Nonpenetrating trauma to the thoracic aorta

Twenty-seven patients underwent surgical repair for nonpenetrating injuries of the thoracic aorta. Emergency operation was performed in 19 patients with acute aortic injury and there were 12 survivors. Left heart bypass (LHB), external shunts, and simple aortic cross-clamping were methods employed during repair. All operative deaths occurred in the left heart bypass group. Morbidity, hospital stay, operative time, and blood loss all were markedly less in patients repaired with an external shunt or simple cross-clamping. Systemic heparinization related adversely to mortality and morbidity. Eight patients had repair of chronic post-traumatic descending aortic aneurysms. One of these had previous repair elsewhere with paraplegia and subsequent mycotic aneurysm at the graft repair site. He presented to us with massive hemoptysis. Surgical correction in the chronic group was performed using either left heart bypass, external shunt, or simple aortic cross-clamp with graft interposition. The only death occurred in a patient repaired on left heart bypass.     

Acute traumatic aortic aneurysm: the Duke experience from 1970 to 1990.

Improvements in the operative management of acute traumatic thoracic aortic aneurysm have resulted in safe and expeditious repair. Nonetheless, multisystem injuries continue to inflict significant numbers of deaths. From 1970 to 1990, 108 patients with acute traumatic thoracic aortic aneurysm were evaluated. Mean injury severity score, excluding aortic injury, was 17.5. Ninety-three patients (86%) survived beyond initial resuscitation and came to operation. Median interval from injury to aortic repair was 8 hours (range, 2 hours to 19 days); there were five operative deaths. Lethal nonaortic injuries included 18 closed head injuries, four myocardial contusions, two intraabdominal vascular injuries, and one pulmonary contusion. The overall mortality rate was 39% of total admissions (42 of 108), and 29% of survivors of resuscitation (27 of 93). It is significant that only 11 of the 42 deaths (26%) were directly attributable to thoracic aortic aneurysm. Adjuncts to prevent spinal cord ischemia (shunt/bypass) were used in 76 patients, whereas 12 underwent clamp/repair. Postoperative paraplegia developed in 5 of 79 patients (6.8%, including 4 of 68 (5.9%) repaired with shunt/bypass and 1 of 11 (9.1%) repaired with clamp/repair (p = NS). Among those who developed paraplegia, the injury severity score was 27.0, and the median interval from injury to repair was 4.9 hours (range, 2 to 6.5). Intraoperative hypotension occurred in three of five patients with paraplegia. Death in patients with thoracic aortic aneurysm is due primarily to associated injuries and has remained relatively constant over the 20-year period of review. Overall injury severity, intraoperative hypotension, and extensive aortic tissue destruction may correlate with the development of postoperative paraplegia; however, a larger population sample is required to confirm this conclusion. A plea is made for standardized reporting of all patients with thoracic aortic aneurysm.     

Composite graft repair of Marfan aneurysm of the ascending aorta: results in 100 patients

One hundred consecutive patients with the Marfan syndrome underwent composite graft repair of an ascending aortic aneurysm between September 1976 and June 1989. Twenty-two patients had ascending aortic dissection at the time of composite graft repair; 18 patients also had a mitral valve procedure. There were no hospital deaths among 92 patients undergoing elective repair. One of 8 patients undergoing emergency repair of a ruptured aneurysm died in the operating room. The overall hospital mortality rate was 1%. There have been ten late deaths among the 99 hospital survivors (10.1%). Five deaths occurred among the first 11 patients in this series and five occurred among the last 88 patients (5.7%). Three late deaths resulted from composite graft endocarditis; 3 other patients with endocarditis are alive after aortic root replacement with cryopreserved homografts. Late coronary dehiscence caused death in 1 patient and was successfully repaired in a second. Actuarial survival for the 100 patients was 92.6% at 5 years and 75.8% at 10 years. Currently, composite graft repair of Marfan aneurysms of the ascending aorta can be performed with low hospital and late mortality. Marfan aneurysms with a diameter of 6 cm or greater should be repaired with the Bentall composite graft procedure, even if the patient is asymptomatic.     

