Crawford type II thoracoabdominal aortic aneurysm repair using deep hypothermic circulatory arrest and continuous proximal aortic perfusion

We successfully operated a patient with Crawford type II dissecting thoracoabdominal aortic aneurysm using deep hypothermic circulatory arrest and continuous proximal aortic perfusion. A 70-year-old male who had a history of chronic Stanford type B aortic dissection treated by Y-graft replacement of the abdominal aorta 2 years ago underwent dissecting thoracoabdominal aotic aneurysm repair due to expansion of the aneurysm. A preoperative examination revealed 90% stenosis in his coronary system. We used deep hypothermic circulatory arrest (bladder temperature: 22 degrees C) and continuous proximal aortic perfusion as adjuncts to prevent organ malperfusion (including the coronary arteries) or embolism because sequential aortic clamping seemed impossible and the true lumen became narrowed. To minimize the duration of the extracorporeal circulation (ECC), visceral branches were reattached using a selective shunt after conclusion of ECC. The duration of aortic cross-clamping, ECC, and operation was 170, 302, and 1,020 minutes, respectively. The patient required mechanical ventilation for 12 days but survived the operation and was discharged after 42 days hospitalization without any neurologic sequela. A perioperative intensive treatment must be required to prevent morbidities related to extensive thoracoabdominal aortic aneurysm repair.     

Deep hypothermic circulatory arrest for thoracoabdominal aortic aneurysm repair in a patient with a large intracranial anterior communicating artery aneurysm

Abdominal aortic aneurysms occasionally occur concomitantly with an intracranial artery aneurysm (ICA). The association of an ICA with a thoracoabdominal aortic aneurysm (TAAA) is relatively rare. A patient with this condition is presented. Coiling of the ICA was not an option preoperatively because of the dissected false lumen of the TAAA, rendering a femoral artery approach impossible. The TAAA was repaired during deep hypothermic circulatory arrest.     

Results of aortic arch repair with hypothermic circulatory arrest and retrograde cerebral perfusion

BACKGROUND: Repair of aortic arch pathology is reliably performed with hypothermic circulatory arrest, but the best method of brain protection is controversial. METHODS: We reviewed a consecutive series of 67 patients who had aortic arch repair with hypothermic circulatory arrest. Retrograde perfusion of arterial blood into the superior vena cava (SVC) during systemic arrest was used in 87%. Average age was 65 years. Acute dissection was present in 25%. Average circulatory arrest time was 37 minutes, and average temperature 17.7 degrees C. RESULTS: Hospital mortality was 1.5%. Strokes occurred in 4.5%. Temporary neurological dysfunction occurred in 16%. Multivariate logistic regression analysis showed that acute dissection was the only independent predictor of the combined risk of stroke and temporary neurological dysfunction (odds ratio 8.5). Duration of circulatory arrest and patient age were not risk factors for adverse neurological outcome. CONCLUSION: Continuous arterial perfusion of the SVC during hypothermic circulatory arrest provides excellent cerebral protection for aortic arch repair. Acute dissection is an independent risk factor for adverse neurological outcome. Arrest time is not a predictor of neurological dysfunction.     

深低温停循环技术在胸腹主动脉瘤外科手术中的应用

目的探讨深低温停循环在复杂胸腹主动脉瘤外科治疗中的应用及近中期效果。方法回顾性分析2009年8月至2018年6月本中心34例胸腹主动脉瘤近端无法常规阻断的临床资料,全组均在深低温停循环下行外科手术。男23例,女11例;年龄23~67岁,平均(42.26±10.96)岁。Crawford分型Ⅰ型12例,Ⅱ型22例;动脉瘤最大直径50~120mm,平均(65.26±16.09)mm;马方综合征15例,动脉粥样硬化14例,主动脉缩窄5例;合并高血压病22例;首次主动脉手术28例,再次主动脉手术6例。手术经胸腹联合切口,覆膜外入路,采用股动脉及下腔静脉插管,使用深低温停循环技术完成近端吻合口,动脉管法重建肋间动脉,腹腔脏器供血动脉与四分支血管分支进行吻合,四分支血管与Y形人工血管主干进行端端吻合,双侧髂动脉分别于Y形人工血管的10mm人工血管进行端端吻合。结果全组无颅脑神经系统并发症。深低温停循环(17.68±4.88)min,呼吸机辅助(34.88±16.04)h,术后肾功能衰竭5例,经CRRT治疗后均恢复,术后截瘫1例,经脑脊液引流减压等治疗后肌力恢复,全组死亡1例,系多脏器功能衰竭死亡,术后随访3个月~5年,效果满意,随访期间无因主动脉问题死亡者,5例因远端血管扩张再次手术,4例重建的肋间动脉闭塞但未发生截瘫。结论对于胸腹主动脉瘤近端无法直接进行阻断患者,采用深低温停循环下进行近端吻合口吻合是安全的。     

