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II. Anaesthesia for Aortic Surgery
9.5 Conclusion
The anaesthetic management of patients undergoing endovascular treatment is greatly simplified compared
with that for patients undergoing open surgery. Nevertheless, the procedure is mainly reserved for patients
with high morbidity risk or in a traumatic context. A
general anaesthesia enables the insertion of the stentgraft in a highly comfortable condition for the patient
and the operators, even more so since it is now possible
to moderate the depth of the anaesthesia and to ensure
a high degree of security, especially haemodynamic stability.
The evaluation of the technique will enable us to
better pinpoint the indications. Should the procedure be
extended to patients in good medical condition, or
should it still mainly be reserved for older patients with
associated comorbidity, which incurs supplementary
constraints for the anaesthetic management?
References
1. Baker AB, Bookallil MJ, Lloyd G. Intentional asystole during endoluminal thoracic aortic surgery without cardiopulmonary bypass. Br J Anaesth 1997; 78:444±448.
2. Hashimoto T, Young WL, Aagaard BD, Joshi S, Ostapkovich N, Pile-Spellman J. Adenosine-induced ventricular
asystole to induce transient profound systemic hypotension in patients undergoing endovascular therapy. Anesthesiology 2000; 93:998±1001.
3. Kahn RA, Marin ML, Hollier LH, Parson R, Griepp R. Induction of ventricular fibrillation to facilitate endovascular stent graft repair of thoracic aortic aneurysms. Anesthesiology 1998; 88:534±536.
4. Weigand MA, Motsch J, Bardenheuer HJ. Adenosine-induced transient cardiac arrest for placement of endovascular stent-grafts in the thoracic aorta. Anesthesiology
1998; 89:1037.
5. Zarins CK, White RA, Schwarten D, Kinney E, Diethrich
EB, Hodgson KJ, Fogarty TJ. AneuRx stent graft vs. open
surgical repair of abdominal aortic aneurysms: multicenter prospective clinical trial. J Vasc Surg 1999; 29:292±308.
6. Fuchs RJ, Lee WA, Seubert CN. Transient paraplegia after
stent grafting of a descending thoracic aortic aneurism
treated with cerebrospinal fluid drainage. J Clin Anesth
2003; 15:59±63.
7. Kahn RA, Faries PL, Leibowitz AB. Anesthetic techniques
for endovascular repair of thoracic aortic aneurysms: influence of endovascular device design and prevention of
spinal cord ischemia. 2001 ASA meeting abstracts.
8. Ortiz-Gomez JR, Gonzalez-Solis FJ, Fernandez-Alonzo L.
Reversal of acute paraplegia with cerebrospinal fluid drainage after endovascular thoracic aneurysm repair. Anesthesiology 2001;9 5:1288±1289.
9. Ling E, Arellano R. Systematic overview of the evidence
supporting the use of cerebrospinal fluid drainage in thoracoabdominal aneurysm surgery for prevention of paraplegia. Anesthesiology 2000; 93:1115±1122.
10. Coplin WM, Avellino AM, Kim DH, Winn HR, Grady MS.
Bacterial minigitis associated with lumbar drains: a retrospective cohort study. J Neurol Neurosurg Psychiatry
1999; 67:468±473
11. Weaver KD, Wiserman DB, Farber M, Ewend MG, Marston W, Keagy BA. Complication of lumbar drainage after
thoracoabdominal aortic aneurysm repair. J Vasc Surg
2001; 34:623±627.
12. Heller LB, Chaney MA. Paraplegia immediately following
removal of a cerebrospinal fluid drainage catheter in a patient after thoracoabdominal aortic aneurysm surgery.
Anesthesiology 2001; 95:1285±1287.
13. Killen DA, Weinstein CL, Reed WA. Reversal of spinal
cord ischemia resulting from aortic dissection. J Thorac
Cardiovasc Surg 2000; 119:1049±1052.
14. Zimmer S, Heiss MM, Schardey HM, Weilbach C, Faist E,
Lauterjung L. Inflammatory syndrome after endovascular
implantation of an aortic stent ± a comparative study.
Langenbecks Arch Chir Suppl Kongressbd 1998;
115(Suppl I):13±17.