Aortic Dissections Complicating Open Cardiac Surgery: Report of Three Cases

Between June 1991 and February 1999, three patients suffered ascending aortic dissection as a complication of cardiopulmonary bypass operations with aortic cannulation at our hospital. The dissection occurred during the operation in two of the three patients and several months after the operation in one. Among a total of 2 207 cardiac operations performed during this period, the incidence of perioperative ascending aortic dissection was 0.14%. In addition to visual inspection and palpation, either epicardial or transesophageal echocardiography proved extremely useful for establishing an intraoperative diagnosis of ascending aortic dissection as a complication of open cardiac operation. One of the three patients underwent closed plication but subsequently died of vital organ ischemia. In this case, failure of reapproximation of the injured intima by closed plication might have led to extension of the dissection. Despite prolonged cardiopulmonary bypass and myocardial ischemic time, graft replacement of the ascending aorta was successfully carried out in the other two patients. Thus, we believe that graft replacement of the ascending aorta should be performed for patients with extensive aortic dissection complicating an open cardiac operation. Received: August 12, 1999 / Accepted: May 30, 2000     

Thoracic aortic injury. A ten-year experience

Between 1974 and 1983, 41 patients arrived alive at Loma Linda (Calif) University Medical Center after sustaining a traumatic disruption of the thoracic aorta. Four patients died during the resuscitation attempts and the 37 patients who survived underwent thoracotomy for attempted definitive repair. There were six hospital deaths (16.22%) among those who underwent definitive repair; associated injuries (mostly orthopedic and neurologic) were contributing factors. Four patients were discharged with spinal cord injuries, two were paraplegic on arrival at the hospital, and two became paraplegic postoperatively (surgical spinal cord injury, 5.41%). Most injuries were distal to the left subclavian artery (97.56%). Cardiopulmonary (left heart) bypass was gradually abandoned in favor of more simple techniques, including ventriculoaortic and aorto-aortic heparinized shunts or a "clamp and sew" method. Experience has demonstrated that most traumatic aortic disruptions can be repaired safely by direct suture technique (without graft interposition) if accomplished during the acute episode.     

Progress in surgery of the aortic arch]

We summarize our experience out of 133 operations involving the aortic arch which were performed in 130 patients throughout the last 13 years. Aortic pathology was aneurysmal disease in 57 cases, acute aortic dissection in 44, and chronic aortic dissection in 29 patients. Operative strategies included partial replacement or repair of the aortic arch in 80 cases and subtotal or total replacement of the transverse arch in 53 patients. In 19 cases presenting with aneurysms of the descending thoracic aorta, implantation of an elephant trunk prothesis was performed simultaneously. The operations were performed during circulatory arrest (10-64 min, mean: 27 min) and in deep hypothermia (nasopharyngeal temperature: 11-25 degrees C). Recently, two modifications of the technique were introduced: First, the site of arterial inflow cannulation is changed by intubating the prothesis directly during reperfusion providing antegrade perfusion. Second, in patients with acute aortic dissection, the false lumen of the aortic root and arch is filled with resorcinformol glue and the layers are readapted by this means after anatomical reconstruction. Overall, early mortality was 14.3% and was much higher in acute dissection (22.7%) when compared to chronic dissection (6.9%, p = 0.110). A total of 24 reoperations were necessary in 16 patients of this group with subsequent replacement of the descending thoracic aorta being most frequently performed (n = 14). Actuarial survival after 5 years was not significantly different between the groups (69.1%) but showed a progressive decline for patients with aneurysms and chronic dissection (11 late deaths) while no late deaths occurred in acute dissections.(ABSTRACT TRUNCATED AT 250 WORDS)     

