RESECTION OF THE THORACIC AORTA WITH REPLACEMENT BY HOMOGRAFT FOR ANEURYSMS AND CONSTRICTIVE LESIONS

Retrograde Cerebral Perfusion May Decrease Stroke Risk During Elective Aortic Arch Surgery

OBJECTIVE

Controversy remains regarding the optimal neuroprotection strategy for elective hemiarch replacement (HEMI). This study sought to compare outcomes in patients who underwent HEMI utilizing the 2 most common contemporary methods of cerebral protection.

METHODS

The ARCH international aortic database was queried, and 782 patients undergoing elective HEMI with circulatory arrest from 2007 to 2012 were identified. There were 418 patients who underwent HEMI using moderate hypothermia (nasopharyngeal temperature 20.1 to 28.0 °C) and antegrade cerebral perfusion (MHCA/ACP). There were 364 patients who underwent HEMI using deep hypothermia (nasopharyngeal temperature 14.1 to 20 °C) and retrograde cerebral perfusion (DHCA/RCP). Adverse outcomes were compared between the groups using both univariable and multivariable analyses.

RESULTS

Patients who underwent MHCA/ACP were older (64 vs 61 years, P = 0.01) and more frequently had peripheral vascular disease than DHCA/RCP patients (28.5% vs 7.1%, P < 0.001). Patients in the DHCA/RCP group had a greater incidence of full aortic root replacement (55.8% vs 26.4%, P < 0.001) and more frequently had a central cannulation strategy (83% vs 55.7%, P < 0.001). Cardiopulmonary bypass (170 vs 157 min, P = 0.002) and aortic cross-clamp (134 vs 92 min, P < 0.001) times were significantly longer in the DHCA/RCP group. On univariable analysis, overall mortality was statistically similar between groups (MHCA/ACP 3.4% vs DHCA/RCP 2.3%, P = 0.47), but permanent neurologic deficits were significantly lower in the DHCA/RCP cohort (MHCA/ACP 3.9% vs DHCA/RCP 1.0%, P = 0.02). Multivariable analysis showed no difference in mortality nor perioperative stroke between perfusion cohorts.

CONCLUSIONS

Both MHCA/ACP and DHCA/RCP are excellent neuroprotective strategies that produce low mortality in patients undergoing elective HEMI. DHCA/RCP may demonstrate theoretically improved neurologic outcomes compared with MHCA/ACP, but this topic warrants further study.

Early experience of thoracic endovascular aortic repair: a local single hospital experience

Purpose

The purpose of this retrospective study was to evaluate the short- to mid-term results of thoracic endovascular aortic repair (TEVAR) in Wonkwang University School of Medicine & Hospital.

Methods

Between February 2009 and May 2011, 8 consecutive patients had undergone endovascular stent-grafting for thoracic aortic diseases. Five patients were treated for traumatic thoracic aortic injuries, two patients were treated for thoracic aneurysms and one patient was treated for a pseudoaneurysm due to penetrating aortic ulcers. Attempted stent-graft deployment was performed electively in 6 patients and emergently in 2. Follow-up was performed at 1-month, 6-month, 1-year, and annually thereafter.

Results

Technical success rates were achieved in 87.5% and the 30-day mortality rate was 0%. Mean hospital length of stay after TEVAR was 30 days in traumatic thoracic aortic injuries and 10 days in thoracic aneurismal diseases. Intra-operative Type I endoleak due to migration at deflation was visualized in 1 patient, which was treated by insertion of another stent-graft. During follow-up, a major complication was encountered in one patient who received carotid-subclavian bypass to relieve left arm ischemia. After 5 months he was treated with arch replacement for aortic arch aneurysm with type I endoleak at proximal site after endovascular treatment. The 30-day mortality rate was 0%. However, 1 case of mortality (12.5%) was observed during the follow-up period.

Conclusion

The short and mid-term results of endovascular repair of thoracic aortic diseases are promising. TEVAR is an effective procedure in the management of thoracic aortic diseases.

Endovascular treatment of thoracoabdominal aneurysm

OPINION STATEMENT

The use of endovascular modalities for the treatment of simple descending thoracic aneurysms has become standard of care. Expanding endovascular techniques for the treatment of thoracoabdominal aneurysms is now possible with the evolution of branched and fenestrated grafts.

Surgery Insight: the dilated ascending aorta—indications for surgical intervention

Awareness of the clinical significance of thoracic aortic aneurismal disease has increased in recent years. As diagnostic tools have improved our ability to identify aortic pathology, surgical outcomes have also improved, making intervention a life-saving option in the majority of cases. Here, we aim to examine the indications for surgical intervention on the dilated aorta, particularly the ascending segment. Studies of the natural history of ascending aortic aneurysms indicate that aneurysms exceeding 6 cm in maximum diameter are associated with a particularly high risk of complications. In the interest of providing some margin of safety, most surgeons would agree that intervention is indicated with an aortic diameter of 5.5 cm. Many would intervene even earlier (at 5.0 cm) for patients at low surgical risk, or for those with known connective tissue disorders such as Marfan's syndrome. In some cases, only the ascending aortic segment needs to be treated, while in others full root replacement is required. Reduction aortoplasty has been superseded largely by interposition graft replacement. The standard procedure involves replacement of the valve and root with a composite mechanical conduit or tissue root prosthesis, and results are excellent. Recently developed valve-sparing root reconstructive options, however, are promising and have encouraged an even more aggressive surgical stance.

