Use of the balloon catheter for distal occlusion of the aorta in prosthetic replacement of aortic arch aneurysms

A balloon catheter was utilized to occlude the distal aorta during prosthetic replacement of an aortic arch aneurysm in 4 consecutive patients under conditions of separate cerebral and peripheral perfusion and deep hypothermia. All patients survived the procedure, and 3 were doing well 1 to 1.5 years following operation. One patient sustained a cerebral infarction and recovered with some sequent disability. The use of a balloon occlusion catheter allowed us to perform the operation through a median sternotomy only, and eliminated the procedure of pulmonary dissection for distal clamping and the risk of emboli. In addition, its use provided a relatively bloodless field and sufficient protection for organs in the lower body through adequate perfusion, even when their function was poor or when the distal anastomosis was prolonged. We realized improved surgical results in the treatment of aneurysms of the aortic arch.     

Open distal anastomosis or aortic balloon occlusion technique during complete aortic arch replacement

The technique of open distal anastomosis or application of aortic balloon occlusion catheter designed to occlude the descending thoracic aorta have been used in 33 and 19 patients, respectively, to control bleeding during the procedure of distal anastomosis for complete aortic arch replacement with a prosthetic graft. These two techniques allowed us a simple approach to the lesion and the avoidance of clamp injury to the fragile aortic tissue. Open distal anastomosis was applied for 91% patients of operated aortic dissection and all emergent cases, it’s duration ranged from 10 to 110 minutes with an average of 58 minutes under 18.2°C of lowest esophageal temperature. On the other hand, aoritc occlusion balloon was inserted for mainly true aortic aneurysm patients without an emergency, and helped to maintain the perfusion pressure on a lower part of body around 50 mmHg by the 1550 ml/min in an average of perfusion flow femoral artery under 21.2°C of temperature. The difference of postoperative renal and liver function evaluated by serum enzyme levels of total bilirubin, GOT, GPT, LDH, creatinine and BUN did not reach to statistical significance between the patients using open distal anastomosis and balloon occlusion, however, the incidence of postoperative complication including either renal, liver dysfunction, abdominal problem or paraplegia was significantly higher in the patient group with open distal tecnhipue. Either open distal anastomosis or aortic balloon occlusion tecnhique would be appropriately selected according to the patient’s characteristics or the condition of aortic disease to be operated.     

Use of a balloon occlusion catheter for descending aortic aneurysm after total arch replacement using the elephant trunk technique

A 74-year-old man who had previously undergone prosthetic graft replacement of the total aortic arch using the elephant trunk technique and of the abdominal aorta was admitted to our hospital for surgical treatment of descending aortic aneurysm. Computed tomography (CT) on admission revealed descending aortic aneurysm of 6.5 cm in diameter, and the previously placed prosthetic graft was detected in the aneurysm. Surgery for the descending aorta was performed under femoro-femoral partial bypass. During the operation, a balloon occlusion catheter introduced through the right brachial artery into the 'elephant trunk' graft was inflated before the aneurysm was opened, then the previously placed prosthetic graft was cross-clamped and the descending aorta was replaced with a new prosthetic graft with usual fashion. The postoperative course was uneventful.     

Partial brachiocephalic perfusion in aortic arch replacement

Eleven patients who underwent replacement of the aortic arch or adjacent areas for aneurysmal disease between 1989 and 1991, using hypothermic cardiopulmonary bypass at 20° to 23°C with partial brachiocephalic perfusion, were studied. Selective perfusion of the innominate artery was performed in all 11 patients through the right axillary artery, while partial brachiocephalic perfusion was carried out using a separate arterial roller pump with a perfusion flow rate of 10ml/kg per min. Direct cannulation to the left common carotid and left subclavian artery was not performed in this method. There were 4 men and 7 women who ranged in age from 26 to 78 years, with a mean age of 56 years. The etiology of aneurysmal disease was aortic dissection in 10 patients, and aortitis syndrome in 1. The cardiopulmonary bypass time was 214.3±39.3 min, aortic cross-clamp time 131.5±33.4 min, and partial brachiocephalic perfusion time 57.6±15.1 min. There were three operative deaths (27.3%), the causes being multiple organ failure, acute peritonitis, and infection of the composite graft in the ascending aorta, in one patient each, respectively. However, there were no deaths related to the technique of partial brachiocephalic perfusion and no neurological complications were seen in this series. Thus, we believe that partial brachiocephalic perfusion under hypothermic cardiopulmonary bypass is safe and effective in surgery for aortic aneurysms involving the aortic arch.     