The midterm results of stent graft treatment of thoracic aortic injuries

INTRODUCTION AND OBJECTIVES: Several publications document the technical feasibility of stent graft repair of aortic transection. We report our mid-term results of endovascular repair of thoracic aortic transections using covered stent grafts and compare this to a cohort undergoing open repair during the same time period to demonstrate the shift in practice pattern at our institution. MATERIALS AND METHODS: A retrospective review of patients who sustained blunt thoracic transection was undertaken. Medical records were examined to identify the clinical outcome of the procedure, and follow-up CT scans were reviewed to document adequate treatment of the transection. Outcome measures include procedure-related mortality, neurological morbidity, and successful immediate and mid-term coverage of the thoracic false aneurysm and absence of graft migration or endoleak. RESULTS: From July, 2000 to October, 2004, 27 patients were identified with descending thoracic aortic transection at our level I trauma center. Fourteen patients were managed nonoperatively, five patients underwent thoracotomy and direct aortic repair, and eight patients underwent endoluminal stent graft repair. Of the endovascular group (n=8), repairs were performed with stacked AneuRx aortic cuffs (Medtronic, Inc., Minneapolis, MN) (n = 6), a Gore thoracic aortic stent graft (Thoracic EXCLUDER; W.L. Gore, Flagstaff, AZ) (n=1), or a Medtronic Talent thoracic endograft (Medtronic, Inc.) (n=1). Access for stent graft deployment was the common femoral artery (n=2), iliac artery (n=4), or distal abdominal aorta (n=2). Completion arch aortography and postoperative CT scanning confirmed successful management of the aortic transection in each patient. There were no procedure-related deaths, paraplegia, or stroke. Postoperative complications included a brachial artery thrombosis in one patient as well as an external iliac artery dissection and acute renal failure in a second patient for a complication rate of 37.5%. Two patients died as a result of their injuries unrelated to the stent graft repair. Mean follow-up of 16.6 mo has shown no evidence of endoleak or stent graft migration. Of the open repair group (n=5), one patient died in the operating room during attempted aortic repair, and one patient had a postoperative stroke. CONCLUSIONS: Due to technical success and absence of delayed complications including endoleak and graft migration, stent graft repair of traumatic aortic transection has replaced open aortic repair as the primary treatment modality in the multiply injured trauma patient at our institution. The postoperative complication rate observed in this small series tempers the success to some degree, but the severity of the complications compares favorably with those observed in the open repair group.     

Surgical treatment of acute ascending aortic dissection.

Since adopting a policy of immediate operation on patients with acute dissection of the ascending aorta, 42 men and 6 women (ages 18-67 years) have been managed surgically. Thirty-two patients had graft replacement of the ascending aorta and resuspension of the incompetent aortic valve. One of these had a coronary graft. There were five deaths in this group. Eight patients required aortic valve replacement because of a diseased aortic valve as well as grafting of the ascending aorta, with one death. Three patients had resuspension of the aortic valve and primary repair of their dissection without mortality. Two patients were managed successfully with an intraluminal prosthesis and resuspension of the aortic valve. Another patient had successful repair with a valved conduit and reimplantation of the coronaries. Two patients dissected 4 and 6 years after aortic valve replacement and neither survived operative repair. Of the surviving patients, one required dialysis, one a femoral-femoral bypass graft, and one an axillo-femoral bypass graft. One patient required a pacemaker for heart block, and two underwent successful repair of suture line aneurysms, both occurring three years after operation. On the basis of this experience, prompt surgical intervention for acute ascending aortic dissection is the treatment of choice. A variety of techniques are available to repair the dissected aorta. Long-term results for resuspension of the aortic valve in acute ascending aortic dissection have been excellent and emphasize that valve replacement should be reserved for those patients found at operation to have a primary abnormality of the aortic valve.     

Primary repair of acute ascending aortic dissection

Primary repair of acute ascending aortic dissection was performed in 14 patients. Repair included resection of the intimal tear where applicable, a circumferential suture line in the ascending aorta at the site of the tear, and wrapping of the intrapericardial ascending aorta with Teflon felt to contain the distal residual false channel. The aortic valve was resuspended in 6 patients. The single operative death was unrelated to the method of repair. Two late deaths at 4 and 6 years were due to preexisting multisystem disease. In 1 patient, new aortic insufficiency with an isolated aneurysm of the noncoronary sinus of Valsalva developed at 26 months, and was repaired successfully at another institution. These results compare favorably with those reported by others employing more extensive surgical procedures for repair of acute ascending aortic dissection.     