Clinical study on surgical treatment of aortic arch aneurysm using selective cerebral perfusion or hypothermic circulatory arrest

To improve the surgical results of aneurysms of the transverse aortic arch, it is essential to select the optimal support technique to protect the cerebral ischemia during the aortic arch occlusion. In the four year period between 1983 and 1987, 21 consecutive patients had surgical correction of aneurysms of the transverse aortic arch at our institution. The causes of aneurysms were dissection (type A) in 16 patients and arteriosclerosis in 5 patients. Seven patients had emergency operation for frank or impending rupture. Two method for cerebral protection were employed during the period of arch exclusion. In Group I, 11 patients underwent selective cerebral perfusion both to innominate and left common carotid arteries via one roller pump at a rate of 600 ml/min (25 degrees C). The average cerebral perfusion time was 70.4 +/- 20.5 minutes. In Group II, 10 patients underwent deep hypothermia (15 degrees C to 20 degrees C) and total circulatory arrest to allow repair of the transverse aortic arch. The concomitant AVR was performed in two patients and CABG in one patient. The average cerebral arrest time was 35.2 +/- 3.4 minutes. Two out of 10 patients had additional cerebral perfusion because cerebral ischemic time exceeded over 45 minutes. There were three early deaths (14.3%) in this series. The causes of early death were bleeding in two patients and renal failure in one patient. There were no cerebral complications in both groups. The duration of extracorporeal bypass necessary for cooling and rewarming phase in Group II was longer than that in Group I.(ABSTRACT TRUNCATED AT 250 WORDS)     

Deep hypothermic systemic circulatory arrest and continuous retrograde cerebral perfusion for surgery of aortic arch aneurysm.

From 1987 to February 1991, we have repaired or replaced the aortic arch in ten patients using deep hypothermic systemic circulatory arrest with continuous retrograde cerebral perfusion (CRCP). CRCP can be implemented using the bypass connecting the arterial and venous lines of the extracorporeal circuit to reverse the flow into the superior vena cava cannula after induction of circulatory arrest. CRCP flow required to maintain an internal jugular vein pressure of 20 mmHg ranged from 100 to 500 ml/min. After completion of suturing of the aortic arch graft, air is evacuated retrogradely from the open arch vessels prior to reestablishing the usual arterial return. Two patients died, one from sepsis and the other from liver cirrhosis 1 month postoperatively. CRCP times ranged from 11 to 56 min, and minimal nasopharyngeal temperatures ranged from 16 degrees to 18 degrees C. The difference in oxygen content between the perfused blood and the blood draining from the arch vessels during CRCP most likely reflected the steady-state metabolism of the brain during the deep hypothermic state. This technique offers advantages including the need for dissecting and clamping the arch branches, providing sufficient metabolic support to the brain during deep hypothermia, and eliminating embolism of particulate debris from the aortic arch.     

Visceral and limb perfusion during thoracoabdominal aortic aneurysm repair

Patients undergoing thoracoabdominal aortic aneurysm repair are at high risk of operative morbidity and death. Aortic clamping and unclamping stresses the myocardium, interrupts visceral and limb perfusion, and leads to metabolic acidosis. Use of a simple technique to preserve distal perfusion during the period of aortic clamping may reduce perioperative morbidity. We describe a technique of visceral and limb perfusion that may reduce surgical risk in high-risk patients.     

Hypothermic circulatory arrest and hypothermic perfusion for extensive disease of the thoracic and thoracoabdominal aorta

Background: Hypothermic cardiopulmonary bypass with or without an interval of circulatory arrest has been evaluated for the treatment of complex aortic disease of the descending thoracic and thoracoabdominal aorta. Hypothermia has a protective effect on spinal cord function, and its use should reduce the incidence of paraplegia and paraparesis in traditionally high-risk patients. Experimentally, the protective effect of hypothermia has been related to amelioration of excitotoxic injury by reduction of neurotransmitter release and to inhibition of delayed apoptopic cell death.Methods: During a 12-year period, 114 patients with descending thoracic or thoracoabdominal aortic disease underwent replacement of the involved aortic segments using hypothermic cardiopulmonary bypass and intervals of circulatory arrest. The mean age of the patients was 60 years (range 22 to 79 years). Acute or chronic dissection was present in 40 patients (35%). Sixty-four patients (56%) had Crawford Types I, II, or III thoracoabdominal aneurysms.Results: The hospital mortality was 8% (9 patients). Paraplegia occured in 2 and paraparesis in 1 of the 108 patients whose lower limb function was assessed postoperatively (2.8%). None of 40 patients with aortic dissection and none of the last 81 patients in the series developed paralysis. One patient developed renal failure that required dialysis.Conclusions: Our experience with hypothermic cardiopulmonary bypass and circulatory arrest confirms that hypothermia provides substantial protection against spinal cord ischemic injury. It allows complex operations on the descending thoracic and thoracoabdominal aorta to be performed with acceptable mortality, a low incidence of renal failure, and an incidence of other complications that does not exceed that reported with other techniques.     

