimoto H, Ohue K, Shimizu Y. Extensive thoracoabdominal aortic aneurysm repair using deep hypothermic bypass and circulatory arrest. Asian Cardiovasc Thorac Ann 2004; 12:69-74. [PMID: 14977747 DOI: 10.1177/021849230401200117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We sought to evaluate the safety and usefulness of deep hypothermic cardiopulmonary bypass with intervals of circulatory arrest for extensive thoracoabdominal aortic aneurysms. Between March 1994 and December 2002, 17 patients with Crawford type I and II were reviewed retrospectively. The patients were divided into two groups: group H (hypothermic circulatory arrest, n = 8) and group N (normothermic cardiopulmonary bypass, n = 9). In group H, in-hospital mortality was 12.5%, and that in group N was 11.1%. Operation times were similar between the two groups though the cardiopulmonary bypass time was significantly shorter in group N than in group H (p < 0.05). Postoperative paraplegia occurred in 1 patient of group N. Postoperative renal dysfunction occurred in none of group H except in 1 preoperative dialysis case, whilst it occurred in 6 patients of group N. Postoperative creatinine levels were significantly higher in group N than in group H. Three cases in group H required tracheostomy. Our experience with hypothermic cardiopulmonary bypass and circulatory arrest for diffuse type thoracoabdominal aortic aneurysm confirms the safety and efficacy of this technique. Although respiratory complications remain a problem, the technique is considered to be effective for renal protection.
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Affiliation(s)
- Hiroyuki Nishi
- Department of Cardiovascular Surgery, Osaka General City Hospital, Osaka, Japan.
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Kouchoukos NT, Masetti P, Murphy SF. Hypothermic cardiopulmonary bypass and circulatory arrest in the management of extensive thoracic and thoracoabdominal aortic aneurysms. Semin Thorac Cardiovasc Surg 2003; 15:333-9. [PMID: 14710374 DOI: 10.1053/s1043-0679(03)00083-2] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hypothermic cardiopulmonary bypass, usually in combination with an interval of circulatory arrest, was used for the treatment of 211 patients with extensive thoracic or thoracoabdominal aortic disease during a 17-year interval. Profound hypothermia, distal perfusion, and intravenous methylprednisolone and thiopental were used for neuroprotection. No other technique or other adjunctive agents were used. The 30-day mortality rate was 7.1% (15 patients). It was 40% (8 of 20) for patients undergoing emergent operations for aortic rupture or acute dissection and 3.7% (7 of 191) for all other patients (P<0.001). Paraplegia occurred in 5 and paraparesis in 1 of the 205 operative survivors whose lower limb function could be assessed postoperatively (2.9%). Of the 121 survivors with thoracoabdominal aortic disease, paraplegia occurred in 1 of 38 patients with Crawford type I disease (2.6%), 2 of 49 with type II (4.1%), and 2 of 34 with type III (5.9%). Paralysis developed in 1 (1.7%) of the 58 patients who underwent aortic dissection. Renal dialysis was required in 6 (2.9%) of the 205 operative survivors, prolonged inotropic support (>48 hours) in 23 (11%), reoperation for bleeding in 10 (5%), mechanical ventilation (>48 hours) in 50 (24%), and tracheostomy in 21 (10%). Four (1.9%) patients sustained a stroke. Hypothermic cardiopulmonary bypass provides safe and substantial protection against paralysis, and renal, cardiac, and visceral organ system failure that equals or exceeds that of other currently used techniques but without the need for other adjuncts.
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Affiliation(s)
- Nicholas T Kouchoukos
- Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, St. Louis, MO 63131, USA.