Usefulness of the axillary artery as vascular access for cardiopulmonary bypass

AIM: In this paper we report our clinical experience with extended utilization of axillary artery cannulation for cardiopulmonary bypass (CPB) and discuss the indications and the results of the procedure in terms of complications and usefulness. METHODS: Between January 1999 and May 2004, 26 patients underwent right axillary artery cannulation for CPB. Fifteen patients presented acute type A aortic dissection and were operated urgently. Axillary cannulation was also used in 11 elective cases: 3 reoperative coronary surgery, 3 valve redo-operations and 5 cases of aortic valve regurgitation+aneurysm of the ascending aorta. RESULTS: All axillary artery cannulations were successful (21 direct and 5 with a side graft) without neurologic or vascular injuries to the right upper extremities. Hospital mortality was 7.7% and included 2 patients operated in an emergency procedure because of acute type A aortic dissection. In all cases, this cannulation site provided adequate perfusion, with a range of peak flows from 4.1 to 5.7 L/min. CONCLUSION: Our preliminary results demonstrate that the right axillary artery may be considered an alternative cannulation site for achieving full CPB and providing antegrade flow, thus avoiding complications related to retrograde flow when femoral artery perfusion is performed. This safe and useful method may be used not only in aortic surgery but in other such complex cardiac procedures as redo-operations.     

Surgical treatment of dissecting aneurysms of the aortic arch

Since May 1987 to May 1988, 8 cases of dissecting aneurysms of the aortic arch were treated surgically at the Department of Cardiovascular Surgery. Justus-Liebig University. Four cases were Standford A type and 4 were Stanford B type. All the patients were operated on under deep hypothermia (20 degrees C) and circulatory arrest, and aneurysms were repaired using pre-clotting graft without clamping the aortic arch. Bleeding from anastomosis line was controlled by fibrin coagulum. In addition, the auto-blood transfusion was applied using the cell saver system. This procedure could be performed in a short circulatory arrest and cardiac ischemic time. Seven patients were alive and discharged without neurological complication. Only one patient died because of the carotid artery dissection to the aortic dissection on the 2nd. post-operative days the clinical results were almost satisfactory. It appeared that surgical repair for dissecting aneurysm of the aortic arch could be performed safely and easily by this surgical technique and the know-how.     

Left axillary artery perfusion in surgery of type A aortic dissection

PURPOSE: A left axillary artery perfusion instead of a femoral perfusion has the benefit of avoiding false lumen perfusion and atheroembolization into the brain, which is caused by retrograde perfusion in type A aortic dissection surgery. We performed type A aortic dissection surgery using the left axillary artery perfusion technique and reviewed this method. PATIENTS AND METHODS: From April 2002 to January 2004, 8 patients with a mean age of 70 years (48 to 81), underwent axillary artery cannulation with a side graft technique in type A aortic dissection operations. Six patients had acute type A and 2 had chronic type A dissections. The surgical procedures were ascending aortic replacement in 5, hemiarch replacement in 2, and total arch replacement in 1. RESULTS: In all patients, a cardiopulmonary bypass was established through the left axillary perfusion. There were no operative deaths and no hospital deaths. All patients were able to avoid cerebral vascular accidents. One patient required a femoro-femoro bypass on the 10th postoperative day because of malperfusion of the left leg, which occurred suddenly. Postoperative hemorrhaging requiring resternotomy occurred in 2 patients. CONCLUSION: A left axillary artery perfusion is safe and useful for arterial inflow for type A aortic dissection surgery.     

