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Ann Thorac Surg 1999;67:72-78
© 1999 The Society of Thoracic Surgeons

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Original Articles

Predictive factors for mortality and cerebral complications in arteriosclerotic aneurysm of the aortic arch

^a Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan

Accepted for publication June 11, 1998.

Address reprint requests to Dr Okita, Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka, Japan 565
e-mail: yokita{at}ncvc.hsp.go.jp

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. The incidence of cerebral complications is high in patients with aortic arch aneurysm.

Methods. Between December 1977 and December 1995, 246 patients with arteriosclerotic arch aneurysm underwent operation. Thirty-nine patients had an aneurysm involving the entire arch, 193 had only distal arch aneurysm, and 14 had arch aneurysm extending to the descending aorta. Eighty-seven patients underwent replacement of the total arch, 85 had replacement of only the distal arch, 14 had simultaneous replacement of the descending aorta, 45 had patch repair, and 15 had thromboexclusion. Selective cerebral perfusion was used in 112 patients and partial bypass in 58 in the earlier series of patients, but deep hypothermic circulatory arrest with retrograde cerebral perfusion technique was exclusively applied in the most recent 76 patients.

Results. There were 50 (20%) early deaths and 37 (19%) late deaths. Postoperative stroke was found in 26 (11%) patients of which 13 (50%) died. Mutual predictive factors for postoperative mortality and stroke were earlier series, preoperative chronic renal failure, ruptured aneurysm, arch clamping during procedure, and using partial cardiopulmonary bypass. Among 129 patients operated on during the most recent 5 years, early mortality and incidence of stroke decreased to 14.7% and 6.9%, respectively.

Conclusions. Results of operations for arteriosclerotic aneurysms of the transverse aortic arch in 246 patients during a period of 17 years have been improving but are still not satisfactory.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Although recent progress has been achieved in surgical procedures for thoracic aortic aneurysm, the incidence of complications involving the central nervous system is still high, especially in patients with aortic arch aneurysm. The present report deals with our surgical experience of 246 patients with arteriosclerotic aneurysm of the transverse aortic arch. Strategies for preventing postoperative stroke are also discussed.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
From December 1977 to December 1995, 246 patients with arteriosclerotic aneurysm of the transverse aortic arch underwent operation at the National Cardiovascular Center in Osaka, Japan. Age at operation ranged from 44 to 88 years (mean, 66.5 ± 9.2 years). Thirty-nine patients had an aneurysm involving the entire aortic arch, 193 had only distal arch aneurysm, and 14 had arch aneurysm extending to the descending aorta. Fourteen patients had had previous aortic operation, including arch replacement in 6 patients, extraanatomic bypass for aortic aneurysm in 2, repair of aortic dissection in 2, replacement of the descending aorta in 1, Bentall operation in 1, wrapping of the ascending aorta in 1, and replacement of the thoracoabdominal aorta in 1. Thirty-one patients underwent emergency operation because of ruptured aneurysm or impending rupture. Preoperative complications included severe chronic obstructive lung disease in 9, coronary artery disease in 22, valvular heart disease in 9, chronic renal failure in 13, stroke or cerebral transient ischemic attack in 26, abdominal aortic aneurysm in 44, and peripheral vascular obstruction in 5. Patients with aortic dissection involving the aortic arch were excluded from this study. Twenty patients had coexistent aortic dissection that involved only the ascending aorta, DeBakey type II (2 patients), and the descending aorta, type III (10 patients).

Midsternal approach was used in 152 patients, left thoracotomy in 83, and combined in 11. Eighty-seven patients underwent total replacement of the aortic arch, 85 had replacement only of the distal arch, 14 had simultaneous replacement of the distal arch and descending aorta, 45 had patch aortoplasty, and 15 had extraanatomic bypass. Clamping of the arch for the purpose of anastomosis was applied in 61 patients.

Concomitant cardiac procedures were performed in 18 patients. Bentall operation in 8, aortocoronary bypass in 8, replacement of the abdominal aortic aneurysm in 2, and carotid endarterectomy in 1. Arterial cannulation of the femoral artery was done in 190 patients and of the ascending aorta in 56. For circulatory support, selective cerebral perfusion (112 patients), left heart bypass (43), and femoro–femoral bypass (15) was used in the earlier series, but deep hypothermic circulatory arrest with retrograde cerebral perfusion technique was exclusively applied in the most recent 76 patients from 1993 on. Patients who had arch operations with temporary bypasses from the ascending aorta to arch vessels or to the descending aorta without cardiopulmonary bypass were included in the left heart bypass group.

