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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3734_Библиотеки_им_академика_М_И_Перельмана
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336
Left hear
super
https://t.me/med1917
t vent in right
ior pulmonary v.
Retrograde
cardioplegia cannula
A. Kulik and N. T. Kouchoukos
LITA pedicles
Fig. 3 The left heart is vented through the right superior pulmonary vein. A balloon-tipped cannula is positioned in the coronary sinus through purse-string suture in right atrial wall. (From
Kouchoukos [33])
segment and ow to the lower body is initiated through the femoral arterial cannula. An appropriate sized presewn multibranched graft is positioned in the
opened aortic arch. The distal limb of the graft is positioned into the descending
thoracic aorta beneath the left phrenic and left vagus nerves (Fig.7). The three
adjacent branches of the aortic graft are cut to the appropriate lengths and sutured
sequentially to the brachicephalic arteries, beginning with the left subclavian and
ending with the innominate artery (Fig.7). Perfusion from the right axillary artery
continues while these anastomoses are performed. When the anastomoses are
completed, the aortic graft is clamped distal to the left subclavian artery, the
clamps on the three branches are removed, and air is evacuated from the proximal
open end of the aortic graft. The aortic graft is then clamped just proximal to the
innominate artery and antegrade ow is established through the three arteries,
maintaining the same ow rate, pressure, and temperature (Fig.8). The fourth
branch of the aortic graft is ligated. Flow from the femoral artery cannula is discontinued and the site for attachment of the distal end of the graft to the descending thoracic aorta is determined. This is generally where the diameter of the
Left innominate
Left subclavian a.
a
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Left carotid a.
Innominate a.
337
v.
Fig. 4 The ascending aorta is clamped, if feasible, and antegrade cardioplegia is administered.
The left inferior pulmonary ligament is divided to mobilize the left lung and the distal limit of
excision of the descending aorta is identied. (From Kouchoukos [33])
Left phrenic & left vagus nerves
Antegrade cardioplegi
remaining dissected aorta does not exceed 3.5–4.5cm. A segment of the septum
between the true and false lumens of the distal aorta is excised to permit perfusion
of both channels. The graft is stretched tightly to avoid buckling and is anastomosed to the open descending thoracic aorta, reinforcing the suture line with a
strip of polytetrauoroethylene felt (Fig.8). Intercostal arteries above the seventh
intercostal space are ligated. Those below this level, if patent, are preserved by
beveling the aorta to preserve the posterior wall. As the distal suture line is being
completed, femoral arterial perfusion is initiated slowly to evacuate distal air and
debris. Rewarming then commences, using only arterial ow through the right
axillary artery. During rewarming, aortic valve or aortic root replacement and
coronary artery bypass grafting are performed, if indicated. The proximal end of
the aortic graft is sutured to the ascending aorta at the level just above the aortic
commissures (Fig.9), to an existing aortic graft, or to a newly inserted composite
graft. CPB is discontinued once rewarming is completed. The axillary artery graft
is subsequently ligated close to the artery and divided.
338
Right subcla
vian a.
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Fig. 5 After circulatory
arrest is established, the
axillary graft and femoral
venous lines are clamped.
A clamp is placed on the
descending thoracic aorta
distal to the aneurysmal
segment. The ascending
aorta is incised vertically
on the anterior surface and
the incision is extended
across the aortic arch up to
the level of the left phrenic
nerve. A separate incision
is made in the descending
thoracic aorta lateral to the
left vagus nerve. The three
brachiocephalic arteries are
transected from their
origins or more distally, if
necessary. (From
Kouchoukos [
33])
vian a.
A. Kulik and N. T. Kouchoukos
Left carotid a.
Left subclavian a.
Left phrenic
& vagus nerves
Carotid arteries
Left subcla
Right axillary a.
Right subclavian a.
Fig. 6 Perfusion from the axillary artery is slowly initiated to remove air and debris from the
brachiocephalic arteries. (From Kouchoukos [33])
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Fig. 7 After brain
perfusion is established, a
presewn multigraft branch
is positioned in the open
end of the aortic arch,
passing the distal limb into
the descending thoracic
aorta beneath the phrenic
and vagus nerves. The
three adjacent branches of
the graft are cut to the
appropriate lengths and
sutured sequentially to the
brachial arteries beginning
with the left subclavian
artery. (From Kouchoukos
[33])
Results
Left subclavian a.
sewn to graft
339
During a 21-year interval ending in December, 2015, we employed the technique
described above to treat 80 patients with chronic, extensive aortic dissection and
aneurysmal enlargement of the thoracic aorta. During the procedure, all aneurysmal
aorta was resected and replaced with graft; this included the ascending aorta, the
aortic arch, and varying lengths of the descending thoracic aorta. One half or more
of the descending thoracic aorta was replaced in 62 of the 80 patients. Seventy-three
patients had type A dissection (61 of whom had previously undergone repair of
acute type A dissection), and seven patients had type B dissection with proximal
extension. The mean patient age was 57 years (range, 22–81 years), and 72% were
men. Thirteen patients (16%) had genetically mediated connective tissue disorders.