A reconsideration of cerebral perfusion in aortic arch replacement

Ten patients underwent aortic arch replacement for aneurysmal disease from 1970 to 1985 using a simplified cardiopulmonary bypass (CPB) technique with partial brachiocephalic perfusion, low CPB flow (30 to 50 ml/kg/min), moderate systemic cooling (26 degrees to 28 degrees C), and topical hypothermic myocardial protection. The arterial line from a single pump head has a Y shape to perfuse the femoral artery (20F cannula) and either the innominate or left carotid artery (14F). Of the 10 patients (mean age, 58 years) with arch aneurysm (6 atherosclerotic, 2 dissections, and 2 degenerative), 3 had previously undergone major cardiovascular operations. Concomitant procedures included aortic valve replacement in 4 and coronary artery bypass grafting in 3. Eight patients survived the procedure, and 1 died three weeks after operation of a ruptured abdominal aneurysm. Among the survivors, CPB time was 119 +/- 36 minutes (+/- standard deviation), myocardial ischemia time was 79 +/- 32 minutes, and intraoperative blood requirement was 5.9 +/- 3.4 units. There were no postoperative strokes. Neurological complications were only minor and included an asymptomatic miosis and ulnar nerve paresthesias in 1 patient and transient vocal cord palsy in another. Applicable in most patients undergoing elective resection of degenerative and atherosclerotic arch aneurysms and in selected patients with arch dissections, this simplified technique of brachiocephalic perfusion without circulatory arrest provides an attractive and safe alternative; the potential advantages are technical simplicity, reduced CPB and operating times, and satisfactory cerebral protection.     

Aortic balloon occlusion technique versus moderate hypothermic circulatory arrest with antegrade cerebral perfusion in total arch replacement and frozen elephant trunk for acute type A aortic dissection

BackgroundModerate hypothermic circulatory arrest (MHCA) with antegrade cerebral perfusion (ACP) is safe and efficient in total arch replacement (TAR) and frozen elephant trunk (FET) for acute type A aortic dissection (ATAAD). Complications related to hypothermia and ischemia are inevitable, however. The aortic balloon occlusion (ABO) technique is performed to elevate the lowest nasopharyngeal temperature to 28°C and shorten the circulatory arrest time. In this study, we aimed to evaluate the efficacy of this new technique.MethodsWe reviewed the clinical data of patients with ATAAD who underwent TAR and FET, including 79 who underwent ABO and 109 who underwent MHCA/ACP.ResultsCirculatory arrest time was significantly lower in the ABO group compared with the MHCA/ACP group (mean, 4.8 ± 1.2 minutes vs 18.4 ± 3.1 minutes; P < .001). The composite endpoint was comparable in the 2 groups (11.4% for ABO vs 13.8% for MHCA/ACP; P = .631). Fewer patients in the ABO group developed high-grade acute kidney injury (AKI) according to a modified RIFLE criterion (22.8% vs 36.7%; P = .041), and the rate of hepatic dysfunction was lower in the ABO group (11.4% vs 28.4%; P = .005). Multivariable logistic analysis showed that the ABO technique is protective against duration of ventilation >24 hours (odds ratio [OR], 0.455; 95% confidence interval [CI], 0.234-0.887; P = .021), hepatic dysfunction (OR, 0.218; 95% CI, 0.084-0.561; P = .002), and grade II-III AKI (OR, 0.432; 95% CI, 0.204-0.915; P = .028).ConclusionsThe ABO technique significantly shortens the circulatory arrest time in TAR and FET. Available clinical data suggest that it has a certain protective effect on the liver and kidney. Future large-sample studies are warranted to thoroughly evaluate this new technique.     

Case of traumatically bleeding shock patient rescued by using an aortic occlusion balloon catheter during surgery

A 55-year-old (163 cm, 70 kg) man with traumatic intra-abdominal bleeding underwent emergency operation. The patient was in a state of hemorrhagic shock with 82 mmHg of systolic blood pressure (SBP) at hospital arrival. His condition became severer within about 1 hr, and tracheal intubation and mechanical ventilation were consequently started in the ambulatory emergency room. SBP decreased to 60 mmHg when he was transferred to the operating room. Anesthesia was induced with intravenous fentanyl and vecuronium, and was maintained with inhalation of sevoflurane in 50% oxygen. After laparotomy, it was impossible to detect the bleeding source because of a large quantity of hemorrhage. To reduce the blood loss, aortic occlusion balloon catheter (AOBC) was inserted into the upper abdominal aorta via the right femoral artery. Aortic occlusion was performed twice each for twenty minutes. The evelation of SBP and decrease of bleeding dose were secured by aortic occlusion. Thereby the source of bleeding could be detected and surgical procedure could be finished with survival of the patient. The insertion of AOBC for the surgical patient with intra-abdominal hemorrhagic shock may be advantageous for uncontrollable bleeding.     