Our principle in selective cerebral perfusion [1] included cannulating the right axillary artery, left common carotid artery, and femoral artery. The left axillary artery was also cannulated in patients with a dominant left vertebral artery. As soon as cardiopulmonary bypass was begun, selective cerebral perfusion was started to avoid cerebral emboli from the femoral artery. Cerebral perfusion flow was kept at 300 to 500 mL/min, and the mean pressure in the superficial temporal artery ranged from 40 to 60 mm Hg with a nasopharyngeal temperature of 20° to 25°C. Open distal anastomosis was frequently performed, and distal occlusive balloon was sometimes applied. Arch vessels were anastomosed finally.

In 76 patients, deep hypothermic circulatory arrest with retrograde cerebral perfusion was exclusively applied. Through a median sternotomy, retrograde cerebral perfusion was implemented using the bypass connecting the arterial and venous lines of the extracorporeal circuit to reverse the flow into the superior vena caval cannula after the initiation of total circulatory arrest at a nasopharyngeal temperature of less than 18°C. Continuous retrograde cerebral perfusion flow was regulated to maintain an internal jugular vein pressure of 15 to 20 mm Hg. Blood draining into the aortic arch was aspirated [2]. Through a left thoracotomy, cardiopulmonary bypass was initiated with left atrial venting. The descending aorta was clamped proximal to the arterial cannulation and the distal aortic arch aneurysm was incised after cooling to 18°C. Retrograde cerebral perfusion was initiated at a central venous pressure of 15 to 18 mm Hg. Proximal anastomosis of a graft with the distal aortic arch was performed during the retrograde cerebral perfusion [3]. Topical external cooling of the brain by ice jacket is a prerequisite to maintaining cerebral hypothermia.

Since January 1991 (recent group), our main principle for avoiding atheroembolism focused on not clamping the arch and performing anastomosis in an open manner [4]. We routinely used epiaortic echocardiography for searching an appropriate site for arterial cannulation and aortic clamping. The other strategies for preventing atheroembolism, such as antegrade pump flow, were applied as soon as possible. In patients with severe atheromatous descending aorta, abdominal aortic aneurysm, and occlusive disease in iliac arteries, retrograde arterial perfusion from the femoral cannula is strictly avoided. If femoral cannulation is unavoidable, antegrade cardiac output is maintained during at least the first 10 minutes of bypass to prevent debris from the descending or abdominal aorta reaching the brain. An additional arterial return line is always inserted for pump rewarming by antegrade flow through a side branch of the arch graft. None of the existing diagnostic tools used to monitor cerebral metabolism during arch procedures, such as electroencephalogram, near infrared oximetry, and monitoring of oxygen saturation of the jugular vein, can predict or prevent the occurrence of cerebral embolization.

Thirty-five perioperative variables that were considered to affect postoperative mortality and morbidity (Table 1) were entered for analysis by multivariate logistic regression. Early and late death were defined as a death within hospital or a death after discharge. Postoperative stroke was defined as newly developed neurologic deficit, new lesions diagnosed by computed tomography, or unresponsiveness 3 days after operation. Postoperative complications were not taken into account as variables in analyzing postoperative brain damage (Table 2). Statistical analysis was done by ² test and multivariate logistic regression analysis, and Cox regression analysis was performed using all variables to determine the relative importance of individual values. The estimated relative risk was defined as the likelihood of an event in the presence of a variable compared with its likelihood in the absence of that variable. Postoperative survival was analyzed using the Kaplan-Meier method. Statistical significance was assumed at a p level of less than 0.05.

	Results

Top Abstract Introduction Patients and methods Results Comment References

View larger version (10K): [in this window] [in a new window]   Fig 1. Postoperative long-term survival excluding in-hospital death.

View larger version (14K): [in this window] [in a new window]   Fig 2. Postoperative long-term survival of patients with or without postoperative stroke (in-hospital deaths were excluded). (Circle = patients without postoperative stroke; square = patients with postoperative stroke.)

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Although brain complication remains a rare event after cardiac operations [5], its occurrence has dominated postoperative mortality and morbidity in thoracic aortic operations because of the growing population of elderly patients undergoing aortic operations [6–10].

Multiple mechanisms of stroke are speculated as causes, including hypoperfusion or hyperperfusion during or after operation, embolization from a variety of sources, including the extracorporeal circuit, left side of the heart, the aorta itself, iliac artery, or carotid bifurcation [5]. In spite of the recent advent of diagnostic modalities, difficulties are often encountered when it comes to determining which of these mechanisms are implicated in a particular patient [11]. However, a recent report indicated that the majority of permanent neurologic injuries were caused by strokes resulting from embolic phenomena and were not directly related to the method of cerebral protection used [10]. Blauth and associates [12] demonstrated a direct correlation between age, severe arteriosclerosis of the ascending aorta, and atheroemboli. We also found that age was a significant risk factor for stroke in the univariate analysis.

