One-stage intrathoracic repair of extended aortic aneurysms

Aortic arch replacement and elephant trunk procedure: an interdisciplinary approach to surgical reconstruction, perfusion strategies and blood management

Surgical treatment of patients who present with large aneurysms of the ascending aorta, transverse arch and descending aorta, including the thoracic and abdominal aorta typically consists of a two-staged elephant trunk procedure. Typically, these operations are lengthy, requiring long cardiopulmonary bypass times, deep hypothermic circulatory arrest and multiple anastamotic suture lines, which increases the risks for coagulopathic bleeding and the need for massive transfusions. The purpose of this report is to describe our approach, involving advanced surgical techniques and the innovative perfusion considerations as well as modified blood management strategies to minimize perioperative blood loss and the need for transfusions. All of the above will highlight critical cardiac team communications. An ever-evolving case requires forward thinking, revised judgments, open discussion and the continued involvement of all team members. In turn, this ensures evidence-based medical and perfusion practices that lead to achieving a positive peri-operative course, with optimal blood conservation.

Optimization of Aortic Arch Replacement With a One-Stage Approach

BACKGROUND

Staged procedures for extensive aneurysmal disease of the thoracic aorta are associated with a substantial cumulative mortality for the two procedures and death in the interval between, often from aortic rupture. We have used a one-stage approach for operative repair of most, or all, of the thoracic aorta.

METHODS

Sixty-nine patients were treated using a bilateral anterior thoracotomy with transverse sternotomy, hypothermic circulatory arrest, and reperfusion of the arch vessels first to minimize brain ischemia. Forty-two patients had chronic ascending aortic dissections (all but 1 had a previous operation), 24 had degenerative aneurysms, and 3 had chronic descending aortic dissections with proximal extension. The ascending aorta and aortic arch were replaced in all patients combined with resection of various lengths of descending aorta.

RESULTS

In-hospital mortality was 7.2% (5 patients). Morbidity included reoperation for bleeding (13%), mechanical ventilation for more than 72 hours (50%), temporary tracheostomy (13%), and temporary renal dialysis (9%). No patient sustained a stroke. There have been 9 late deaths unrelated to the aortic disease. Four patients have undergone successful reoperation on the aorta for false aneurysm in 1, endocarditis in 1, and progression of disease in 2. Survival at 5 years was 71%.

CONCLUSIONS

The one-stage arch-first technique is a safe and suitable alternative to the two-stage procedure for repair of extensive thoracic aortic disease.

The Elephant Trunk Technique for Staged Repair of Complex Aneurysms of the Entire Thoracic Aorta

BACKGROUND

Extensive thoracic aortic aneurysms that involve the ascending, arch, and descending segments require challenging repairs associated with substantial morbidity and mortality. The purpose of this report is to evaluate contemporary outcomes after surgical repair of extensive thoracic aortic aneurysms using a two-stage approach with the elephant trunk technique.

METHODS

During a 15 1/2-year period, 148 consecutive patients underwent total aortic arch replacement using the elephant trunk technique. Seventy-six of these patients (51%, 76/148) returned for second-stage repair of the descending thoracic or thoracoabdominal aorta 4.9 +/- 7.5 months after the first stage.

RESULTS

Operative mortality after the proximal aortic stage was 12% (18/148). Seven patients (5%) had strokes. Among the patients who subsequently underwent distal aortic repair, operative mortality was 4% (3/76). Two patients (3%) developed paraplegia. Long-term survival after completing the second stage of repair was 70 +/- 6% at 5 years and 59 +/- 7% at 8 years.

CONCLUSIONS

Contemporary management of extensive thoracic aortic aneurysms using the two-stage elephant trunk technique yields acceptable short-term and long-term outcomes. This technique remains an important component of the surgical armamentarium.

Surgery for Acute Type A Aortic Dissection

PURPOSE

To review the management of patients with acute type A aortic dissection.

METHODS

Between June 1967 and December 2003, 246 patients (151 males and 95 females, 20-82 years; median 59 years) underwent operation for type A dissection. Early mortality and aortic dissection-related late events (reoperation and death related to aortic dissection) were assessed and correlated with the surgical approach.

