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Ann Thorac Surg 1995;59:19-27
© 1995 The Society of Thoracic Surgeons

Aortic Arch Operation: Current Treatment and Results

Department of Surgery, Baylor College of Medicine and The Methodist Hospital, Houston, Texas

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Between January 13, 1987, and December 31, 1993, 227 patients were treated surgically for aortic disease involving the transverse aortic arch. Forty-eight patients (21.14%) had acute aortic dissection (group A), 69 (30.40%) had chronic dissection (group B), and 110 (48.46%) had nondissecting fusiform or saccular aneurysms (group C). The replacement of the transverse arch involved 194 graft replacements, 27 elephant trunk procedures, and 6 patch graft repairs. Concomitantly, 22 patients had aortic valve resuspension, 18 patients had composite valve graft insertions, and 75 had separate aortic valve replacement. The frequency of prior cardiac operation was 20.83% (10 patients) in group A, 69.57% (48 patients) in group B, and 15.45% (17 patients) in group C. Profound hypothermic circulatory arrest was used in all patients during their transverse arch procedures. The mean circulatory arrest times (in minutes) were 29.18 ± 1.39, 36.62 ± 1.91, and 29.25 ± 1.46 for groups A, B, and C, respectively. Retrograde cerebral perfusion through the superior vena cava cannula was used in 111 (48.9%) patients during the circulatory arrest period. In-hospital mortality was 6.17% (14 deaths). Long-term follow-up was 100% complete. There were 20 late deaths, with a long-term mortality rate of 9.26% (20/216).

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
See also page 26.

Surgical repair of abnormalities of the aortic arch remains one of the difficult challenges facing the cardiac and aortic surgeon. Clearly, great strides have been made since 1957 when DeBakey and associates [1] reported the first successful replacement of the aortic arch with perfusion of the cerebral circulation accomplished directly by means of the brachiocephalic vessels. The single most important advance was the clinical introduction of deep hypothermia and circulatory arrest by Niazi and Lewis [2] in the same year. However, the technique was not popularized for use in the adult patient with an aortic arch aneurysm until Griepp and colleagues [3] reported on its use for this purpose in 1975. Crawford and Saleh [4] expanded on this concept and, in 1981, demonstrated its practicality with their finding of a decline in morbidity and mortality in a substantial number of patients. That same year, Cooley and Livesay [5] reported on their adoption of circulatory arrest for routine use in patients with an acute type I aortic dissection. Svensson and colleagues [6] reported the largest experience to date in the treatment of adults undergoing aortic operations in which deep hypothermia with circulatory arrest was used: In 656 patients operated on between 1979 and 1991, the incidence of transient or permanent stroke was 7% (44 patients) and that of early death was 10% (66 patients).

Because the central nervous system is so exquisitely sensitive to anoxia, subsequent neurologic injury remains the most feared complication of aortic arch repair. We report here our findings from a retrospective review of a contemporary group of 227 patients who underwent surgical treatment of an aortic arch abnormality; both the morbidity and mortality were less in these patients as opposed to findings in earlier patients.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Between January 13, 1987, and December 31, 1993, 227 patients were treated surgically for aortic disease involving the transverse aortic arch or the arch and ascending aorta. Forty-eight patients (21.14%) were treated for acute dissection (group A), 69 (30.40%) for chronic dissection (group B), and 110 (48.46%) for nondissecting fusiform or saccular aneurysms (group C). There were 33 male (68.75%) and 15 female patients (31.25%) in group A (mean, 58 years; range, 21 to 82 years); 56 male (81.12%) and 13 female patients (18.85%) in group B (mean, 60 years; range, 27 to 86 years); and 44 male (40%) and 66 female patients (60%) in group C (mean, 66 years; range, 29 to 85 years).

No patient with acute dissection presented without symptoms; 8 patients in group B and 16 in group C were asymptomatic. Chest pain was the most common presenting symptom and occurred in 41 patients in group A, 31 patients in group B, and 40 patients in group C. Congestive heart failure was present in 30 patients (13.22%): 10, 9, and 11 in groups A, B, and C, respectively. There were 4 patients whose initial symptom was stroke: 2, 1, and 1 in groups A, B, and C, respectively. The recurrent laryngeal nerve was affected in 9 patients: 1, 3, and 5 in groups A, B, and C, respectively.

Hypertension was the most common associated disease, and overall occurred in 140 patients (61.67%). Other commonly associated diseases were aortic valve insufficiency (52.42%), coronary artery occlusive disease (37.88%), and chronic obstructive pulmonary disease (23.35%). The greater incidence of aortic valve insufficiency in group A (acute dissection) (29/48; 60.41%) versus that in group B (37/69; 53.62%) or C (53/110; 48.18%) was due to the dissection involving the aortic valve commissures.