Spinal cord protection during thoracoabdominal aortic aneurysm repair; efficacy of distal aortic perfusion and segmental aortic clamping

Despite improvement in adjuncts for thoracoabdominal aortic aneurysms (TAAA) repairs, many devastating complications remains after the surgery. Our experience with these aneurysms has been reviewed in order to identify those methods at risk of major morbidity, as well as which further improvements required. During last 16 years, 53 consecutive patients were operated on TAAA. The mean age was 58 years. Twenty patients had dissecting aneurysms and 13 patients had had prior aortic surgery. A femoro-femoral bypass was used to maintain distal aortic perfusion in most patients. Reimplantation of intercostal or lumbar arteries under the multi-segmental aortic clamping is consistent in our technique. Motor evoked potentials (MEP) were measured to monitor spinal cord protection since 2000. The hospital mortality was 9.4% (5/53), 22.2% (2/9) for emergency operation and 15.4% (2/13) for patients with prior aortic surgery. The mortality for the first and elective operations was 3.2% (1/31). No any neurologic dysfunction was observed in all patients including the hospital deaths. In view of clinical results, our adjuncts and techniques are useful for prevention of spinal cord ischemia during the TAAA surgery.     

Selective visceral perfusion during thoracoabdominal aortic aneurysm repair.

PURPOSE: To evaluate the effectiveness of selective visceral perfusion during repair of an thoracoabdominal aortic aneurysm (TAAA), we compared the postoperative renal and hepatic functions (blood urea nitrogen, serum creatinine, total bilirubin, glutamate pyruvate transaminase) between the two groups with and without perfusion. PATIENTS AND METHODS: We operated on 52 patients with TAAA. Among them, the visceral vessels were reconstructed in 22 patients with selective visceral perfusion and in 12 patients without perfusion. The average selective perfusion time was 49.5+/-25.5 min. in the celiac and superior mesenteric arteries and 32.8+/-18.8 min. in the renal arteries. The average perfusion flow rate per each visceral vessel was 155.4+/-97.4 ml/min. RESULTS: There were five hospital deaths. There was no significant difference between the groups in the postoperative value of four factors. The selective perfusion time for vessel reconstruction in the selective visceral perfusion group was significantly longer than the arterial clamp time for vessel reconstruction in the non-perfusion group (49.5+/-25.5 min. vs. 25.6+/-13.4 min.). CONCLUSION: Our selective visceral perfusion method is not only beneficial for organ protection, but also provides us with the necessary time to reimplant the visceral as well as intercostal or lumbar arteries.     

Repair of thoracic and thoracoabdominal aortic aneurisms by the use of hypothermic circulatory arrest

From 1993 to 2003, repair of thoracic and thoracoabdominal aortic aneurysms using hypothermic circulatory arrest via the left thoracotomy was performed in 115 patients at our hospital. Ninety-one of them were elective cases and 24 of them were emergent cases. Hospital mortality rate was 3.3% in elective cases and 12.5% in emergent cases. Over all hospital mortality rate was 5.2%. Ischemic spinal cord injury was occurred in 2 patients (1.7%). Both of them needed total replacement of thoracoabodominal aorta by the graft. In the near future, Adamkiewicz artery may be detected by the imaging technology preoperatively and we expect the repair of thoracoabdominal aortic aneurysm may become safer operation avoiding spinal cord injury. Hypothermic circulatory arrest is a relatively safe and reliable method for the repair of thoracic and thoracoabdominal aortic aneurysms.     

Hypothermic circulatory arrest and hypothermic perfusion for extensive disease of the thoracic and thoracoabdominal aorta.