15. Shimazaki T, Ishimaru S, Kawaguchi S, Yokoi Y, Watanabe
Y. Blood coagulation and fibrinolytic response after endovascular stent grafting of thoracic aorta. J Vasc Surg 2003;
37(6):1213±1218.
16. Cross KS, Bouchier-Hayes D, Leahy AL. Consumptive coagulopathy following endovascular stent repair of abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2000;
19(1):94±95.
Surgical Treatment
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Hans-Joachim Schåfers
Chapter
10
Contents
10.1 Introduction ......................
10.2 Prevalence, Symptoms ................. 115
10.3 Pathology ........................ 116
10.4 Prognosis, Indication for Treatment ......... 116
10.5 Diagnostic Investigations ...............117
10.6 Cerebral Protection .................. 117
10.7 Operative Technique ..................118
10.7.1 Incision .................... 118
10.7.2 Cannulation .................. 119
10.8 Type of Replacement .................. 119
10.9 Results .......................... 121
10.10 Conclusions .......................122
115
10.1 Introduction
The treatment of aortic arch aneurysms by aortic replacement was first attempted in the 1950s utilizing
temporary shunts or selective perfusion of the supraaortic vessels to maintain cerebral circulation [1, 2]. The
introduction of deep hypothermic circulatory arrest
greatly facilitated aortic repair, which was standardized
in the 1980s [3, 4]. Several technical modifications have
been proposed in the past 20 years, some of which seem
to be of benefit in special situations. Research in the
past 15 years has focused on cerebral protection in order to minimize the risk of neurological complications
further. Today replacement of the aortic arch for degenerative aneurysm has become a standard and reproducible surgical procedure with low mortality and morbidity.
10.2 Prevalence, Symptoms
While the exact prevalence of aortic arch aneurysms is
unknown, they are less frequent than aneurysms of the
ascending or the infrarenal aorta [5]. This is due to the
fact that aneurysms of the aortic arch may easily be
overlooked in the course of cardiologic diagnostic studies, and an arch aneurysm is rarely diagnosed on a rou-
a
b
Fig. 10.1. Typical computed tomography of the chest with con-
trast in a 65-year-old patient with a true proximal aortic aneurysm. The main involvement is in the ascending aorta, and this
patient can be treated by ascending and partial arch replacement
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III. Treatment of Thoracic Degenerative Aortic Aneurysms
tine chest radiograph performed for other reasons.
Most frequently, arch aneurysms are found as an extension of proximal or distal aortic aneurysms (Fig. 10.1).
Degenerative aneurysms of the arch are commonly
asymptomatic. Occasionally, hoarseness due to stretching of the left recurrent laryngeal nerve leads to the diagnosis of arch aneurysm. Symptoms, such as chest
pain, mostly occur once the aneurysm has either ruptured or perforated into a mediastinal structure.
10.3 Pathology
As in ascending aortic aneurysms, atherosclerosis and
connective tissue disorders are the two most frequent
underlying diseases [5, 6]. Luetic aneurysms have become a rarity. Morphologically, degenerative aneurysms
of the aortic arch are mainly seen in two distinct forms.
The majority of aneurysms are fusiform and thus socalled true aneurysms. They are rarely found isolated in
the arch, but most often represent the arch extension of
proximal, or ± less frequently ± distal aortic aneurysms
(Fig. 10.2). The combination of both proximal and distal aneurysmal disease is not infrequent and is often referred to as mega-aortic syndrome. Saccular aneurysms
are seen in the aortic arch as in other parts of the distal
aorta [7]. They most frequently arise from a ruptured
Fig. 10.2. Two-dimensional reconstruction of computed tomo-
graphy of the chest of a 74-year-old patient with a true distal
aortic aneurysm beginning in the arch and extending into the
distal thoracic aorta. A one-stage operation could be performed through the left chest. Because of the risk of embolism
and the presence of chronic obstructive lung disease a twostage approach with total arch replacement followed by distal
repair seems advisable
Fig. 10.3. Severe atherosclerosis in a 68-year-old patient with
hoarseness of 3 months' duration. There is moderate dilatation
of the arch and a saccular aneurysm, which measured over
3 cm in its largest diameter. The vascular wall of the arch exhibits marked atheroma with a relevant chance of embolism.