Medial degeneration was the underlying disorder in 119 patients (52.42%): 29 in group A, 39 in group B, and 51 in group C. Marfan's syndrome was present in 15 patients (6.6%); there were 5, 8, and 2 patients in groups A, B, and C, respectively. A false aneurysm stemming from a prior operation was the cause in 2 patients in group B and in 7 patients in group C, but none of the patients in group A had this abnormality. Aortitis was superimposed on the medial degeneration in 9 patients in group C, but was not encountered in any of the patients in groups A and B.

Postoperative stroke was defined as a focal or general neurologic deficit that was not present before operation but was identified after operation. Any patient who was not awake and neurologically normal by 48 hours after operation was considered to have suffered a stroke. Postoperative electroencephalograms were obtained in all patients, and those with abnormal recordings or with stroke were evaluated by a neurologist and also underwent computed tomography or magnetic resonance imaging.

Intraoperative electroencephalographic monitoring was carried out in all elective and most emergent cases using a standard ten-lead montage [7]. Systemic cooling was maintained until the electroencephalogram demonstrated electrical silence, and then cooling was continued for an additional 3 minutes. Barbiturates and steroids were not routinely administered. Acid-base balance was maintained using the alpha-stat method of pH control [8, 9]. After repair was completed, all patients were warmed to a rectal temperature of 37° to 38°C.

The cardiopulmonary bypass circuit involved an in-line membrane oxygenator and a centrifugal pump for arterial blood infusion. The circuit was primed with 2,000 to 2,400 mL of a balanced crystalloid solution and 5,000 units of heparin. At the initiation of cardiopulmonary bypass, 5 g of aminocaproic acid (Amicar) or 1 g of tranexamic acid (Cyklokapron) was added. Cooling was maintained with an arterial infusion temperature of 8° to 10°C. Hemodilution (hemoglobin levels, 6 to 7 mg/dL) was employed until rewarming, when hemoconcentration was initiated. To reduce the amount of blood shed into the operative field when the aortic aneurysm was opened, exsanguination into a reservoir was carried out immediately after circulatory arrest.

Femoral arterial cannulation and bicaval cannulation were used routinely. When the posterior portion of the sternum was intimately involved in the anterior wall of the aneurysm, and therefore there was a risk of aortic entry upon sternotomy, femorofemoral cannulation and systemic cooling were instituted before sternotomy. When reverse cerebral perfusion was used, a Y connector was placed in the arterial and superior vena caval cannulas to allow for connection and perfusion by means of the superior vena cava during the circulatory arrest period. Retrograde cerebral flow was maintained at 300 to 600 mL/min, with the proximal venous pressure monitored and kept at 25 mm Hg or less to prevent cerebral edema.

Patients with aneurysmal disease, either fusiform or dissecting, underwent graft replacement of all of the aortic arch with an island of aortic tissue containing the brachiocephalic vessels, after the distal anastomosis to the proximal descending aorta had been performed (Fig 1). Aneurysmal involvement of the brachiocephalic vessels was treated individually with the placement of separate Dacron tube grafts as necessary. Patients with aortic arch disease affecting only the lesser curvature, and most patients with acute dissection, were treated by transection of the arch at the level of the innominate artery along the greater curvature and the proximal descending aorta along the lesser curvature to permit a beveled replacement of the arch with a single distal anastomosis (Fig 2). The treatment in those with a concomitant descending or thoracoabdominal aortic aneurysm consisted of the elephant trunk technique and staged repair of the distal aneurysm [10]. The treatment for an ascending aortic abnormality and valvular disease consisted of the technique previously described [11–13].

View larger version (122K): [in this window] [in a new window]   Fig 1. . (A) Preoperative drawing and aortogram of a patient who had undergone prior descending and abdominal aortic aneurysm repair, and who now has an ascending and arch aneurysm secondary to dissection and a thoracoabdominal aortic aneurysm secondary to degenerative disease. (B) Results after graft replacement of the ascending and transverse aortic arch and coronary artery bypass grafting. (C) Results after thoracoabdominal aortic aneurysm repair.

View larger version (63K): [in this window] [in a new window]   Fig 2. . (A) Preoperative aortogram and drawing of a patient with Marfan's syndrome, annuloaortic ectasia, and a chronic type II aortic dissection with an aneurysm of the ascending aorta and aortic arch. (B) Computed tomogram and drawing of same patient showing a massive ascending aortic aneurysm. (C) Arteriogram and drawing showing results in this patient after composite valve graft replacement (Cabrol technique) with hemiarch repair.

View larger version (99K): [in this window] [in a new window]   Fig 3. . (A) Preoperative drawing and aortogram of a patient who had undergone prior aortic valve and ascending aorta replacement who is now presenting with dissection and aneurysm of the distal ascending aorta, innominate artery, and transverse arch. (B) Results of arch replacement.

For the patients who did not have dissection (group C), graft replacement alone was performed in 39 patients, graft replacement and valve resuspension in 1 patient, graft replacement and separate aortic valve replacement in 43, composite valve graft replacement in 7, the elephant trunk procedure in 9, the elephant trunk procedure and aortic valve replacement in 5, and patch graft repair in 6 patients.