Among the 61 patients undergoing reoperation, the mean interval between the initial and the 1-stage procedures was 62.5 months (range, 1.7–265 months).
In the operating room, the mean transfusion requirements were 8±5.1 units of
packed red blood cells, 6.3±3.9 units of fresh-frozen plasma, 4.6±3 units of platelets, and 10.8±18 units of cryoprecipitate. The average hospital length of stay after
surgery was 20.5 days (median, 11; range, 6–71 days). Regarding early outcomes,
the hospital and 30-day mortality rates were 2.5% (two patients). Six patients (7.5%)
required reoperation for bleeding. Stroke occurred in one patient (1.2%), and spinal
cord ischemic injury (paraplegia) occurred in one patient (1.2%). Renal failure
requiring dialysis occurred in six patients (7.5%), and two of the six patients were
receiving dialysis at the time of hospital discharge. Twelve patients (15%) required
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Fig. 8 After completion of the branch anastomoses, the aortic graft is clamped distal to the left
subclavian artery. The clamps on the three branches are released, and after evacuation of air, the
aortic graft is clamped just proximal to the innominate artery and antegrade ow is established
through the three arteries (arrows). The fourth branch of the graft is ligated. Arterial ow from the
femoral artery is discontinued, and the clamp on the distal thoracic aorta is removed. A segment of
the septal tissue between the true and false lumens is excised to permit perfusion of both lumens,
and the graft is cut to the appropriate length and sutured to the outer circumference of the aorta,
incorporating a strip of polytetrauoroethylene felt. Arterial ow from the femoral artery is discontinued, and antegrade ow is established from the axillary artery. (From Kouchoukos [
A. Kulik and N. T. Kouchoukos
33])
a tracheostomy, nine of whom had the tracheostomy in place at the time of discharge. One patient was treated conservatively for a deep chest wound infection.
At 1-year, the mortality rate was 12% (eight patients). During the follow-up
interval, which extends to 18.2 years, there have been 42 late deaths. No patient
whose cause of death was known died of aortic rupture. Actuarial survival at 5 and
10 years was 76.4% and 52.6%, respectively. Sixty-ve of the 78 hospital survivors
(83%) had serial imaging studies suitable for calculation of growth rates of the
remaining dissected thoracic and abdominal aorta. The annual growth rate of the
distal aorta for the entire cohort was 1.7mm/year. The maximum aortic diameter
increased in 40 patients (mean, 2.8mm/year), remained unchanged in 16 patients,
and decreased in 9 patients (mean, −0.6mm/year). The growth rate was highest for
the 12 patients whose initial aortic diameters were 4.5cm or greater (2.5mm/year).
For the 8 patients in whom the dissection was conned to the thoracic aorta, the
annual growth rate was −0.2 mm/year, whereas it was 1.9 mm/year for the 57
patients in whom the dissection extended into the abdominal aorta.
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Fig. 9 The proximal end
of the graft is cut to the
appropriate length and
sutured to the ascending
aorta just above the aortic
commissures, to an
existing aortic graft, or to a
composite graft. (From
Kouchoukos [
33])
341
Five patients required reoperation on the contiguous thoracic or abdominal aorta
distal to the aortic graft for aneurysmal degeneration at 8, 27, 34, 51, and 174
months postoperatively. Four of the ve patients had replacement of the remaining
thoracic aorta and the abdominal aorta to a level just above the aortic bifurcation,
while the fth patient underwent a hybrid procedure with abdominal debranching
followed by endovascular stent graft repair. No patient whose dissection was conned to the descending thoracic aorta has required reoperation. Actuarial freedom
from reoperation for aneurysmal growth of the contiguous distal aorta at 5 and 10
years was 95.4% and 93% (Fig.10). Seven additional patients required operations
on the aorta or its major branches, on the aortic graft, or the aortic valve for indications unrelated to aneurysmal growth of the contiguous aorta. Actuarial freedom
from any aortic reoperation was 89.2% at 5 years and 81.4% at 10 years (Fig.11).