The lowest risk of stroke can probably be achieved by total
arch replacement including the use of retrograde perfusion
atherosclerotic plaque, and consequently are not encompassed by all layers of the vascular wall (Fig. 10.3).
Both forms of aneurysms are consequences of atherosclerosis, and aortic arch aneurysm is thus accompanied by other manifestations of atherosclerosis in a significant proportion of individuals. Most important are
coronary heart disease and cerebrovascular disease; impaired renal function is usually an indicator of marked,
generalized atherosclerosis.
10.4 Prognosis, Indication for Treatment
The prognosis of these aneurysms largely depends on
their tendency to rupture or originate acute dissection.
Some information exists on the spontaneous prognosis
of true aneurysms [6, 8], even though the data is very
limited compared with the prognostic information on
coronary heart or valve disease. On the basis of the information available it seems to be clear that these aneurysms tend to grow in size and rupture or dissect with
increasing frequency once a diameter of approximately
5 cm has been exceeded [6, 8, 9]. However, the available
studies either do not differentiate between proximal and
distal aneurysms or fail to clearly point out similarities
or differences between, for example, proximal aorta and
arch. There is only minimal information on the natural
fate of saccular or false aneurysms of the arch [7]. Since
the aneurysmal wall is not composed of all three vascular wall layers it is reasonable to assume a higher tendency to rupture compared with true aneurysms. At
this time, however, it is absolutely unclear at what size
a decision in favor of surgery should be made.
The decision for surgical treatment not only depends
on the natural prognosis, but also on the complication
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117
rate of surgical treatment. In this context not only hospital mortality, but also the occurrence of stroke has to
be taken into consideration. Some data indicate that a
diameter of more than 5.5±6 cm warrants aortic replacement [9]. Nonetheless we realize that the objective
information on which these decisions are based is incomplete, and prospective, randomized interventional
studies are required in order to define the cutoffs for or
against surgical treatment.
We currently decide for surgery once a diameter of
5 cm for true aneurysms and 3 cm for false aneurysms
is exceeded, and if the anticipated combined rate of unwanted major complications (death and stroke) does
not exceed 4±5%.
10.5 Diagnostic Investigations
A computed tomography (CT) scan of the chest will be
available for almost all patients at the time of referral.
It gives almost all the information necessary regarding
the aorta itself, i.e., diameters, extension of the aneurysmatic process, and anatomical relationship with neighboring structures including the chest wall. If not already available, a CT or an MRI scan should be available before every operation performed on an elective
basis. It is of vital importance when planning any aortic
reoperation in order to be able to develop the operative
strategy including entry into the chest.
Coronary heart disease and chronic obstructive pulmonary disease are the two commonest associated entities. Carotid artery disease is less common, and the role
of carotid stenosis or its treatment in the context of
aortic surgery has not been well defined.
It is advisable to perform an echocardiogram and a
left heart catheterization for every patient over the age
of 40 years scheduled for elective arch surgery. If coronary artery or heart valve disease is documented, it will
also influence the type of procedure to be performed.
An aneurysm of the distal arch can be reached well
through a left-sided incision; in the presence of significant coronary disease it is better approached through a
sternotomy. In the presence of severe left ventricular
dysfunction without correctable cardiac disease, the patient's prognosis will primarily be determined by this
factor, and one should reconsider a decision for surgical
treatment of the arch aneurysm.
The results of pulmonary function testing will similarly influence the decision for surgery. The presence of
chronic obstruction lung disease has been shown to
have an adverse effect on postoperative long-term survival even in patients that appeared to be good or reasonable surgical candidates. More importantly, severe
pulmonary dysfunction may carry a prognosis that is
worse than that of the aneurysmal disease, and it is
doubtful whether the patient will benefit from any pro-
cedure. The presence of respiratory limitations must
also be taken into consideration in choosing the surgical approach; a median sternotomy is much better tolerated in these instances than a bilateral or posterolateral
incision.
