Eur J Cardiothorac Surg 2001;19:25-29
© 2001 Elsevier Science NL
Aortic arch repairs through three different approaches
Hitoshi Oginoa,
Yuichi Uedab,
Takaaki Sugitac,
Katsuhiko Matsuyamac,
Keiji Matsubayashic,
Takuya Nomotoc,
Tatsuya Yoshiokac
a Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
b Department of Thoracic Surgery, Nagoya University, School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan
c Department of Cardiovascular Surgery, Tenri Hospital, 200 Mishima-cho, Tenri, Nara 632-8552, Japan
Received 22 May 2000;
received in revised form 18 September 2000;
accepted 19 October 2000.
Corresponding author. Tel.: +81-6-6833-5012; fax: +81-6-6872-7486
e-mail: hogino{at}hsp.ncvc.go.jp
 |
Abstract
|
|---|
Objectives: The outcome of aortic arch repairs by means of three different approaches between 1990 and January 2000 was reviewed. Methods: In total 39 patients aged 71.5±6.2 years were operated on. The three different surgical approaches depended on the anatomical positions of the aneurysms and on their proximal or distal extension; a median approach was employed in 23 patients, whereas a left postero-lateral approach was used in eight patients. More recently, in eight cases a left antero-lateral approach was applied. All patients underwent open aortic anastomosis without any clamp on or around the aortic arch. During the procedure, the brain was protected by a combination of profound hypothermic circulatory arrest and several techniques of retrograde cerebral perfusion. Results: Permanent cerebral dysfunction occurred in four patients: two in the median approach and two in the left postero-lateral approach. There were two hospital deaths (5.3%) and six late deaths, all of which belonged either to the median group or to the postero-lateral group. The antero-lateral approach did not produce any cerebral dysfunction, early death, or late death. Conclusions: The outcome of aortic arch repairs using profound hypothermic circulatory arrest and variable techniques of retrograde cerebral perfusion, by means of three different approaches, was satisfactory. Of the three approaches, the antero-lateral approach can be employed easily, whether aneurysms extend proximally or distally.
Key Words: Aortic arch repair • Surgical approach • Hypothermic circulatory arrest • Retrograde cerebral perfusion • Open aortic anastomosis
|
1. Introduction
|
|---|
Although surgery for aortic aneurysms located on the arch or involving it has been standardized, there remain challenging aspects, especially regarding cerebral safety [1]. Surgical access to aneurysms, through either mid-sternal or left lateral thoracotomy, also remains controversial. Both approaches have some benefits and drawbacks including surgical view, cannulation site for cardiopulmonary bypass (CPB), extent of prosthetic graft replacement, brain and myocardial protection, and influence on respiratory function. Our previous strategy for surgical access to aortic arch aneurysms therefore mainly depended on the anatomical positions of aneurysms [2,3]. If they extended proximally, a median approach was preferred; for distal extension, a left postero-lateral approach was employed. Alternatively, since 1997 an antero-lateral approach combining the advantages of two conventional approaches has been employed with favorable results. In this article, the surgical outcome of these three different approaches, in conjunction with profound hypothermic circulatory arrest (HCA) and relevant manners of continuous retrograde cerebral perfusion (RCP), are reviewed to confirm an appropriate approach to the treatment of aneurysms.
|
2. Materials and methods
|
|---|
Between 1990 and January 2000, 39 patients underwent surgical repairs for atherosclerotic aortic aneurysms originating from the aortic arch, or involving a part of the aortic arch. Patients with dissecting aneurysms or thoracoabdominal aneurysms are excluded from this review. Initially, a median approach through a mid-sternal incision was mostly used with standard CPB. In more distally extensive cases, a postero-lateral approach via a left postero-lateral thoracotomy has been employed since 1994; the median approach was retained in proximally extensive cases. From 1997, an antero-lateral approach through a left antero-axillary thoracotomy [4–6] has been employed; the median approach was retained in proximally extensive cases. Overall, 23 patients aged 74.1±7.9 years, including five cases with a ruptured aneurysm, underwent the median approach (June 1990 to May 1998), eight patients aged 67.1±8.2 years underwent the postero-lateral approach (March 1994 to July 1997), and eight patients aged 68.4±6.7 years, including one case with a ruptured aneurysm, underwent the antero-lateral approach (June 1997 to January 2000).
