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Ann Thorac Surg 1997;63:88-92
© 1997 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Aortic Arch Operation Using Selective Cerebral Perfusion for Nondissecting Thoracic Aneurysm

Niigata University School of Medicine, Niigata; Hokkaido University School of Medicine, Sapporo; Sapporo Medical University School of Medicine, Sapporo; Tohoku University School of Medicine, Sendai; Chiba University School of Medicine, Chiba; Keio University School of Medicine, Tokyo; Tokyo Women's Medical College, Tokyo; National Nagoya Hospital, Nagoya; Oosaka University Medical School, Suita; Oosaka Prefectural Hospital, Oosaka; and National Cardio-vascular Center, Suita, Japan

Accepted for publication July 15, 1996.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Background. Risks of increasing mortality and disability in aortic arch operations using the selective cerebral perfusion method for nondissecting aneurysm have not yet been determined. A multicenter, retrospective study was employed.

Methods. The subjects were 143 patients who were admitted to one of the nine cardiovascular centers between January 1988 and December 1993, including 15 with ruptured aneurysm. A graft replacement of the transverse aortic arch or distal arch was performed in 80 patients, extensive aortic reconstruction comprising simultaneous replacement of the ascending or descending thoracic aorta (or both) in 46, and patch repair of involved arch in 17. The mean postoperative follow-up period was 19 months.

Results. Hospital mortality was 36/143 patients (25.2%). Univariate analysis revealed that age of 70 years or more, ruptured aneurysm, and renal dysfunction affected hospital mortality. Neurologic deficits were noted in 15 patients (10.5%). Reoperation was performed in 13 patients for residual distal aneurysm or false aneurysm. Late death occurred in 10 patients and were due to vascular complications in 6. Multivariate analysis confirmed that aneurysmal rupture and renal dysfunction were independent predictors for vascular death including hospital mortality.

Conclusions. The present study confirmed that age, aneurysmal rupture, and renal dysfunction were significant predictors for mortality and disability in the aortic arch operation using selective cerebral perfusion for nondissecting thoracic aneurysm.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
For editorial comment, see page 9.

Several communications dealing with aortic arch operations using the selective cerebral perfusion method demonstrated early good outcomes and the usefulness of selective cerebral perfusion in aortic arch operations [1–4]. However, these reports included predominantly acute and chronic Stanford type A aortic dissection and a small number of patients with atherosclerotic thoracic aneurysm. On the other hand, some authors have continued to stress the usefulness and

For editorial comment, see page 9.

excellent outcomes of thoracic aneurysmal operations using hypothermic circulatory arrest [5, 6], and the retrograde cerebral perfusion method [7, 8], and a more simplified technique [9]. Our recent experiences implied that aortic arch operations still have a potential risk at neurologic injury and risk for death despite the increasing probability of survival using various supporting adjuncts. We therefore reviewed our series of aortic arch operations using selective cerebral perfusion on atherosclerotic and degenerative thoracic aortic aneurysms without dissection and investigated the risks of increasing mortality and permanent functional disabilities.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The subjects were 143 patients (112 men and 31 women) who received an aortic arch operation for nondissecting thoracic aneurysm at one of nine Japanese cardiovascular centers between January 1988 and December 1993. Those who had a concomitant aortic dissection and those receiving an operation using hypothermic circulatory arrest or retrograde cerebral perfusion were not included in the present study. The age at operation ranged from 37 to 81 years, with a mean ± standard deviation of 67 ± 8 years. Only 3 patients had concomitant annuloaortic ectasia, and none had Marfan's stigmata.

All cases were fusiform or saccular aneurysm due to an atherosclerotic or degenerative cause. Maximal aneurysmal diameter measured on computed tomograms or echoaortograms at admission ranged from 37 to 120 mm; the mean diameter was 64, 61, and 53 mm for the entire group, distal arch aneurysms, and saccular-type aneurysms, respectively. The following potential risks were noted: hypertension in 108 (75.5%), diabetes mellitus in 13 (9.1%), hyperlipidemia in 20 (14%), ischemic heart disease in 33 (23.1%), cerebrovascular disorder in 17 (11.9%), renal dysfunction in 20 (14%), and respiratory dysfunction in 19 (13.3%). Coronary angiography, stress myocardial scintigraphy, and brain computed tomography with or without selective cerebral angiography were performed in most cases with nonruptured aneurysm. Ruptured aneurysm was confirmed when massive hematoma around the involved aorta was revealed at operation. Aneurysmal rupture was observed in 15 patients, and 9 of them received an urgent operation. Of 128 patients with nonruptured aneurysm, 3 with distal arch aneurysm needed an urgent operation due to severe aneurysmal symptoms.