Intraoperative aortic dissection--a case report

Intraoperative aortic dissection is a rare but potentially fatal complication of cardiac surgery. Prompt recognition and repair are necessary to limit the extent of dissection to minimize morbidity and mortality. Here, we present a case of acute type A dissection of ascending aortic artery occurring after removal of aortic cannula at the end of cardiopulmonary bypass. The surgeon immediately recannulated him at the femoral artery and repaired the dissection under deep hypothermia. Ascending aorta was replaced with Hemashield graft and venous graft was reimplanted. Unfortunately, the patient expired the following day due to cardiac tamponade resulting from uncontrolled bleeding. Long-standing severe hypertension, severe atherosclerotic change of the aortic wall, thin and dilating ascending aorta and cystic medial necrosis or collagen vascular disease were thought to predispose him to this complication. Gentle manipulation and surgical discreetness to forestall aoratic injury could minimize the risk of intraoperative aortic dissection. Once aortic dissection has been suspected, prompt application of transesophageal echocardiography to confirm the diagnosis, and rapid as well as appropriate surgical management are necessary to grasp a better outcome.     

Traumatic injury to the proximal superior mesenteric vessels

Twenty-one patients were treated for 25 injuries to the proximal superior mesenteric vessels (eight, superior mesenteric artery; nine, superior mesenteric vein; four, superior mesenteric artery plus superior mesenteric vein). Mechanisms of injury were stab wounds (11 cases), motor vehicle accidents (9 cases), and iatrogenic (one case). Ten patients (48%) arrived at the emergency room in shock (two with no obtainable case blood pressure). Superior mesenteric artery repair was performed by lateral suture (seven cases), end-to-end anastomosis (three cases), autogenous vein graft (one case), and no repair (one case). All 13 venous injuries were repaired by lateral suture. Four patients (19%) died in the operating room secondary to acute blood loss and irreversible shock. There were no late deaths and no second-look operations. Further improvement in survival depends on rapid transportation from injury site to operating room.     

Secondary aortoesophageal fistula after endoluminal exclusion because of thoracic aortic transection

Secondary aortoesophageal fistula (AEF) is a rare but catastrophic complication that occurs after thoracic aortic reconstruction. Recently endoluminal stent grafts have been used in selected patients with a thoracic aortic aneurysm, dissection, or traumatic aortic transection. A 24-year-old woman had massive upper gastrointestinal tract bleeding 15 months after endoluminal stent graft placement because of traumatic descending thoracic aortic transection. Evaluation demonstrated an AEF from the mid-esophagus to the endoluminal stent graft. The endoluminal graft was explanted, with primary repair of the thoracic aortic defect and simultaneous primary repair of the esophageal injury. The patient is well 15 months after open repair of the AEF.     

Spontaneous aortic dissection in the presence of coexistent or previously repaired atherosclerotic aortic aneurysm.

Acute aortic dissection occurred in 18 patients who had previously diagnosed atherosclerotic aneurysms of the thoracic and/or abdominal aorta. These patients were reviewed to assess the clinical course when these two forms of aortic pathology coexist. Patients were grouped according to status of their atherosclerotic aneurysm (previously repaired vs. untreated) and the segments of the aorta effected by the acute spontaneous dissection. Group 1 patients (n = 5) had previously undergone-abdominal aortic aneurysmectomy (AAA) repair, and the abdominal aortic suture line effectively terminated the dissection process. In Group 2 patients (n = 5), the acute dissection and the atherosclerotic aneurysm involved different segments of the aorta. Group 3 patients (n = 8) experienced spontaneous aortic dissection involving atherosclerotic aneurysms (five infrarenal, three thoracoabdominal), with threatened or actual rupture occurring in six patients, resulting in three deaths. In Group 3 patients, rupture occurred both at the atherosclerotic aneurysm (four patients) and at the site of the aortic intimal tear of the dissection (two patients) after AAA repair. The use of Magnetic Resonance Imaging (MRI) has proven to be highly accurate in delineating the nature and extent of pathology in recently encountered patients with complicated aortic disease. Coexistence of atherosclerotic aneurysm and acute dissection appears to increase the risk of aortic rupture, in both proximal and distal aortic segments.     

Thoracic aortic dissection following cannulation for perfusion

Three patients with aortic dissection originating from a thoracic aortic cannulation site are discussed and recommendations are made for preventing this complication.     

Axillary versus femoral cannulation for aortic surgery: enough evidence for a general recommendation?