At first, to reduce morbidity and mortality, CPB was established in several ways. Standard ascending aortic cannulation and bicaval venous drainage was routinely employed in the median approach, whereas in the postero-lateral approach a femorofemoral bypass circuit, with or without venous drainage from the main pulmonary artery, was established. In the antero-lateral approach, a desirable ‘central cannulation technique’, including arterial return into the ascending aorta and venous drainage from the vena cavae, the pulmonary artery, or the right atrium, was facilitated. Hazardous aortic cross-clamping on or around the aortic arch was avoided [7]. An open aortic anastomosis technique in conjunction with profound HCA [8] was indicated to prevent atheromatous emboli or aortic wall trauma and to enhance cerebral safety. For brain protection relevant techniques of RCP were used in conjunction with HCA at 18°C (Table 1). In the median approach, RCP via a cannula in the superior vena cava (SVC-RCP), a technique originated by Ueda [2,3] in our unit, was applied. In the postero-lateral approach, ‘active’ retrograde systemic venous perfusion (RSVP) via cannulae in the right atrium inserted into the femoral vein [9,10] was employed in four patients. In the further four patients ‘passive’ RCP was arranged by higher central venous pressure elevated by a low flow perfusion via the femoral artery (FA) and by temporary cross-clamping of the mid-descending thoracic aorta (passive RCP), a technique originated by Takamoto [10,11]. In the antero-lateral approach, the most desirable SVC-RCP was performed in four patients. In the other four patients with difficulty of SVC cannulation RSVP or passive RCP was used. In all cases, collagen-impregnated Hemashield woven Dacron grafts (Boston Scientific, USA) of size 20–26 mm were employed for replacement of aneurysms. Aortic repairs consisted of distal arch replacement in ten patients and total arch replacement with arch-vessel reconstruction in 13 patients through the median approach, distal arch to proximal descending aortic replacement in six patients and distal arch to entire descending aortic replacement in two patients through the postero-lateral approach, and distal arch to proximal descending aortic replacement in seven patients and distal arch to entire descending aortic replacement in one patient through the antero-lateral approach (Table 2). In the two lateral approaches, a blocking endotracheal tube was used to allow the left lung to collapse and aprotinin at a dose of 2 million units was routinely administered in the most recent ten patients to prevent pulmonary hemorrhage.
Distal arch replacement was defined as graft replacement of the distal part of the aortic arch without arch-vessel reconstruction. Total arch replacement was defined as graft replacement of the aortic arch with arch-vessel reconstruction. Concerning neurological morbidity, temporary neurological dysfunction was defined as the occurrence of postoperative confusion, agitation, and severe delirium without any localizing neurologic signs. Permanent neurological dysfunction was defined as the presence of focal (stroke) or global (coma) permanent neurologic deficits persisting at discharge from the hospital.