In the present study, earlier experience was found to be significant for postoperative stroke. During the past 15 years, elucidation of the need to protect the cerebral circulation and development of new technology has led to greater improvement in brain protection in aortic arch operations. Although our result is not optimal, among 129 patients for the past 5 years, early mortality and incidence of stroke decreased to 14.7% and 6.9%, respectively. It is noteworthy that no stroke was demonstrated in 26 patients with preoperative cerebrovascular obstruction. This is corroborative evidence that the majority of postoperative stroke was caused by cerebral embolism and not hypoperfusion of the brain. Factors of chronic renal failure, peripheral arterial obstruction, and abdominal aortic aneurysm were likely to be associated with severe arteriosclerosis of the aortic arch; however, only chronic renal failure was found to be a significant risk factor for stroke. In patients with ruptured aneurysms, a deteriorated hemodynamic state could compromise the cerebral circulation, and in such a setting retrograde arterial perfusion from the femoral artery is likely to cause cerebral embolization with debris. Concomitant cardiac procedures, coexisting aortic dissection, and redo operations for aorta were not observed to be significant for stroke. Partial bypass perfusion technique and procedures including descending aorta or thromboexclusion were significant predictors for postoperative stroke, whereas extension of the aneurysm was not. Clamping the aortic arch for anastomosis, when open anastomosis technique was not used, was demonstrated to be the strongest risk factor for stroke. Risk of cerebral embolism because of dislodging loose atheromatous plaque or mural thrombi steeply increases by clamping the involved portion of the aorta. The technique of partial bypass for arch repair or thromboexclusion required arch clamping. Cannulation in the ascending aorta was also likely to dislodge mural thrombi or debris when the ascending aorta was involved in the aneurysm or arteriosclerotic changes. Although variables including duration of selective cerebral perfusion greater than 120 minutes and duration of circulatory arrest and retrograde cerebral perfusion more than 60 minutes were found to be insignificant, more analysis of a larger series of patients are required to conclude this with greater certainty.

Svensson and associates [13] evaluated 656 patients after aortic operations using deep hypothermia with circulatory arrest by logistic regression analysis. In their 380 patients with arteriosclerotic arch aneurysm, there were 7.6% early mortality and 6.1% strokes [13]. Borst and associates [8] reported that 10% early mortality and 3 cerebral deaths occurred in 58 arteriosclerotic aneurysms operated on using deep hypothermic circulatory arrest since 1980. A more recent series by Coselli and associates [14] using deep hypothermic circulatory arrest with retrograde cerebral perfusion demonstrated that early mortality was 6.3%, incidence of stroke was 4%, and late mortality was 6.8% among 110 patients with arteriosclerotic aneurysm. Ergin and associates [7] showed that temporary neurologic dysfunction occurred in 19% of patients and permanent neurologic deficits were seen in 9% of patients who underwent arch operations using deep hypothermic circulatory arrest. Strokes occurred in 11% of their patients but were associated with permanent deficits in 6.9%. Age and the duration of the arrest period were the only determinants of the occurrence of postoperative neurologic dysfunction. A close correlation between duration of arrest and cerebral injury, especially the rapid rise in the incidence of temporary dysfunction beyond 50 minutes of arrest time, was demonstrated.

The retrograde cerebral perfusion technique [2, 3] added a new idea that can augment cerebral protection during circulatory arrest [15], but the actual mechanism by which retrograde cerebral perfusion provides cerebral protection is still obscure. Criticism stating uneven or under distribution of the retrograde cerebral perfusion to the brain were raised [16, 17]. On the other hand, Pagano and associates [18] demonstrated that radioisotope tracers accumulated throughout the white and gray matter of the brain during retrograde cerebral perfusion in human beings. In our experience, no correlation was found between duration of circulatory arrest with retrograde cerebral perfusion and incidence of postoperative stroke [19]. Besides the main argument for this method, it is clearly effective in maintaining cerebral hypothermia, providing continuous cooling of the whole head, preventing debris and air from reaching the terminal vessels of the brain [20], and washing out some metabolites to delay the onset of acidosis in the ischemic brain.