There is a trend towards cannulation of the axillary artery for extracorporeal circulation in patients requiring aortic arch surgery. We analyzed the published data comparing axillary and femoral cannulation for safety and outcome. End points were death; stroke, neurologic, and vascular complications; and malperfusion. Femoral cannulation is safe for extracorporeal circulation in patients without aortic arch surgery. In patients with type A dissections, malperfusion may occur owing to retrograde perfusion of the false lumen and subsequent occlusion of the origin of the supra aortic vessels. Cannulation of the axillary/subclavian artery results in antegrade flow, at least in the right carotid artery, with the possibility of antegrade cerebral perfusion during aortic arch repair. There was a trend towards improved neurologic outcome when the axillary artery was used for extracorporeal circulation in such patients. When different techniques were compared, the use of a side graft for axillary cannulation reduced the complication rate. The lack of randomized trials and the high variety of inclusion criteria in the different studies do not allow a general recommendation for the use of the axillary artery as cannulation site.     

Aortic valve sparing operations: an update

Background. Aortic valve sparing operations in patients with ascending aorta and/or aortic root aneurysms have been performed for a decade in our institution. Initially only patients with normal aortic valve leaflets had these operations, but more recently we utilized them in patients with prolapse of a single leaflet and in those with a bicuspid aortic valve. This article is an update on the clinical results of these operations.

Methods. From May 1988 to December 1997, 126 patients with ascending aorta and/or aortic root aneurysms and aortic insufficiency underwent replacement of the ascending aorta with reconstruction of the aortic root and preservation of the native aortic valve. There were 85 men and 41 women, with a mean age of 54 years (range, 14 to 84). Thirty-two patients had the Marfan syndrome; 17 patients had acute and 10 had chronic type A aortic dissection; 23 had a transverse arch aneurysm; 26 had coronary artery disease, and 8 had mitral regurgitation. The aortic valve sparing operation consisted of simple adjustment of the sinotubular junction in 33 patients, adjustment of the sinotubular junction and replacement of one or more aortic sinuses in 60, and reimplantation of the aortic valve in a tubular Dacron (C.R. Bard, Haverhill, PA) graft in 33. Fifteen patients also had repair of aortic leaflet prolapse. Only 4 patients had a bicuspid aortic valve.

Results. There were 3 operative deaths due to cardiac failure. Patients were followed from 2 to 117 months, with a mean of 31. There were 11 late deaths: 7 cardiovascular and 4 from unrelated causes. The actuarial survival was 72 ± 8% at 7 years. Two patients required aortic valve replacement; the freedom from aortic valve replacement was 97 ± 2% at 7 years. Doppler echocardiography revealed absent, trivial or mild aortic insufficiency in most patients; only 9 patients had moderate aortic insufficiency.

Conclusions. Aortic valve sparing operations are feasible in most patients with ascending aorta and/or aortic root aneurysms who have normal or near normal aortic leaflets. The functional results of the repaired aortic valve are excellent, and the repair appears to be durable.     

Influence of complete revascularization on chronic mesenteric ischemia.

Complete revascularization for chronic intestinal ischemia is controversial. Fifty-eight patients (119 arteries) underwent mesenteric revascularization between 1981 and 1988. There were 46 women and 12 men (mean age: 63 years). Sixty percent of patients had three-vessel disease. Twenty-one patients underwent concomitant aortic reconstruction. Operative mortality was 10%. Four of the six deaths occurred in patients undergoing aortic surgery. Late graft failure occurred in five patients (10%). Five-year survival for patients with three-vessel involvement who underwent three-vessel repair was 73%, compared with 57% for two-vessel repair and 0% for one-vessel repair (p = NS). Similarly, graft patency in patients with three-vessel disease was highest in those patients who had complete revascularization (90%, 54%, and 0%, respectively) (p = NS). We conclude that increased graft patency and survival in patients with three-vessel disease was most frequent with complete revascularization. Diseased inferior mesenteric arteries should be repaired if feasible. Concomitant aortic operations should be avoided if possible.