|
3. Results
|
|---|
The median duration of HCA in the two modalities of lateral approaches was relatively shorter than in the median approach (Table 3). This result was similar even if the comparison included ten patients with isolated distal arch replacement through the median approach and excluded the other 13 patients with total arch replacement. There was no difference between the three approaches in the duration of CPB and surgery and in the postoperative recovery including the duration until full awakening and until extubation, and the periods of ICU-stay and hospitalization (Table 3). All these approaches revealed favorable recovery of patients following surgery. Regarding postoperative neurological complications, no temporary neurological dysfunction occurred. However, four patients (10.5%) developed a permanent neurological dysfunction, including two octogenarians in the median group requiring emergency total arch replacement for a ruptured aneurysm. One of them had severe stenosis of the left common carotid artery as well. Another two patients with severe aortic atheromatosis in the postero-lateral group suffered from a stroke. No neurological complication occurred in the antero-lateral group. In terms of other postoperative complications (Table 4), the incidence of respiratory failure was slightly higher in the lateral groups than in the median group. There were two hospital deaths (5.3%) of octogenarians. The one octogenarian (described above) with a permanent deficit died from sudden onset thrombosis of the superior mesenteric artery (SMA) 2 months after surgery. Another octogenarian suffering preoperatively from pulmonary emphysema in the postero-lateral group died from multiorgan failure secondary to respiratory failure 1 year postoperatively. There were six late deaths after hospital discharge. Five patients (ages 73, 83, 81, 80 and 78 years at surgery) in the median group died from cerebral infarction 10 months after surgery, sudden death following a permanent cerebral deficit (described above) 5 months after surgery, sudden onset SMA emboli 5 months after surgery, aggravation of preoperative respiratory failure 9 months after surgery, and lung cancer 5 years 8 months after surgery, respectively. Another patient (77 years) in the postero-lateral group who had been suffered from a stroke (described above) died from pneumonia 5 years after surgery. Two of the six were ‘related’ late deaths. There has been no mortality in the antero-lateral group (Table 5). The mean follow-up period of the overall 30 survivors excluding a patient lost to follow-up (follow-up rate of 96.8%) was 47.6±28.1 months. Specifically, it was 61.1±26.0 months (range 22–110 months) for the median approach, 53.3±15.2 months (range 32–72 months) for the postero-lateral approach, and 16.1±9.0 months (range 2–33 months) for the antero-lateral approach. All have remained in good condition without further surgery.
|
4. Discussion
|
|---|
This review addresses the surgical repair of limited atherosclerotic non-dissecting (‘true aneurysms’) aneurysms located on or involving the aortic arch by means of three different approaches. The arch vessels are included in such aneurysms or are close to them. Therefore, aortic cross-clamping around them is dangerous, particularly in the atherosclerotic aneurysms and risk of cerebral complications during the repair is a major concern in surgery. In these circumstances, surgical access as well as relevant brain protection techniques are controversial, regarding whether the median approach [1–3] or the postero-lateral approach [1,10,12–15] is preferable. Each has advantages and shortcomings. Benefits of the median approach are feasibility of ascending aortic cannulation and use of an ordinary CPB system, feasibility of combined aortic valve and coronary surgery, feasibility of ascending aortic and total arch replacement, more appropriate brain and myocardial protection, and less impairment of respiratory function than in lateral approaches. By contrast, the postero-lateral approach provides a wider view of the distal part of the aortic arch to the entire descending aorta, ease of distal aortic anastomosis, feasibility of more distal descending aortic replacement, and shorter brain ischemic time in proximal open aortic anastomosis. Our earlier choice of surgical access to aortic arch aneurysms was therefore dependent on the anatomical position of the aneurysms, and particularly on the distal ends of the aneurysms [2,3]. If the aneurysm extended proximally and the distal end was above the hilus, the median approach was chosen; if below the hilus, with distal extension, the postero-lateral approach was employed. However, the median approach presented difficulty in distal aortic anastomosis since it was distant from the sternum, particularly in larger male patients. The postero-lateral approach also has some shortcomings. A standard femorofemoral bypass circuit is normally established in this setting, which has its own drawbacks; it might not provide sufficient flow in patients with severe aortoiliac disease, and it might produce serious atheromatous emboli as a result of hazardous retrograde femoral perfusion [16]. In fact, the two patients with aortic atheromatosis likely developed a stroke caused by retrograde femoral perfusion. Maintenance of the patient's own heart beat for as long as possible during core cooling might be preferable in preventing cerebral emboli in femoral perfusion for the prevention of atheromatous emboli. In this setting, there is also a risk of atheromatous emboli dropping into the arch vessels in cases with severe atheromatosis during proximal anastomosis. Another shortcoming of the postero-lateral approach is that reconstruction of the left carotid artery or the brachiocephalic artery is difficult. This approach can not be applied in cases with significant aortic valve insufficiency.