Coral reef aorta: a long-term study of 21 patients

Coral reef aorta is a rare calcifying disease of the juxtarenal and suprarenal aorta. We report here our surgical experience in treating 21 patients, with a mean follow-up of 4 years and 7 months. Both genders were equally affected. Ten male (48%) and 11 female (52%) patients with a mean age of 54.6 years (range 42-76 years) underwent surgery. The main symptoms were limb claudication (n = 11, 52%), renovascular stenosis (n = 9, 43%) with concurrent renovascular hypertension (n = 5, 24%), and angina abdominalis (n = 7, 33%). Most patients had multiorgan vascular disease such as iliofemoral arterial occlusive disease (n = 14, 66%), coronary artery obstruction (n = 8, 38%), or obstruction of the carotid artery (n = 6, 28%). Risk factors did not differ between coral reef patients and those with other occlusive vascular diseases. All patients were treated through vascular operations, including open thromboendarterectomy of the suprarenal (n = 9, 43%), infrarenal (n = 4, 19%), or supra- and infrarenal aorta (n = 8, 38%), and thromboendarterectomy of the following vessels: celiac artery (n = 7, 33%), superior mesenteric artery (n = 12, 57%), inferior mesenteric artery (n = 3, 14%), unilateral renal artery (n = 3, 14%), or bilateral renal artery (n = 9, 43%). Bypass reconstructions were performed in 39% (n = 8). A thoracoabdominal approach was used in 14 patients (67%) and a median laparotomy in 7 (33%). Our results show that coral reef aorta is not confined to either gender. It appears most frequently in the context of general atherosclerotic disease and patients benefit from timely diagnosis and operation before onset of severe, life-threatening visceral and renal complications.

Coarctations of descending and abdominal aorta: long-term results of surgical therapy

PURPOSE

Nonarteriosclerotic and nonarteritic descending and abdominal aortic coarctation (DAAC) is a rare disease with a great variety of morphologic findings. The additional affliction of renal and other splanchnic arteries often affords complex corrective procedures. We report on our single-center long-term experiences with operative treatment of this malformation.

METHODS

Over a period of 21 years, 15 patients (10 female and 5 male patients; age range, 8 to 57 years) were operated on for DAAC. Six patients had additional stenoses of eight renal arteries, and three had splanchnic arterial obstructions. At 4 to 25 years after the operation, all surviving patients underwent a clinical and a spiral computed tomography examination.

RESULTS

There was one intraoperative death due to exsanguination after the rupture of a poststenotic aneurysm of the infrarenal aorta. Fourteen patients were discharged free of symptoms. During follow-up, four repeated operations were necessary for renal arterial bypass stenoses or aneurysms. One late death occurred as the result of an unrelated disease.

CONCLUSIONS

Complete operative correction of DAAC usually can be accomplished as a single-stage procedure with low morbidity and mortality rates. The reconstruction of all renal arteries is essential to cure hypertension. Consequent follow-up is recommended for detection of late postoperative complications.

Endoaortic calcific proliferation of the upper abdominal aorta

Endoaortic calcified proliferation, also known as coral reef atherosclerosis represents a rare form of atherosclerosis characterized by a gross appearance and location in the thoracic and celiac aorta. We report two new cases of calcified obstruction of the aorta. In the first case, clinical examination revealed hypertension, abdominal angina associated with abdominal bruit, and diminished femoral pulses. The second case was diagnosed postoperatively when intractable hypertension and renal failure ensued following reconstruction of an abdominal aortic aneurysm. Accurate evaluation of lesions was possible through Doppler sonography, CT scan, and aortography. Because of hypertension and visceral ischemia, surgical treatment was required. Hypertension and intestinal angina were completely relieved in the first case, while hypertension and renal failure improved greatly in the second.

Acquired coarctation of the abdominal aorta

An unusual case of aortic obstruction, not heretofore described, is presented. This obstruction consisted of a perforate diaphragm which occurred in the abdominal portion of the aorta below the renal arteries. Diagnosis and operative method are discussed with several references to the literature.

Ruptured non-traumatic aneurysms of the descending thoracic aorta

Two cases of ruptured non-traumatic aneurysm of the descending thoracic aorta and a third in which rupture was imminent are discussed with regard to two simple operative techniques, both of which were employed with success. Partial aneurysmectomy was employed in one case and a temporary to permanent shunt graft in the other two. The simplicity of the techniques is such that they may be used in hospitals which are not equipped for extracorporeal perfusion.

Multiple and Infraductal Coarctations of the Aorta

Reports of multiple and infraductal coarctations are appearing more frequently in the literature as interest in the treatment of cardiovascular disease grows.

A case with 4 distinct coarctations is presented.