Survival free of aortic reoperation at 5 and 10 years was 68.6% and 43.9%,
respectively.
Discussion
We have used the 1-stage technique exclusively since 1995 for patients with chronic
aortic dissection who require extensive resection of the thoracic aorta. The bilateral
anterior thoracotomy incision provides excellent exposure of the heart, the
342
P
at Risk
Freedom from Reoperation Contiguous Aorta(%)
100
P
at Risk
Freedom from Any Aortic Reoperation (%)
80 42 19
3
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A. Kulik and N. T. Kouchoukos
100
75
50
25
atients
Reoperation
1 year 98.6% (95%Cl: 90.4%, 99.8%)
5 years 95.4% (95%Cl: 86.3%, 98.5%)
10 years 93.0% (95%Cl: 82.0%, 97.4%)
15 years 74.4% (95%Cl: 26.5%, 93.6%)
0
0
80 45 21
51015
Years Postoperatively
3
Fig. 10 Freedom from reoperation on the contiguous distal aorta for aneurysmal degeneration
after the 1-stage surgical procedure. CI condence interval. (From Kouchoukos etal. [27])
75
50
Reoperation
1 year 97.3% (95%CI: 89.5%, 89.3%)
25
5 years 89.2% (95%Cl: 78.5%, 94.7%)
10 years 81.4% (95%Cl: 67.4%, 89.9%)
15 years 60.1% (95%Cl: 26.8%, 82.2%)
0
0
atients
51015
Years Postoperatively
Fig. 11 Freedom from any aortic reoperation after the 1-stage surgical procedure. CI condence
interval. (From Kouchoukos etal. [27])
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brachiocephalic arteries, both phrenic and the left vagus nerves, and the entire
descending aorta. Injury to the dilated ascending aorta (that can occur with sternotomy during reoperation) is avoided because the transverse thoracotomy incision
is generally made below this level. The wide exposure of the left pleural cavity helps
avoid excessive manipulation of the left lung and the potential for intrapulmonary
hemorrhage in a fully heparinized patient. In the usual scenario, mobilization of the
heart from the pericardium is necessary only along the lateral surface of the right
atrium and the interatrial groove. However, if concomitant CABG is required, exposure of the coronary arteries is easily accomplished. Tricuspid or mitral valve procedures can also be performed with exposure of the right atrium and the
interatrial groove.
Use of the bilateral anterior thoracotomy technique permits resection of the
entire thoracic aorta. This eliminates the need for two-stage procedures and the
attendant mortality and morbidity that can occur in the interval between the stages
or during the second thoracic aortic procedure [34–36]. While the traditional method
for total arch replacement involves the distal aortic anastomosis rst before the arch
anastomosis [37–39], we apply an arch-rst approach and implant a branched aortic
graft. This differs from the older technique where a cuff of aorta surrounding the
brachiocephalic arteries was sutured to the aortic graft. Since longer periods of circulatory arrest are associated with greater risk of perioperative stroke and death [39,
40], with the 1-stage technique described above, antegrade hypothermic cerebral
perfusion is rapidly initiated to minimize the duration of brain ischemia, and the
mean duration of circulatory arrest was 12.1±6.7min. Arterial brain perfusion is
provided via the axillary artery, thus avoiding the need for direct cannulation of the
brachiocephalic arteries (a potential cause of stroke) or a separate perfusion circuit
for the brain.
Several alternative options exist for the management of chronic dissecting aneurysms conned to the thoracic aorta. These include a staged approach, commonly
using the elephant trunk technique, or hybrid procedures using debranching and
stent graft techniques [17–19, 36, 41, 42]. One of the major limitations of a staged
approach relates to the cumulative risk of the two operations and the risk of aortic
rupture in the interval between the stages. In four of the largest reported series of
elephant trunk procedures, which contain a substantial number of patients with
chronic aortic dissection (31–39% of the total), the cumulative mortality for the two
procedures and the risk of death from aortic rupture in the interval between the two
procedures exceeded 20% [18, 19, 34, 36]. Our mortality rate of 2.5% for the 1-stage
operation compares favorably with the early mortality associated with the conventional elephant trunk procedure for the rst stage of a two-stage procedure [18, 19,
34, 36, 43–46]. Applying newer techniques, the frozen elephant trunk operation has
a reported mortality rate of 10.2–15.5% [21–23, 47, 48], and the early mortality
associated with the hybrid debranching option has ranged from 3% to 17% in
reported series [24–26].