Using selective cerebral perfusion [21] Bachet and associates [22] reported that the operative mortality was 13%, and that 3 serious neurologic complications were found among 54 patients Although their study was small in patient number, Kazui and associates [23] also demonstrated excellent surgical results of neurologic sequelae and 3 early deaths in 32 patients with arch aneurysm. Our experience of selective cerebral perfusion in patients with arteriosclerotic aortic arch aneurysm demonstrated that early mortality was 23% and incidence of postoperative stroke was 11%. Tabayashi and associates [24] reported incidences of 11% early mortality and 19% stroke after aortic arch repair using selective cerebral perfusion in patients with arteriosclerotic aneurysms. The most important advantage of the method is that it provides the luxury of time, allowing for a deliberate repair. However, there are some shortcomings in costs of this luxury. To perfuse the brain evenly, at least two cannulas are required. These cannulations may increase the risk of embolization from aortic manipulation, as well as from cannula-related accidents and disarrangement. Moreover, in an emergency case without known cerebral circulation, cannulation into all neck vessels is necessary to keep the brain circulation sound. Although there was no statistically significant difference regarding incidence of postoperative brain damage between the two strategies of brain protection, presently we exclusively use deep hypothermia with retrograde cerebral perfusion technique because of its simplicity.

Intraoperative echocardiography provides precise mapping of the nature of the aortic wall, such as calcification, arteriosclerotic ulceration or plaque, and mural thrombi in aortic aneurysm, and of deceptive anatomic relationship between the true and false lumen of the aortic dissection [25]. Wareing and associates [26] modified their technique for cardiac procedures according to intraoperative echocardiography, including alterations in the site of aortic cannulation, aortic clamping, attachment of the vein grafts, and cannulation for infusion of cardioplegia, or they even performed hypothermic circulatory arrest without clamping the aorta. Among modern diagnostic modalities, only transesophageal echocardiography and direct epiaortic echocardiography are able to detect mild to moderate atheromatous thickening of the intima and media of the aortic wall, especially at the anastomosis site, which may cause cerebral embolization of debris from the anastomosis suture line. Neither preoperative angiography nor computed tomographic scan can achieve such a precise mapping of the aortic wall.