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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:S1885-7; discussion S1892-8. [PMID: 12440687 DOI: 10.1016/s0003-4975(02)04153-x] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Hypothermic cardiopulmonary bypass with circulatory arrest is an important adjunct for operations on the distal aortic arch, the descending thoracic, and the thoracoabdominal aorta. The safety and efficacy of this technique when compared with other adjuncts (ie, simple aortic clamping, partial cardiopulmonary bypass, regional hypothermia) is not clearly established. METHODS One hundred and ninety-two patients (age range, 20 to 83 years) with descending thoracic or thoracoabdominal aortic disease had resection and graft replacement of the involved aortic segments using hypothermic cardiopulmonary bypass and intervals of circulatory arrest (mean, 38 minutes). The technique was used when the location and severity of disease precluded placement of clamps on the proximal aorta (31 patients) or (in 161 patients) when extensive thoracic (47) or thoracoabdominal (114) aortic disease was present, and the risk for development of spinal cord ischemic injury was judged to be increased. Lower intercostal and lumbar arteries were attached separately to the aortic graft in 101 of the 161 patients (63%) who had extensive aortic replacement. No other adjuncts for spinal cord protection were used. RESULTS The 30-day mortality was 6.8% (13 patients). It was 40% (8 of 20) for patients having emergent operations (acute aortic dissection or rupture) and 2.9% (5 of 172) for all others (p < 0.001). The 90-day mortality was 12.5% (24 patients). Paraplegia occurred in 4 and paraparesis in 1 (full recovery) of the 186 operative survivors whose lower limb function could be assessed postoperatively (2.7%). Among the 109 survivors with thoracoabdominal aortic disease, early paraplegia occurred in 1 of 36 with Crawford extent I, 0 of 42 with extent II, and 2 of 31 with extent III disease. One patient (extent II) developed paraplegia on the 9th postoperative day after a hypotensive episode. None of the 47 patients with aortic dissection developed paralysis. Among the 186 operative survivors, renal dialysis was required in 4 patients (2.2%), prolonged inotropic support in 18 (10%), reoperation for bleeding in 9 (5%), mechanical ventilation (> or = 48 hours) in 64 (34%), and tracheostomy in 17 (9%). Four patients (2%) sustained a stroke. CONCLUSIONS Hypothermic cardiopulmonary bypass with circulatory arrest provides safe and substantial protection against paralysis and renal, cardiac, and visceral organ system failure that equals or exceeds that of other currently used techniques but without the need of other adjuncts.
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Affiliation(s)
- Nicholas T Kouchoukos
- Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, St. Louis, USA.
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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; 72:699-707; discussion 707-8. [PMID: 11565644 DOI: 10.1016/s0003-4975(01)02800-4] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Hypothermic cardiopulmonary bypass with circulatory arrest is an important adjunct for operations on the distal aortic arch and the descending thoracic and thoracoabdominal aorta. Its safety and efficacy compared with other techniques (eg, simple aortic clamping, partial cardiopulmonary bypass, and regional hypothermia) are not clearly established. METHODS One hundred sixty-one patients (ranging from 20 to 83 years old) with descending thoracic or thoracoabdominal aortic disease had resection and graft replacement of the involved aortic segments using hypothermic cardiopulmonary bypass usually with intervals of circulatory arrest (mean interval, 38 minutes). RESULTS The 30-day mortality rate was 6.2% (10 patients). It was 41% (7 of 17) for patients having emergent operations (rupture or acute dissection) and 2.1% (3 of 144) for all other patients (p < 0.001). The 90-day mortality rate was 11.8% (19 patients). Paraplegia occurred in 4 and paraparesis in 1 of the 156 operative survivors whose lower limb function could be assessed postoperatively (3.2%). Among the 91 survivors with thoracoabdominal aortic disease, early paraplegia occurred in 1 of 33 patients with Crawford type I disease, 0 of 34 with type II disease, and 2 of 24 with type III disease. One patient (type II disease) had development of paraplegia on the tenth postoperative day. None of the 50 patients with aortic dissection experienced paralysis. Renal dialysis was required in 4 (2.5%) of the 157 operative survivors, prolonged inotropic support (> 48 hours) in 17 (11%), reoperation for bleeding in 8 (5%), mechanical ventilation (> 48 hours) in 31 (20%), and tracheostomy in 13 (8%). Three patients (1.9%) sustained a stroke. CONCLUSIONS Hypothermic cardiopulmonary bypass provides safe and substantial protection against paralysis and renal, cardiac, and visceral organ system failure that equals or exceeds that of other currently used techniques but without the need of other adjuncts.
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Affiliation(s)
- N T Kouchoukos
- The Heart Center, Missouri Baptist Medical Center, St. Louis, USA.
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Gygax E, Schüpbach P, Carrel TP. Thoracoabdominal aortic repair in a 190-kg patient: optimized perfusion with two oxygenators. Ann Thorac Surg 2001; 71:347-9. [PMID: 11216778 DOI: 10.1016/s0003-4975(00)02157-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A 190-kg patient was referred because of an acute type B aortic dissection. Conservative management was initially performed but the 34-year-old patient was shown to have an increasing aortic diameter 2 months later and was scheduled for elective repair of the thoracoabdominal aorta. To anticipate potential difficulties with perfusion and oxygenation the cardiopulmonary bypass circuit was constructed with two parallel oxygenators, which allowed an adequate oxygen supply through all phases of the intervention and accelerated the estimated rewarming time.
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Affiliation(s)
- E Gygax
- Clinic for Cardiovascular Surgery, University Hospital, Berne, Switzerland
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Robe J, Carell TP, Neidhart P. Anaesthetic management of patients undergoing surgery on the descending aorta. Best Pract Res Clin Anaesthesiol 2000. [DOI: 10.1053/bean.2000.0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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