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A. Kulik and N. T. Kouchoukos
Despite the sacrice of both internal thoracic arteries using the bilateral anterior thoracotomy approach, we have noted excellent wound healing and only one
deep wound infection in our series. With regards to other perioperative morbidity,
the prevalence of stroke, renal failure, and left recurrent laryngeal nerve injury in
our experience has not exceeded that reported for patients undergoing conventional
rst-stage elephant trunk procedures [17–19, 36, 46], and the intraoperative transfu-
sion requirements have been substantially less [17, 19]. Our rates of stroke (1.2%)
and renal failure requiring dialysis (7.5%) also compare favorably to those reported
from series of patients undergoing the frozen elephant trunk procedure (2.2–9.8%
and 12–22%, respectively) [20–23, 47, 48], or hybrid stent graft procedures (3–8%
and 0–11%, respectively) [24–26]. Of note, in a recent meta-analysis summarizing
the data from 1103 patients treated with the frozen elephant trunk procedure, the
prevalence of spinal cord ischemic injury was 7.9% [49]. With the hybrid procedure,
potentially fatal complications such retrograde aortic dissection can occur [24–26].
The relatively high prevalence of pulmonary dysfunction and need for tracheostomy rate have been considered by other groups to be signicant limitations of the
1-stage procedure [20, 50, 51]. However, our rate of pulmonary complications does
not exceed that reported for the rst stage of a two-stage approach [39]. Among
patients undergoing the conventional 2-stage elephant trunk procedure (sternotomy
for the rst stage), the prevalence of tracheostomy has been reported at 16.5% following the two procedures [46]. For patients undergoing the frozen elephant trunk
procedure, the frequency of prolonged intubation for more than 72 h has been
reported at 12–24% [21, 23]. In our experience with the 1-stage technique, tracheostomy was required in 15% of patients, and with increasing experience, this rate
has decreased [27].
The fate of the distal aorta and the need for subsequent aortic interventions are
important considerations for the management of patients after extensive thoracic
aortic repair. For patients in whom the conventional elephant trunk procedure is
used to treat patients with extensive chronic thoracic aortic dissection, a second
open or endovascular procedure is almost always required, and there is a risk of
death from aortic rupture during the interval between the operations. For patients
treated with the frozen elephant trunk procedure, reintervention on the distal aorta
during follow-up is not infrequent, ranging from 22% to 25% in two of the largest
published series [21, 47]. In the largest series of patients with chronic aortic dissection treated with hybrid procedures, additional stent grafts were needed in 18% of
patients for type I and type II endoleaks during a mean follow-up interval of only 2
years [26]. This may relate to the progressive thickening and stiffening of the septum between the true and false lumen, as well as the presence of multiple septal
fenestrations, limiting the ability of stent grafts to xate to the aortic wall and induce
complete thrombosis of the false lumen [52, 53]. In the aggregate, a substantial
number of aortic reinterventions are necessary following elephant trunk or hybrid
techniques.
However, after the 1-stage procedure, we have noted a reoperation rate on the
contiguous downstream aorta of only 7% at 10 years and a low overall rate of growth
of the distal aorta. These ndings indicate that after replacement of the more
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345
proximal aneurysmal aortic segments using this technique, distal aneurysm formation is infrequent. Possible explanations for the low rates of growth and aneurysm
formation after the 1-stage procedure include stabilization of the aorta at the distal
anastomosis that results from rm xation to the aortic graft with felt buttressing,
and maintenance of ow into both the true and false lumens. Despite the low rate of
reoperation in our series, we continue to advocate annual surveillance with serial
imaging studies after the 1-stage procedure, which is of particular importance in
patients with Marfan syndrome and other genetically mediated conditions, especially since reoperations were required as late as 174 months postoperatively.
Conclusion
Our extended experience with the 1-stage open procedure conrms its safety and
durability for the treatment of chronic aortic dissection with enlargement conned
to the thoracic aorta. The procedure is associated with low operative risk and a low
incidence of reoperation on the contiguous distal aorta. The prevalence of spinal
cord ischemic injury is substantially less than that reported for the frozen elephant
trunk and hybrid procedures. By limiting the duration of circulatory arrest and providing hypothermic cerebral perfusion with axillary cannulation, we have been able
to achieve low rates of stroke and temporary neurologic dysfunction. It remains our
treatment of choice for extensive chronic aortic dissection with aneurysmal dilatation conned to the thoracic aorta, and we believe it represents a suitable alternative
to the 2-stage, frozen elephant trunk and hybrid procedures that are also used to treat
this condition. Because growth of the distal aorta occurs at a variable rate, lifelong
surveillance of patients with chronic aortic dissection is required.
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