RESULTS

Over 37 years, early mortality has markedly improved, 50% in 1970s, 22% in 1980s, 17% in 1990s, and 11% after 2000. However, late deaths occurred at a constant rate, overall late survival at 10 and 20 years were 59% and 9%, respectively, and this did not improve after the 1990s. Preoperative hemodynamic instability, myocardial and kidney malperfusion, smoking history, prolonged bypass and cross-clamp time, and year of surgery were found to be risk factors for early death. The main cause (21%) of late deaths was aortic dissection-related events, especially in the distal aorta. However, no intraoperative risk factors were found to be predictive of late dissection-related events. Surgical techniques including complete resection of the intimal tear or distal extent of the surgery had no impact on late distal event-free survival.

CONCLUSION

Despite improvement of short-term outcome over 37 years, patients who had aortic dissection are still living with elevated risk of death. Although late events in the distal aorta were a major risk, aggressive surgical approaches did not improve these outcomes. Vigilant follow-up is necessary for these patients.

Single-stage repair of extensive thoracic aortic aneurysms: Experience with the arch-first technique and bilateral anterior thoracotomy

BACKGROUND

Staged procedures for extensive aneurysmal disease of the thoracic aorta are associated with a substantial cumulative mortality (>20%) that includes hospital mortality for the 2 procedures and death (often from aortic rupture) in the interval between the 2 procedures. We have used a single-stage technique for operative repair of most or all of the thoracic aorta.

METHODS

Forty-six patients with extensive disease of the thoracic aorta were managed with a single-stage procedure by using a bilateral anterior thoracotomy and transverse sternotomy, hypothermic circulatory arrest, and reperfusion of the aortic arch vessels first to minimize brain ischemia. Thirty-one patients with chronic, expanding type A aortic dissections had previous operations for acute type A dissection (n = 22), aortic valve repair or replacement (n = 4), coronary artery bypass grafting (n = 4), or no previous operation (n = 1). The remaining 15 patients had degenerative aneurysms (n = 12) or chronic type B dissections with proximal extension (n = 3). The ascending aorta and aortic arch were replaced in all patients combined with resection of various lengths of descending aorta (proximal one third [n = 19], proximal two thirds to three quarters [n = 22], or all [n = 5]). Coronary artery bypass grafting, valve replacement, or both were performed concomitantly in 19 patients.

RESULTS

Hospital mortality was 6.5% (3 patients). Morbidity included reoperation for bleeding (17%), mechanical ventilation for more than 72 hours (42%), temporary tracheostomy (13%), and temporary renal dialysis (9%). No patient sustained a stroke. There have been 5 late deaths (3, 18, 34, 51, and 79 months postoperatively) unrelated to the aortic disease. Four patients have undergone successful reoperation on the aorta (false aneurysm [n = 1], endocarditis [n = 1], and progression of disease [n = 2]). Five-year survival was 75%.

CONCLUSION

The single-stage, arch-first technique is a safe and suitable alternative to the 2-stage procedure for repair of extensive thoracic aortic disease.

Long-Term Effectiveness of Operative Procedures for Stanford Type A Aortic Dissections

BACKGROUND

The object was to evaluate the long-term effectiveness of strategies for managing the aortic root and distal aorta in type A dissections.

METHODS

From 1990 to 1999, 50 patients (32 men (64.07%); 18 women, (36.0%); mean age 57.4 +/- 11.1 years) underwent operation for ascending aortic dissection. Surgical strategies included aortic root replacement with a composite graft (21/50; 42.0%), valve replacement with supracoronary ascending aortic graft (3/50, 6%), and valve preservation or repair (26/50; 52.0%).

RESULTS

Overall hospital mortality rate was 18.0%. Follow-up was completed for 47 patients (94.0%) and ranged from 1 month to 10.5 years (mean 28.8 months). Actuarial survival for patients discharged from the hospital was 84% at 1 year, 75% at 5 years, and 66% at 10 years. There was no significant difference between the various procedures regarding mortality, neurological complications, long-term survival, and proximal reoperations. The ascending aorta alone was replaced in 8 of 50 patients (16%), ascending and hemiarch in 30 of 50 patients (60%), and arch and proximal descending aorta in 12 of 50 patients (24%). Hospital mortality (11.5%, 20.0%, and 16.7%, respectively; p > 0.05) and 5- and 10-year survival (p > 0.05) were not statistically dependent on the extension of the resection distally. Residual distal dissection was not associated with a decrease in late survival. With regard to emergency surgery (36/50) there was no significant difference in hospital mortality (p > 0.05) and 5-year survival (p > 0.05) between those who had undergone coronary angiography (19/36; 52.8%) on the day of surgery with those who had not (17/36; 47.2%).