BACKGROUND: Hypothermic cardiopulmonary bypass with or without an interval of circulatory arrest has been evaluated for the treatment of complex aortic disease of the descending thoracic and thoracoabdominal aorta. Hypothermia has a protective effect on spinal cord function, and its use should reduce the incidence of paraplegia and paraparesis in traditionally high-risk patients. Experimentally, the protective effect of hypothermia has been related to amelioration of excitotoxic injury by reduction of neurotransmitter release and to inhibition of delayed apoptopic cell death. METHODS: During a 12-year period, 114 patients with descending thoracic or thoracoabdominal aortic disease underwent replacement of the involved aortic segments using hypothermic cardiopulmonary bypass and intervals of circulatory arrest. The mean age of the patients was 60 years (range 22 to 79 years). Acute or chronic dissection was present in 40 patients (35%). Sixty-four patients (56%) had Crawford Types I, II, or III thoracoabdominal aneurysms. RESULTS: The hospital mortality was 8% (9 patients). Paraplegia occured in 2 and paraparesis in 1 of the 108 patients whose lower limb function was assessed postoperatively (2.8%). None of 40 patients with aortic dissection and none of the last 81 patients in the series developed paralysis. One patient developed renal failure that required dialysis. CONCLUSIONS: Our experience with hypothermic cardiopulmonary bypass and circulatory arrest confirms that hypothermia provides substantial protection against spinal cord ischemic injury. It allows complex operations on the descending thoracic and thoracoabdominal aorta to be performed with acceptable mortality, a low incidence of renal failure, and an incidence of other complications that does not exceed that reported with other techniques.     

Clinical outcome of the operation using deep hypothermic cardiopulmonary bypass with intervals of circulatory arrest in thoracoabdominal aortic aneurysm

Deep hypothermic cardiopulmonary bypass with intervals of circulatory arrest has been used for protection of the spinal cord during operations for thoracoabdominal aortic aneurysm (TAAA) in our hospital. We examined the effect of this adjunct this time. We studied 15 patients who were operated using deep hypothermic cardiopulmonary bypass with intervals of circulatory arrest among 19 patients with the TAAA who we performed the operations from 1995 through 2003. The patients ranged in age from 21 to 80 (an average of 65 +/- 14 SD) years. We used deep hypothermic cardiopulmonary bypass with intervals of circulatory arrest between 16 and 20 degrees C for the adjunct but did not use a monitor of evoked spinal cord potentials or cerebrospinal fluid drainage. Operation time was an average of 805 +/- 168 minutes. Cardiopulmonary bypass time was an average of 403 +/- 73 minutes. Deep hypothermic cardiopulmonary bypass time was an average of 215 +/- 67.5 SD minutes. Duration of spinal cord ischemia to the intercostal arteries were reconstructed was from 25 to 104 (50.5 +/- 24) minutes. We recognized nerve disorder in 6 cases in progress after operation, and respiratory organs management period and a hospitalization period became long, but the hospitalization death was 3 cases, and, as for the paraplegia was no case, 12 patients were discharged in good condition. The deep hypothermic cardiopulmonary bypass with intervals of circulatory arrest was regarded as a useful adjunct for prevention of the paraplegia.     

Repair of the symptomatic aberrant aortic arch aneurysm without hypothermic circulatory arrest

Manifestation of anomalies of the aortic arch in adulthood has been reported in the literature. The symptoms stem from the compression of the trachea and esophagus or peripheral arterial ischemia associated with coarctation of the aberrant arch. The aberrant arch aneurysms are subject to complications of rupture or dissection. This may be the first reported case of a large complex aneurysm of an anomalous aortic arch resected on cardiopulmonary bypass without any period of hypothermic circulatory arrest or distal ischemia.     

The use of an aortoiliac side-arm conduit to maintain distal perfusion during thoracoabdominal aortic aneurysm repair

Thoracoabdominal aneurysm repair continues to be associated with a significant risk of operative complications, many of which are related to the prolonged period of aortic cross clamping inherent in the procedure. A variety of adjuvant techniques have been used in attempts to decrease morbidity, including atriofemoral extracorporal bypass, subarachnoid drainage, epidural cooling, and preliminary axillofemoral bypass. Herein is described a method to maintain distal perfusion with a side-arm conduit, originating from the most proximal aspect of the aortic graft and terminating on the left iliac artery. The technique has the potential to minimize hemodynamic instability while decreasing the period of pelvic and lower extremity ischemia and simplifying reattachment of aortic branch vessels. This method provides another option that can be considered in these technically demanding operative procedures.     

Totally normothermic aortic arch replacement without circulatory arrest

The authors propose a new strategy of normothermic perfusion for replacement of the aortic arch to avoid the complications of profound hypothermic circulatory arrest. Six patients underwent complete replacement of the aortic arch under normothermia using two pumps for the body (one for the brain and the thoracoabdominal aortic branches) and one for the heart. The surgical procedure was performed with no time limit. There were no operative or late deaths. No patients had neurologic deficit and all were rapidly extubated with uneventful postoperative courses. The method preserves autoregulation of cerebral blood flow and maintains body perfusion without high vascular resistances.