单纯无名动脉灌注的主动脉弓置换术21例

目的 探讨主动脉弓置换术中使用单纯无名动脉灌注进行脑保护的安全性和有效性.方法 2004年1月至2007年7月,2l例主动脉弓置换者使用单纯无名动脉灌注技术进行脑保护,男19例,女2例;年龄29-72岁,平均(46.5±11.4)岁.A型(Stanford分型)主动脉夹层19例,其中7例合并主动脉瓣关闭不全;升主动脉及主动脉弓真性动脉瘤伴降主动脉受累2例.所有病例均在深低温、使用单纯无名动脉选择性脑灌注下进行升主动脉、主动脉弓置换+降主动脉覆膜支架置入术.同时行Benlall手术6例,David手术1例.结果 升主动脉阻断(109.6.4-29.6)min;体外循环(186.7±56.2)min;最低鼻咽温(19.O±3.3)℃;选择性脑灌注时间(38.3.4-11.5)Ⅲ.m,流量每分钟(6.8±2.6)ml,l‘g.术后无中枢神经系统并发症.呼吸机辅助(38.6±29.O)h.1例因低心排输出量综合征于术后第5 d死亡.术后随访2-45个月,平均(24.0±12.5)个月,无死亡及心脑血管意外发生.结论 深低温、单纯无名动脉选择性脑灌注下行主动脉弓置换是安全、有效的.     

Transbrachial arterial insertion of aortic occlusion balloon catheter in patients with shock from ruptured abdominal aortic aneurysm

OBJECTIVE: Of 125 surgical patients with abdominal aortic aneurysm (AAA) treated from 1999, 11 patients with deep shock from ruptured AAAs who underwent aortic occlusion balloon catheter (AOBC) insertion before laparotomy were studied. METHODS: With the patients under local anesthesia, the brachial artery was exposed and the balloon catheter was inserted into the thoracic aorta. The balloon was inflated halfway and pulled back gently to the orifice of the left subclavian artery, and was advanced with the aid of blood flow down to the abdominal aorta. After full inflation of the balloon, the catheter was pulled until the balloon was fixed at the proximal shoulder of the AAA. RESULTS: AOBC insertion was completed within 16.1 +/- 5.1 minutes. Systolic blood pressure at presentation was 84.1 +/- 31.7 mm Hg, deteriorated to 60.9 +/- 15.4 mm Hg on arrival in the operating room, and increased significantly (P <.0001) to 123.4 +/- 25.3 mm Hg after AOBC insertion. The balloon burst in three patients. Embolic complications were observed in two patients. There were three deaths, two associated with the balloon bursting. In nine patients whose shock was successfully controlled by AOBC, operative mortality was 11%. CONCLUSION: Transbrachial arterial insertion of an AOBC may be useful to ameliorate hemorrhagic shock in patients with ruptured AAAs.     

Results of a total aortic arch replacement for an acute aortic arch dissection

OBJECTIVES: Recently, the immediate results of a surgical repair for an acute aortic arch dissection have dramatically improved. However, a total aortic arch replacement is recommended in a limited number of patients with an intimal tear located in the aortic arch. We have performed a total aortic arch replacement for all such patients with an acute aortic arch dissection since September 1995. METHODS: During the past 4 years, 27 consecutive patients who had an aortic arch dissection underwent a total aortic arch replacement. Twenty-five patients underwent an emergency operation. In 5 patients the intimal tear was located in the aortic arch, but in the rest of the patients, it was located in the ascending aorta or the proximal descending aorta. To obliterate any false channels, gelatin-resorcin-formol glue was used. RESULTS: The hospital mortality was 11%, and no cerebral complications were observed. Postoperative aortography and computed tomography showed no evidence of any persisting false channels in 15 patients (65%). During the follow-up period (ranging from 5 months to 4 years), two patients underwent a reoperation because of the recurrence of a dissection at the sinus of Valsalva. All patients, except for one who died after a reoperation, are still alive and free from any serious events at this writing. CONCLUSIONS: Resecting both the ascending and transverse aorta, irrespective of whether the intimal tear is located in the aortic arch, may be an acceptable alternative at experienced centers because of its low mortality and good midterm results.     