To overcome these drawbacks, an antero-lateral approach has been employed since 1997 [4–6]. This approach combines the advantages of the two conventional techniques. Specific advantages are as follows. (1) It provides easier access to the aortic arch and a wider view. (2) Ascending aortic cannulation and ordinary CPB with bicaval venous drainage are possible. (3) In prosthetic replacement, the lesions between the ascending aorta to the entire descending aorta are easily replaced. (4) It permits more appropriate brain protection using SVC-RCP [2,3]. (5) Myocardial protection is by means of ascending aortic cross-clamping and antegrade infusion of cardioplegic solution. (6) Respiratory function should be less impaired than in the postero-lateral approach because there is much less muscle division. So far in this approach there has been no serious morbidity involving neurological complications and no mortality, although the number of patients is still too small to prove its reliability. Problems with this approach were a relatively high incidence of wound dehiscence and more pain than in the median approach. Moreover, the most distal site where anastomosis could be made safely with this access was around the T8 level [4–6]. An additional transverse sternotomy may be necessary for full exposure of extensive aortic lesions. This was required in the two early patients; one had a large aneurysm that ruptured into the intrapericardial space, and the other had an extensive aneurysm of the entire descending aorta up to T11.
Ascending aortic cannulation in surgery for aortic arch aneurysms was advocated as ‘central cannulation’ by Westabyand Katsumata [17]. A major advantage is prevention of cerebral and visceral emboli due to hazardous retrograde perfusion from femorofemoral circulation because most of the patients with thoracic aneurysms generally have increased risks of atheromatous emboli. In the median and antero-lateral approaches, arterial cannulation into the proximal part of the ascending aorta can be employed. In addition, the tip of the arterial cannula was oriented toward the aortic valve to prevent dislodging of the intraaortic atheroma. Non-pathological sites should be sought carefully by intraoperative epiaortic echo in this setting. Retracting the pericardium tightly using heavy 5-Ethibond stitches (Ethicon, USA) for exposure of the ascending aorta was employed in the antero-lateral approach. Even then, exposure of the cannulation sites including the SVC and the right atrium (RA) can often be difficult anatomically. In particular, taping and snagging of the SVC for the most desirable SVC-RCP might not always be possible. In such cases, RSVP or passive RCP should be employed as an alternative adjunct for brain protection. An additional transverse sternotomy for easy venous cannulation as proposed by Westaby and Katsumata [17] should not always be necessary. Consequently, there are some differences between the Westaby group technique and ours. In theirs a transverse sternotomy with division of the internal thoracic artery was required. Epiaortic echo was not employed to find a safe site for ascending aortic cannulation. Basic HCA was employed during proximal aortic anastomosis, though beneficial RCP was not employed during HCA.
For brain protection during open aortic anastomosis around the aortic arch, we used three different RCP techniques combined with HCA relevant to the surgical access. SVC-RCP was employed in every median approach and some antero-lateral approaches. RSVP or passive RCP was employed in all postero-lateral approaches and some antero-lateral approaches where SVC cannulation was impossible anatomically. Both RSVP and passive RCP in the lateral approaches, which are not selective RCP, also should be effective for 30 min only for open proximal anastomosis. In all RCP, favorable effects consist of cooling of the brain, provision of oxygen and substrate to it, evacuation of debris or air, and back-flushing of adverse metabolites. We believe the combination with HCA and RCP is much better for cerebral safety than HCA alone for these reasons.
There are some limitations in this review; the series is relatively small. In particular, the number of patients involved in the postero-lateral and antero-lateral approaches is small. Also, the period of each group was different. It is therefore difficult to compare outcomes between the three different approaches. Also, there is bias in our surgical access, since we chose the approach according to the anatomical positions of the aneurysms. The median approach involved 13 patients who underwent more extensive total arch replacement. It was natural that these 13 patients tended to develop more serious complications or have a higher mortality rate due to more invasive surgery. Further experiences are necessary to give a clearer comparison of the three types of access.