Surgical Procedures
Standard cardiopulmonary bypass was performed with a roller pump and membrane oxygenator together with peripheral arterial cannulation via the right or left external iliac artery. Moderate to deep hypothermia was established by cardiopulmonary bypass. During anoxic arrest of the heart or discontinuation of proximal aortic perfusion, myocardial protection was performed by antegrade with or without retrograde perfusion of crystalloid or blood cardioplegic solution.

The cannulating procedure for carotid and subclavian arteries and the number of pumps for selective cerebral perfusion varied according to the year of operation and institution [2, 3]. The cerebral perfusion pressure was maintained between 40 and 60 mm Hg, and nasopharyngeal temperature was less than 25°C during the aortic arch reconstruction. In part of the series and in some institutions, pharmacologic protection of the brain was performed [2]. En-bloc or separate anastomoses to the carotid and subclavian arteries were applied using a pretreated low-porosity Dacron graft or gelatin-impregnated graft [2, 3]. In patients with moderate or severe aortic valve regurgitation, the aortic valve was replaced or a Bentall procedure [10] was performed for coexisting annuloaortic ectasia. The number of patients and mortality according to type of aortic reconstruction and simultaneous procedures for coronary and cardiac valve lesions are listed in Table 1.

Death from any cause during the hospitalization was designated "hospital mortality." We classified late death into the following categories: death related to aortic aneurysm including aneurysmal rupture, death caused by vascular complications including myocardial infarction and cerebrovascular stroke, and death due to miscellaneous causes; and the former two were designated "vascular death." Details of transient and permanent neurologic deficit before and after the operation were also noted. All reoperations performed for residual distal aneurysm or postoperative complications, whether or not they had been scheduled at the time of the first operation, were registered.

Data were analyzed using the SPSS medical package (SPSS Inc). In the present study, hospital mortality, hospital mortality including functional disability, and vascular death including hospital mortality were used as end points for group comparison. Continuous variables were expressed as mean ± one standard deviation. Risk factors for hospital death and for hospital mortality including functional disability were tested for significance by ² test. The Kaplan-Meier method was used for nonparametric estimation of survival differences between subgroups. Probability of survival was expressed as an estimate ± one standard error of the estimate. Risks for vascular death including hospital mortality were identified by multivariate regression analysis. For all analyses, a p value of 0.05 or less was considered significant.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Hospital Mortality
Among 36 patients who died during the hospitalization (overall hospital mortality was 25.2%), 24 (16.8%) died within 30 days after the operation due to cardiac failure, brain injury, multiorgan failure, rupture of the residual distal aneurysm, or miscellaneous causes. The 30-day mortality was 6/15 (40%) and 18/128 (14.1%) for the ruptured and nonruptured aneurysm groups, respectively. In-hospital mortality was 9/47 (19.1%) and 7/33 (21.2%) for transverse arch and distal arch reconstruction, respectively, whereas it was 14/46 (30.4%) for extensive reconstruction of the ascending or descending thoracic aorta together with the aortic arch (see Table 1). Factors tested for a significant relation to hospital mortality are listed in Table 2. Univariate analysis revealed that age of 70 years or more, ruptured aneurysm, urgent operation, and renal dysfunction affected the hospital mortality (p < 0.01 except the last one, p < 0.05). In 89 patients at an age of 69 years or less, hospital mortality was 1/6 (16.6%) and 14/83 (16.8%) for those with ruptured and nonruptured aneurysm, respectively. In 54 patients at an age of 70 or more, however, it was 8/9 (88.9%) and 13/45 (28.9%) for ruptured and nonruptured aneurysm cases, respectively (p = 0.0013). No significant difference was noticed in the incidence of aneurysmal rupture and in the hospital mortality among the nine centers.

Reoperation
Among 143 patients, 10 received a reoperation for residual distal aneurysm (it was scheduled and performed between 2 days and 19 months after the first operation). Distal false aneurysm repair was needed in another 3 patients between 42 days and 17 months after the first operation. All but 2 patients survived reoperation.