CONCLUSIONS

Preservation or repair of the aortic valve can be recommended in the majority of patients with type A dissection. Distal extension of the resection does not increase surgical risk. Residual distal dissection does not decrease late survival. Preoperative coronary angiography may not affect survival in patients undergoing emergency surgery.

Risk factors for descending aortic aneurysm formation in medium-term follow-up of patients with type A aortic dissection

BACKGROUND

After surgery to repair a type A aortic dissection, most late complications and mortality result from descending aorta-related problems. This study was performed to determine the risk factors leading to descending aortic aneurysm formation and late mortality in patients undergoing the type A aortic dissection operation.

METHODS

The medical records of patients who survived the operation for type A aortic dissection between 1984 and 1998 were reviewed. There were 144 patients (95 men and 49 women), ranging in age from 24 to 78 years (mean age, 52 years). Most patients were acutely ill, 15 patients were in shock, and 54 patients had cardiac tamponade at the time of the surgical procedure. One hundred thirty-seven patients had ascending aortic replacement only, and of the other 6 patients 2 had hemiarch and 4 had total arch replacement using the elephant trunk technique. The aortic valve was replaced in 23 patients, resuspended in 100, and untouched in 21. Twenty-four risk factors were evaluated in statistical analyses for the prediction of descending aortic aneurysm formation and 3-year mortality. Risk factors were investigated using univariate and multiple logistic regression and survival analyses.

RESULTS

The 3-year, 5-year, and 8-year cumulative survival rates were 96.2%, 89.1%, and 80.0%, respectively. The 3-year, 5-year, and 8-year cumulative survival rates, free from descending aortic aneurysm formation or descending aorta operation, were 74.7%, 58.6%, and 43.0%, respectively. Multivariate analysis confirmed that patent false lumen and initial descending aortic diameter were statistically significant risk factors for descending aortic aneurysm formation.

CONCLUSIONS

The medium-term survival rate of patients who received operations for type A aortic dissection was satisfactory, despite the high incidence of descending aortic aneurysm formation. The intimal entry site over the aortic arch that was resected during the first operation could decrease the patency rate of a false lumen over the descending aorta. In the absence of a patent false lumen over the descending aorta, the chance of descending aortic aneurysm formation or operation is lessened, and the late survival rate is increased.

A novel modification of elephant trunk technique using a single four-branched arch graft for extensive thoracic aortic aneurysm

Surgical repair for the extensive thoracic aortic aneurysm remains unsatisfactory, especially in elderly patients. We developed a total arch replacement with modified elephant trunk technique under moderately hypothermic cardiopulmonary bypass and selective brain perfusion, in which a 4-branched arch graft with a sewing 'collar' enabled the distal anastomosis just proximal to the innominate artery with open distal method and a long 'elephant trunk' was inserted into the descending aorta by the forceps catheter via the femoral artery. This modification is easy and less invasive, and reduces the risk of postoperative complications.

Long-term effectiveness of operations for ascending aortic dissections

OBJECTIVE

To evaluate long-term effectiveness of a strategy for managing the aortic root and distal aorta according to the pathology in ascending aortic dissection.

METHODS

From 1978 to 1995, 208 patients underwent operations for acute (n = 135) and chronic (n = 73) ascending aortic dissection. Surgical strategies included valve resuspension with supracoronary aortic root repair and ascending aortic graft for normal sinuses and valve (n = 135), composite valve and ascending aortic graft for abnormal sinuses and valve (n = 47), and valve replacement and supracoronary ascending aortic graft for normal sinuses and abnormal valve (n = 26). Resection extended into the arch only if the intimal tear originated in or extended to the aortic arch (n = 31).

RESULTS

Hospital mortality was 14%. Cardiogenic shock (P =.002) and concomitant coronary artery bypass grafting (P =.001) were associated with increased risk; use of circulatory arrest (P =.0003) decreased risk. Survival was 87%, 68%, and 52% at 30 days, 5 years, and 10 years, respectively. Advanced age, earlier date of operation, composite graft, and arch resection were associated with decreased survival; residual distal dissected aorta was not. Reoperation was required for 5 proximal and 8 distal problems.

CONCLUSIONS

In both acute and chronic ascending aortic dissections, (1) circulatory arrest is associated with low early mortality; (2) with normal sinuses and valve, supracoronary repair of the dissected aortic root and valve resuspension is effective long term; and (3) residual distal dissected aorta does not decrease late survival and has a low risk of aneurysmal change and reoperation for at least 10 years.