Postoperative impairment of respiratory function following aortic surgery through left thoracotomy is also a major concern, in particular in the elderly or in patients with preoperative respiratory dysfunction, including chronic obstructive lung diseases. In the presented series, the incidence of respiratory complications in the lateral approaches was slightly higher than in the median approach. The causes are considered to be mechanical and cold lung injuries and intrapulmonary hemorrhage induced by rough manipulation under prolonged full heparinization, as well as left thoracotomy itself. After routine use of a low dose of aprotinin [18] the incidence of pulmonary complications decreased remarkably. Gentle lung manipulation using single lung ventilation, acute reversal of heparin, and avoidance of excessive transfusion of blood is also essential in preventing serious pulmonary complications. In patients with severely impaired respiratory function the median approach with less distal extension of the aneurysm should have priority over the lateral approaches.
In conclusion, our current surgical strategy for aortic arch aneurysms is that all three approaches, in conjunction with the combined techniques of HCA and RCP, should be considered with appropriate choice according to the anatomical sites of the aneurysms and the conditions of the other relevant parts of the heart, brain, arch vessels, lungs, and so on. Regarding the anatomical sites, for aneurysms from the aortic root to the end of the aortic arch, the median approach is preferable. From the end of the ascending aorta to the mid-portion of the descending aorta the antero-lateral approach is more preferable. From the proximal descending aorta to the distal part of the descending aorta the postero-lateral approach should be employed.
|
References
|
|---|
-
Crawford S., Snyder D.W. Treatment of aneurysms of the aortic arch. A progress report. J Thorac Cardiovasc Surg 1983;85:237-246.[Abstract]
-
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]
-
Ueda Y., Miki S., Kusuhara K., Okita Y., Tahata T., Ogino H., Sakai T., Morioka K., Matuyama K. Protective effect of continuous retrograde cerebral perfusion on the brain during deep hypothermic systemic circulatory arrest. J Cardiac Surg 1994;9:584-595.[Medline]
-
Walterbusch G., Marr U., Abramov V., Fromke J. The antero-axillary thoracotomy for operations of the distal aortic arch and the proximal descending aorta. Eur J Cardio-thorac Surg 1994;8:79-81.[Abstract]
-
Sasaguri S., Yamamoto S., Fukuda T., Hosoda Y. Retrograde cerebral perfusion through antero-axillary thoracotomy in the aortic arch surgery. Eur J Cardio-thorac Surg 1997;11:657-660.[Abstract]
-
Sasaguri S., Yamamoto S., Fukuda T., Hosoda Y. Anteroaxillary thoracotomy facilitates the use of retrograde cerebral perfusion in the distal aortic arch reconstruction. Ann Thorac Surg 1996;62:1861-1862.[Abstract/Free Full Text]
-
Yamanaka K., Miki S., Kusuhara K., Okita Y., Tahata T. The prevalence of atherosclerotic lesions in the aortic arch. Nippon Kyobugeka Gakkaishi 1995;43:10-15.
-
Livesay J.J., Cooley D.A., Duncan J.M., Ott D.A., Walker W.E., Reul G.J. Open aortic anastomosis: improved results in treatment of aneurysms of the aortic arch. Circulation 1982;6(Suppl II):II122-II127.