In addition to the aortic graft replacement and treatment of the aortic valve abnormality, the need for concomitant procedures was common. Seventy-six were performed in all, and the most common was coronary artery bypass grafting, performed in 63 patients (27.75%) (Fig 4; Table 3). The descending thoracic aorta was replaced in 10 patients, and 2 required tricuspid valve repair.

View larger version (82K): [in this window] [in a new window]   Fig 4. . (A) Preoperative drawing and aortogram of a patient with an aneurysm of the ascending aorta, arch, and proximal descending aorta, as well as coronary artery disease. (B) Results of graft replacement of the arch.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
The in-hospital mortality for the entire series of 227 patients was 6.17%, with 14 deaths: four in group A, three in group B, and seven in group C, for individual in-hospital mortality rates of 8.33%, 4.35%, and 6.36%, respectively. Although the mortality rate was higher for the group A patients than it was for the patients in either groups B or C, the difference was not statistically significant (p > 0.1), nor was the difference in the mortality rate between groups B and C statistically significant (p > 0.1). The causes of the in-house deaths in Group A were stroke and cardiac failure; cardiac failure was the cause in group B; and multiple-organ failure, cardiac failure, and respiratory distress syndrome were the causes in group C (Table 4).

View larger version (12K): [in this window] [in a new window]   Fig 5. . Kaplan-Meier curve showing long-term survival for the entire group of 227 patients.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Surgical repair of abnormalities of the aortic arch has been and will be for the foreseeable future a formidable undertaking for both the patient and the surgeon. Regardless, during recent decades substantial strides have been made toward reducing the operative mortality and the perioperative morbidity associated with these procedures [14–17].

Neurologic injury (ie, stroke) is the most feared complication resulting from repair of transverse aortic arch aneurysms. The low stroke rate in this series-with stroke occurring in a total of 7 patients (3.1%), in 2 with acute dissection, in 1 with chronic dissection, and in 4 with fusiform aneurysms-substantiates our use of electroencepholographic monitoring and cooling until the recording is isoelectric. This result compares favorably with that cited for Svensson and associates' [6] larger series of 656 patients, of whom 44 patients (7%) suffered transient or permanent stroke. Circulatory arrest, which allows for a quiet, bloodless operative field unencumbered by clamps and eliminates the need for brachiocephalic vessel dissection, has constituted the single most important advance in the treatment of aortic arch aneurysms. The safe period of circulatory arrest for any given core temperature has yet to be firmly established, and is a subject of considerable debate. Svensson and colleagues found in their large series that the risk of postoperative stroke increased when the arrest period exceeded 40 minutes and the risk of death increased when the arrest period exceeded 65 minutes. The brief periods of circulatory arrest in this series of patients (mean, 28, 35, and 23 minutes in those with acute dissection, chronic dissection, and fusiform aneurysmal disease, respectively) no doubt contributed substantially to effecting the overall results observed.

Adjunctive measures for safely prolonging the period of circulatory arrest continue to be evaluated. Retrograde cerebral perfusion via the superior vena caval cannula was employed in 111 patients in this series. There were no transient or permanent postoperative strokes in this group. The advantages of this technique include a cerebral cooling which is more homogeneous and maintained, a washing out of the metabolites that accumulate as the result of ischemia, and a back washing of potential emboli (both air and particulate matter); it also allows for the administration of nutritional substrates during the arrest period [18–20]. Additionally, it provides a potential route for the induction of ``brain-plegia.'' Potential problems posed by cerebral perfusion include increased cerebral edema, additional blood in the operative field, and venous hypertension. The results described here demonstrate the technique to be clinically safe; however, additional work will be required to establish its overall effectiveness.

The early (in-hospital) mortality rate was higher in those patients operated on for the repair of acute dissection (8.33%) than the rate in those with chronic dissection (4.35%) and fusiform aneurysm (6.36%), despite the fact that 48 of the 69 (69.57%) patients with chronic dissection had undergone previous aortic or cardiac procedures. This is attributed to the acute nature of the problem and the multisystem involvement in these patients. As a group, such patients are identified earlier and more frequently than they once were because of the echocardiography, computed tomography, and magnetic resonance imaging capabilities now available.

On the basis of our findings in this series of patients, we conclude that, as described here, the deep hypothermic arrest provided a period of circulatory arrest that was long enough to permit even complex reoperative procedures to be carried out safely. Retrograde cerebral perfusion is a safe adjunct to systemic deep hypothermia, although further laboratory and clinical studies will be needed to establish its clinical efficacy in the setting of arch replacement, particularly in patients requiring brief periods of arrest (20 minutes or less).

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Presented at the Thirtieth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 31-Feb 2, 1994.

Address reprint requests to Dr Coselli, 6535 Fannin, MS B405, Houston, TX 77030.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

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