Long-term results of total aortic arch replacement using selective cerebral perfusion

From June 1994 to July 2001, 92 consecutive patients underwent total aortic arch replacement using hypothermic selective cerebral perfusion. Forty-four patients had nondissecting fusiform or saccular aneurysms (non-ruptured 34, ruptured 10), and 48 patients had dissection (acute 37, chronic 11). Hospital mortality rate was 6.8% in the nondissecting group and 6.3% in the dissecting group. No major operative cerebral complications were observed. There were 9 late deaths in the nondissecting group and 5 late deaths in the dissecting group. The actuarial survival rate was 61.6% after 100 months in the nondissecting group and 82.5% after 86 months in the dissecting group (p = 0.5128). In the postoperative aortic accidents, there were 2 cases of the descending aortic rupture and 2 cases of cholesterol crystal embolization in the nondissecting group and 3 cases of thoracoabdominal grafting, 2 cases of re-operation in the ascending aorta and 1 case of descending aortic rupture in the dissection group. The actuarial freedom from aortic accidents was 88% after 100 months in the nondissecting group and 80% after 86 months in the dissecting group (p = 0.6908). Our surgical outcome of total aortic arch replacement using hypothermic selective cerebral perfusion are satisfactory.     

Use of aortic occlusion balloon catheter for sacral giant cell tumor resection

We report 2 patients for whom anesthetic management using aortic occlusion balloon catheter (AOBC) was performed thrice. A 14-year-old boy and a 43-year-old man with sacral giant cell tumor underwent tumor resection. In both patients, transcatheter arterial embolization (TAE) was performed several times before the operation. Before the surgery, an AOBC was inserted via the right femoral artery. For tumor resection, the AOBC was inflated, and a slight decrease in hemorrhage was observed. The occlusion was maintained for 40-55 min, with a loss of 1,400-3,700 ml of blood. In case 1, moderate bleeding from the epidural venous plexus was observed. In case 2, packed red blood cell transfusion was needed, and the patient returned to surgery for hemostasis. Because the AOBC could not decrease the severity of venous hemorrhage, we expected increased hemorrhage with an increase in the extent of surgery. In addition, preoperative multiple TAE might lead to the development of collateral circulation around the sacrum and augment the amount of blood loss in that region. Although the AOBC could reduce intraoperative hemorrhage, uncontrollable bleeding may occur if the sacral giant cell tumor shows extensive dissemination.     

Long-term comparison of aortic arch replacement with or without elephant trunk procedure via retrograde cerebral perfusion for aortic arch dissection.

OBJECTIVE: The aim of this study is to investigate the effects of the duration of retrograde cerebral perfusion (RCP) in patients with aortic arch dissection. METHODS: Between 1993 and December 2000, 56 patients were operated on for aortic arch dissection. Elephant trunk procedure was performed in 28 patients (Group A) and semiarcus replacement in 28 patients (Group B). Type I dissection (P=0.003), chronic ethiology (P=0.006), medial degeneration (P<0.001), and preoperative hemodynamic instability (P=0.004) were observed significantly more in Group A. In both groups RCP was used for cerebral protection. RESULTS: Hospital mortality was higher in Group A than Group B (32.1% versus 7.1%; P=0.015). Late mortality was observed only in Group A (10.5%; P=0.049). Actuarial survival was 55.1+/-11.55% in Group A and 91.67+/-5.64% in Group B at 5 yr (P=0.0113), while cumulative survival for all patients was 78.38+/-5.77% at 5 yr. RCP time was longer in Group A (62.7+/-16.8 versus 34.2+/-19.5 min; P<0.001). Forward stepwise logistic regression analysis showed that chronic obstructive pulmonary disease (P=0.014) and renal insufficiency (P=0.004) were significantly predictors for hospital mortality, whereas elephant trunk (P=0.052) and RCP (>60 min) (P=0.175) did not increase early mortality. Only hemodynamic instability was significantly (P=0.006) predictors for late mortality. CONCLUSIONS: Preoperative severity of dissection, hemodynamic instability or organ dysfunctions impair early or late outcome. Elephant trunk technique with increased RCP time do not increase early or late mortality. To shorten RCP time (<60-65 min) can improve surgical results.