-
Yasuura K., Okamoto H., Ogawa Y., Matsuura A., Asakura T., Seki A., Hoshino M., Masaki T., Sawazaki M., Itoh T., Abe T. Resection of aortic aneurysms without aortic clamp technique with the aid of hypothermic total body retrograde perfusion. J Thorac Cardiovasc Surg 1994;107:1237-1243.[Abstract/Free Full Text]
-
Ogino H., Ueda Y., Sugita T., Sakakibara Y., Matsubayashi Y., Nomoto T. Two different techniques of retrograde cerebral perfusion for thoracic aortic surgery through a left thoracotomy. Cardiovasc Surg 2000;8:58-65.[Medline]
-
Takamoto S., Okita Y., Ando M., Morota T., Handa N., Kawashima Y. Retrograde cerebral circulation for distal aortic arch surgery through a left thoracotomy. J Cardiac Surg 1994;9:576-583.[Medline]
-
Crawford E.S., Cosseli J.S., Safi H.J. Partial cardiopulmonary bypass, hypothermic circulatory arrest, and posterolateral exposure for thoracic aortic aneurysm operation. J Thorac Cardiovasc Surg 1987;94:824-827.[Abstract]
-
Kieffer E., Koskas F., Walden R., Godet G., Le Blevec D., Bahnini A. Hypothermic circulatory arrest for thoracic aneurysmectomy through left-sided thoracotomy. J Vasc Surg 1994;19:457-464.[Medline]
-
Dossche K., Deferm H., De Geest R. Repair of descending thoracic aneurysms through a left posterolateral thoracotomy using deep hypothermic circulatory arrest. Eur J Cardio-thorac Surg 1996;10:799-802.[Abstract]
-
Yamashita C., Okada M., Yoshimura T., Azami T., Katagiri K., Wakiyama H., Ataka K. Impact of retrograde cerebral perfusion with posterolateral thoracotomy on distal arch aneurysm repair. Ann Thorac Surg 1998;65:955-960.[Abstract/Free Full Text]
-
Dossche K.M., Schepens M.A.A.M., Morshuis W.J., Muysoms F.E., Langemeijer J.J., Vermeulen F.E.E. Antegrade selective cerebral perfusion in operations on the proximal thoracic aorta. Ann Thorac Surg 1999;67:1904-1910.[Abstract/Free Full Text]
-
Westaby S., Katsumata T. Proximal aortic perfusion for complex arch and descending aortic disease. J Thorac Cardiovasc Surg 1998;115:162-167.[Abstract/Free Full Text]
-
Okita Y., Takamoto S., Ando M., Morota T., Tamaki F., Kawashima Y. Is use of aprotinin safe with deep hypothermic circulatory arrest in aortic surgery? Investigations on blood coagulation. Circulation 1996;94(9 Suppl):II177-II181.
This article has been cited by other articles:
|
|
|
|
 
M. Karck and H. Kamiya
Progress of the treatment for extended aortic aneurysms; is the frozen elephant trunk technique the next standard in the treatment of complex aortic disease including the arch?
Eur. J. Cardiothorac. Surg.,
June 1, 2008;
33(6):
1007 - 1013.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Asano and Y. Okita
The importance of distal fixation in total arch replacement for distal aortic arch aneurysm.
J. Thorac. Cardiovasc. Surg.,
May 1, 2008;
135(5):
1188 - 1189.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Asano, K. Okada, K. Nakagiri, H. Tanaka, Y. Kawanishi, M. Matsumori, H. Munakata, and Y. Okita
Total arch replacement for aneurysm of the aortic arch: factors influencing the distal anastomosis
Interactive CardioVascular and Thoracic Surgery,
June 1, 2007;
6(3):
283 - 287.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. Ogino, M. Ando, H. Sasaki, and K. Minatoya
Total arch replacement using a stepwise distal anastomosis for arch aneurysms with distal extension
Eur. J. Cardiothorac. Surg.,
February 1, 2006;
29(2):
255 - 257.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
N. Kawaharada, K. Morishita, J. Fukada, Y. Hachiro, Y. Fujisawa, T. Saito, Y. Kurimoto, and T. Abe
Stroke in surgery of the arteriosclerotic descending thoracic aortic aneurysms: influence of cross-clamping technique of the aorta
Eur. J. Cardiothorac. Surg.,
April 1, 2005;
27(4):
622 - 625.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Spielvogel, M. N. Mathur, and R. B. Griepp
Aneurysms of the Aortic Arch
Card. Surg. Adult,
January 1, 2003;
2(2003):
1149 - 1168.
[Full Text]
|
|
|
Top
Abstract
1. Introduction
