Aortic arch repairs through three different approaches

Impact of preservation of the latissimus dorsi muscle through a left anteroaxillary thoracotomy on spinal cord protection in descending thoracic and thoraco-abdominal aortic operations†

OBJECTIVES

The presence of collateral network circulation to the spinal cord, which is reflected in the repair of a descending thoracic aortic aneurysm (dAo) and a thoraco-abdominal aortic aneurysm (TAAo), has been demonstrated in clinical and animal experimental data. The latissimus dorsi muscle (LDM) including the thoracodorsal artery might be one of the major sources of this collateral network. The objective of this study was to evaluate the impact on spinal cord safety of a left anteroaxillary thoracotomy with minimal muscle division including preservation of the LDM in surgery for dAo and TAAo.

METHODS

Sixty-nine patients [64 (23-85) years old; 56 men] who underwent surgical repair for dAo and TAAo were divided into 2 groups: 29 [65 (23-84) years old] with an anteroaxillary thoracotomy with LDM preservation (PL group) and 40 [61 (28-85) years old] with a lateral thoracotomy without LDM preservation (NL group).

RESULTS

Aortic repairs were performed at the dAo in 30 patients including 14 in the PL group vs 16 in the NL group and at the TAAo in 39 patients including 15 in the PL group vs 24 in the NL group. There were 2 (2.9%) 30-day deaths; 2 (7.9%) in the PL group vs none in the NL group (P = 0.173). No strokes occurred. In patients with a femoro-femoral partial cardiopulmonary bypass with mild hypothermia, the incidence of loss of signal of motor-evoked potentials (>50%) was significantly lower in the PL group; 5.6% vs 31.8% (P = 0.039). The frequency of signal reduction of the remaining motor-evoked potential after surgery was also significantly lower in the PL group: 3.7% vs 25% (P = 0.040). Subsequently, the rate of spinal cord complications were lower in the PL group: 3.4% vs 12.5% (P = 0.188).

CONCLUSIONS

The left anteroaxillary thoracotomy with minimal incision of the muscles including the LDM might have potential advantages for spinal cord protection via preserved intramuscular collateral circulations to the spinal cord in dAo/TAAo open repairs.

Surgical Repair of Distal Aortic Arch Aneurysm With Distal Extension: Sternotomy Versus Thoracotomy

BACKGROUND

There is no consensus as to whether a median approach or a lateral approach is better for distal aortic arch aneurysms with distal extensions. The aim of this study was to compare clinical outcomes of these two approaches for distal aortic arch aneurysms with distal extensions.

METHODS

From January 2001 to December 2017, 212 consecutive patients with distal aortic arch aneurysms with distal extensions underwent surgery using different approaches: hemiarch and descending thoracic aneurysm replacement through thoracotomy (group 1, n = 91); and total arch and descending thoracic aneurysm replacement through sternotomy (group 2, n = 121). Early and late outcomes were compared using scores and inverse probability of treatment adjustments to reduce treatment selection bias.

RESULTS

The in-hospital mortality was 9.89% (9 of 91) in the thoracotomy group and 2.48% (3 of 121) in the sternotomy group (p = 0.02). The sternotomy group had a lower incidence of permanent stroke (2.48%, 3 of 121) compared with the thoracotomy group (10.99%, 10 of 91, p = 0.01). After adjustment, patients who underwent thoracotomy were at a greater risk of hospital mortality (odds ratio 5.0, p = 0.01), permanent stroke (odds ratio 6.83, p < 0.01), and pneumonia (odds ratio 2.99, p = 0.04), compared with patients who underwent sternotomy. The overall survival at 10 years was 69.8% ± 7.0% for the thoracotomy group and 83.0% ± 5.0% for the sternotomy group (unadjusted p = 0.049, adjusted p = 0.034).

CONCLUSIONS

The sternotomy approach showed better outcomes in terms of operative mortality, stroke, and pneumonia, as well as long-term survival compared with the thoracotomy approach. These results suggested that the sternotomy approach was more appropriate for patients with distal aortic arch aneurysms with distal extensions.

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.

Contemporary Results of Total Aortic Arch Replacement

BACKGROUND AND AIM

Aneurysmal dilatation of the aortic arch is uncommon, and the complex anatomy involved imposes unique technical challenges. The results of surgical intervention reported from large centers are improving; however, the degree to which these results are reproducible by other surgeons is less clear. We therefore reviewed our recent experience with total aortic arch replacement.

METHODS

Between July 1, 1997 and July 1, 2001 19 patients underwent complete aortic arch replacement, with or without concomitant procedures. We retrospectively reviewed perioperative results retrieved from the computerized database and clinical records.

RESULTS

The mean age of the study population was 68 +/- 8.3 years (range 52 to 82), with women predominating (11 women, 8 men). All patients had hypertension. Patient history indicated active or past tobacco abuse in 16 patients (80%); cerebrovascular disease in 3, and peripheral vascular disease in 7 patients. Associated procedures included an elephant trunk in 12 (63%), replacement of the upper descending thoracic aorta in 5 (26%), concomitant coronary artery bypass in 5 (26%), and aortic root replacement in 3 (16%). One patient underwent replacement of the entire aorta from sinotubular ridge to iliac bifurcation in a single procedure. Brachiocephalic reconstruction with a "Y-graft" permitting early antegrade cerebral perfusion was performed in 12 patients. Retrograde cerebral perfusion was performed in ten patients (53%). Perioperatively, death occurred in two patients (11%) and stroke in two (11%).

CONCLUSIONS

With cautious application, techniques developed in high-volume centers can also achieve satisfactory results when used at centers with a more modest case volume.