Our experience with operations for arteriosclerotic aneurysms of the transverse aortic arch in 246 patients during a period of 17 years and struggling efforts for reducing postoperative brain complication were presented. Early and late mortality was 20% and 19%, respectively. Incidence of stroke was 11%. Mutual predictive factors for postoperative mortality and stroke were earlier series, preoperative chronic renal failure, ruptured aneurysm, arch clamping during procedure, and using partial cardiopulmonary bypass. Although surgical results for arteriosclerotic arch aneurysms have been improving during this period, there are still problems to be solved.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Ando M., Nakajima N., Adachi S., Nakaya M., Kawashima Y. Simultaneous graft replacement of the ascending aorta and total aortic arch for type A aortic dissection. Ann Thorac Surg 1994;57:669-676.[Abstract]
2. Ueda Y., Miki S., Kusuhara K., Okita Y., Tahata T., Yamanaka K. Surgical treatment of aneurysm or dissection involving the ascending aorta and aortic arch, utilizing circulatory arrest and retrograde cerebral perfusion. J Cardiovasc Surg 1990;31:553-558.[Medline]
3. Takamoto S., Matsuda T., Harada M., Miyata S., Shimamura Y. Simple hypothermic retrograde cerebral perfusion during aortic arch replacement. J Thorac Cardiovasc Surg 1992;104:1106-1109.[Abstract]
4. Livesay J.J., Cooley D.A., Duncan J.M., Ott D.A., Walker W.E., Reul G.J. Open anastomosis: improved results in the treatment of aneurysm of the aortic arch. Circulation 1982;66(Suppl I):I-249-I-56.
5. Taylor K. Brain damage during open-heart surgery. Thorax 1982;37:873-876.[Free Full Text]
6. Crawford E.S., Svensson L.G., Coselli J.S., Safi H.J., Hess K.R. Surgical treatment of aneurysm and/or dissection of the ascending aorta, and transverse aortic arch: factors influencing survival in 717 patients. J Thorac Cardiovasc Surg 1989;98:659-674.[Abstract]
7. Ergin M.A., Galla J.D., Lansman S.L., Quintana C., Bodian C., Griepp R.B. Hypothermic circulatory arrest in operations on the thoracic aorta: determinants of operative mortality and neurologic outcome. J Thorac Cardiovasc Surg 1994;107:788-799.[Abstract/Free Full Text]
8. Borst H.G., Bühner B., Jurmann M. Tactics and techniques of aortic arch replacement. J Cardiac Surg 1994;9:538-547.[Medline]
9. Miller D.C., Oyer P.E., Reitz B.A., Shumway N.E. Operative treatment of aortic dissections. J Thorac Cardiovasc Surg 1979;78:365-382.[Abstract]
10. Okita Y., Takamoto S., Ando M., et al. Predictive factors for postoperative cerebral complications in patients with thoracic aortic aneurysm. Eur J Cardiothorac Surg 1996;10:826-832.[Abstract]
11. Aberg T., Ronquist G., Tyden H., et al. Adverse effects on the brain in cardiac operation as assessed by biochemical psychometric, and radiologic methods. J Thorac Cardiovasc Surg 1984;87:99-105.[Abstract]
12. Blauth C.I., Cosgrove D.M., Webb B.W., et al. Atheroembolism from the ascending aorta. J Thorac Cardiovasc Surg 1992;103:1104-1112.[Abstract]
13. Svensson L.G., Crawford E.S., Hess K.R., et al. Deep hypothermia with circulatory arrest: determinants of stroke and early mortality in 656 patients. J Thorac Cardiovasc Surg 1993;106:19-31.[Abstract]
14. Coselli J., Büket S., Djukanovic B. Aortic arch operation: current treatment and results. Ann Thorac Surg 1995;59:19-27.[Abstract/Free Full Text]
15. Griepp R.B., Stinson E.B., Hollingsworth J.F., Buehler D. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg 1975;70:1051-1063.[Abstract]
16. Filgueiras C.L., Winsborrw B., Ye J., et al. A ³¹P-magnetic resonance study of antegrade and retrograde cerebral perfusion during aortic arch surgery in pigs. J Thorac Cardiovasc Surg 1995;110:55-62.[Abstract/Free Full Text]
17. De Brux J.L., Subayi J.B., Pegis J.D., Pillet J. Retrograde cerebral perfusion: anatomic study of the distribution of blood to the brain. Ann Thorac Surg 1995;60:1294-1298.[Abstract/Free Full Text]
18. Pagano D., Boivin C.M., Faroqu M.H., Bosner R.S. Retrograde perfusion through the superior vena cava perfuses the brain in human beings. J Thorac Cardiovasc Surg 1996;111:270-272.[Free Full Text]
19. Okita Y., Takamoto S., Ando M., Morota T., Matsukawa R., Kawashima Y. Mortality and cerebral outcome in patients who underwent aortic arch operations using deep hypothermic circulatory arrest with retrograde cerebral perfusion: no relation of early death, stroke, and delirium to the duration of circulatory arrest. J Thorac Cardiovasc Surg 1998;115:129-138.[Abstract/Free Full Text]
20. Mills N.L., Ochsner J.L. Massive air embolism during cardiopulmonary bypass: causes, prevention, and management. J Thorac Cardiovasc Surg 1980;80:708-717.[Abstract]
21. Frist W.H., Baldwin J.C., Starnes V.A., et al. A reconsideration of cerebral perfusion in aortic arch replacement. Ann Thorac Surg 1986;42:273-281.[Abstract]
22. Bachet J., Guilmet D., Goudot B., et al. Cold cerebroplegia: a new technique of cerebral protection during operations on the transverse aortic arch. J Thorac Cardiovasc Surg 1991;102:85-94.[Abstract]
23. Kazui T., Inoue N., Yamada O., Komatsu S. Selective cerebral perfusion during operation for aneurysms of the aortic arch: a reassessment. Ann Thorac Surg 1992;53:109-114.[Abstract]
24. Tabayashi K., Ohmi M., Togo T., et al. Aortic arch aneurysm repair using selective cerebral perfusion. Ann Thorac Surg 1994;57:1305-1310.[Abstract]
25. Takamoto S., Kyo S., Yokote Y., Omoto R. Decision-making by transcutaneous and transesophageal Doppler color flow mapping followed by intraoperative direct scanning in dissecting aortic aneurysm. In: Minami K., Korfer R., Wada J., eds. Cardiothoracic surgery. Amsterdam: Elsevier Science, 1992:103-114.
26. Wareing T.A., Davila-Roman V.G., Barzilai B., Murphy S.F., Kouchoukos N.T. Management of the severely atherosclerotic ascending aorta during cardiac operations: a strategy for detection and treatment. J Thorac Cardiovasc Surg 1992;103:453-462.[Abstract]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Yutaka Okita Kenji Minatoya Soichiro Kitamura Shinichi Takamoto Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Okita, Y. Articles by Nakajima, N. Search for Related Content PubMed PubMed Citation Articles by Okita, Y. Articles by Nakajima, N.