Late Outcome
Late death occurred in 10 patients: six late deaths were due to a vascular complication between 4 and 40 months after the operation, and the remaining four were due to rupture of distal aneurysm, pneumonia, a malignant disease, and an unknown cause. Significant differences were noticed in the probability of survival according to age (Fig 1), presence or absence of aneurysmal rupture (Fig 2), and presence or absence of renal dysfunction (Fig 3). Multivariate regression analysis revealed that aneurysmal rupture (p = 0.0096) and renal dysfunction (p = 0.0257) were independent predictors of vascular death including hospital mortality; however, age was not predictive.

View larger version (20K): [in this window] [in a new window]   Fig 1. . Probability of survival according to age. A significant difference was noticed between patients aged 70 years or more and those aged 69 years or less.

View larger version (19K): [in this window] [in a new window]   Fig 2. . Probability of survival according to presence or absence of aneurysmal rupture. A significant difference was noticed between patients with and without aneurysmal rupture.

View larger version (21K): [in this window] [in a new window]   Fig 3. . Probability of survival in patients with renal dysfunction. A higher survival rate was seen in patients without renal dysfunction than in those with renal dysfunction.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

Another important focus in aortic arch operations has been how to prevent brain injury. Use of circulatory supporting methods may lead to better neurologic outcomes. The incidence of postoperative neurologic complications was reported to be 3.6% to 11% in hypothermic circulatory arrest [5, 6, 12], 0% to 11.1% in selective cerebral perfusion [2–4], and 8.3% in retrograde cerebral perfusion [8, 10]. Coselli and colleagues [5] recently reported that postoperative stroke occurred in 4 (3.6%) of 110 patients with nondissecting aortic arch aneurysm who were operated on with deep hypothermic circulatory arrest, and 0% in cases with combined retrograde perfusion and circulatory arrest. However, their series included no patients with ruptured aneurysm and only 1 with preoperative stroke. On the other hand, Ergin and associates [12] reported that temporary and permanent neurologic deficits occurred in 36 (19.3%) and 18 (9.6%) of 187 patients who survived the initial postoperative period after an aortic arch operation using hypothermic circulatory arrest. Age, preoperative stroke, and aneurysmal rupture were pointed out as predictors of neurologic injury. Tabayashi and associates [2] reported that cerebrovascular accident occurred in 4 (11.1%) of 36 patients with atherosclerotic arch aneurysm operated on using selective cerebral perfusion. The cause of neurologic deficit was supposed to be embolization or abnormal distribution of cerebral blood flow [2]. In the present series, neurologic disability occurred primarily in patients with ruptured aneurysm (4/15, 27%) and in elderly patients (9/54, 16.7%); however, further research will be needed to determine the cause of neurologic disturbances in the selective cerebral perfusion method.

Details of long-term outcomes after aortic arch operation have been described in a few articles [2, 3, 6, 14]. According to the report by Svensson and associates [6], among 104 late deaths, 31 were due to cardiac causes, 19 pulmonary, 18 septic, 16 cerebrovascular, and 14 aneurysmal rupture. In the present series, dominant causes of late death were vascular complications including myocardial infarction and stroke, which was similar to Svensson and associates' results.

In conclusion, the present study confirmed that age, aneurysmal rupture, and renal dysfunction were significant predictors for mortality and neurologic disability in aortic arch operations using selective cerebral perfusion for nondissecting thoracic aneurysm.

	Acknowledgments

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
This work was supported by a Research Grant for Cardiovascular Diseases 4C-3 from the Japanese Ministry of Health and Welfare.

We thank Dr Hisanaga Moro and Dr Masa-aki Sugawara (Second Department of Surgery, Niigata University School of Medicine, Niigata, Japan) for help in the data collection and statistical analysis.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Address reprint requests to Dr Hayashi, Second Department of Surgery, Niigata University School of Medicine, 1-757 Asahimachidohri, Niigata city, 951, Japan.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

1. Bachet J, Teodori G, Goudot B, et al. Replacement of the transverse aortic arch during emergency operations for type A acute aortic dissection. J Thorac Cardiovasc Surg 1988;96:878–86.[Abstract]
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