We try to be thorough in our diagnostic workup in
order to be able to make the best decision possible before performing an extensive operation. In addition to
CT, every patient undergoes pulmonary function testing, Doppler examination of the carotid arteries, an
echocardiogram, and left heart catheterization. An aortogram is only performed if stenosis of an arch vessel
is suspected on clinical grounds or by Doppler studies.
10.6 Cerebral Protection
Cerebral protection is of central importance in surgery
of the aortic arch [10, 11]. Historically the first
approach to be utilized was antegrade perfusion of the
supraaortic vessels in order to completely avoid interruption of cerebral blood flow. Although this made the
first replacements of the arch possible, it never gained
wide acceptance. The concept of hypothermic circulatory arrest was based on the early investigations of
Bigelow [12] and others [13, 14], who found that decreased body temperature markedly increased the tissue
tolerance to ischemia. In the 1980s, most surgeons used
hypothermic circulatory arrest only, and reproducible
operations on the aortic arch became feasible [3, 4]. It
became clear, however, that hypothermia alone did not
provide unlimited cerebral protection, and there was
still a relevant risk of stroke.
For many years it was believed that a nasopharyngeal temperature of 16±188C allowed up to 60 min of
circulatory arrest and was thus ªsafe.º Further clinical
experience led to the realization that not only mortality,
but most importantly the risk of stroke increased with
the duration of circulatory arrest if arrest times exceeded 45 min [15, 16]. More recent follow-up information and neuropsychological testing results showed that
the risk of stroke and also neurological dysfunction including confusion increases beyond arrest times of
20±30 min [17±19]. Most importantly, a significant proportion of patients who have recovered from confusion
are later compromised by permanent cognitive dysfunction [19]. On the basis of clinical data from aortic surgery, an arrest time of 20±30 min thus appears safe
[18]; this, however, has not been unequivocally proven.
The experience with hypothermic circulatory arrest in
conjunction with pulmonary thromboendarterectomy
for chronic pulmonary embolism creates an even more
confusing picture. In these operations a circulatory arrest time of 40 min is not uncommon, and in more
than 160 patients treated in our institution there has
been no stroke, and confusion has occurred in less than
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III. Treatment of Thoracic Degenerative Aortic Aneurysms
3% of the patients. Thus, the true safe duration of hypothermic circulatory arrest is still unknown.
Retrograde perfusion was first used by Ueda et al.
[20] in order to provide cerebral blood supply during
the period of antegrade circulatory arrest. It was shown
to provide cooling of the brain and was felt to also provide some protection against embolism of air and atherosclerotic debris. Cerebral edema can occur, however,
and close monitoring of central venous pressure as the
retrograde perfusion pressure is necessary [21]. Subsequent animal research and clinical studies indicated that
the evidence of blood flow and thus oxygen supply to
the brain was weak or nonexistent [22±24]. Thus, the
exact role of retrograde perfusion in cerebral protection
is currently unclear, but it provides additional cerebral
cooling and minimizes the possibility of emboli [21].
Antegrade perfusion ± historically the first technique
of neuroprotection ± has recently been used again with
increasing enthusiasm. Several groups proposed a drastic reduction in the incidence of stroke and temporary
neurological dysfunction [25±28]. It was also felt that
the degree of hypothermia necessary for adequate cerebral protection was less and thus the time of extracorporeal circulation reduced. There are, however, still concerns over the possibility of embolism during introduction of the perfusion catheters and subsequent perfusion. Several clinical series, in which a definite advantage of antegrade perfusion was found, were characterized by long times required for arch repair in excess of
45 or even 60 min [29±32]. It is unclear whether these
times were prolonged because of the presence of perfusion cannulae in the field, or rather by careful performance of difficult operative procedures.
Currently the risk of stroke is approximately 3±5%
in many series for arrest times of up to 30 min, regardless of the type of cerebral protection used [25, 33, 34].
The risk of stroke appears to be primarily related to the
presence of atherosclerotic risk factors and the age of
the patient [16]. While this risk is not negligible, it
compares with an incidence of 2±3% after coronary surgery or aortic valve replacement in patients of similar
age groups [35]. Only if anticipated interruption of cerebral blood flow exceeds 30±40 min, antegrade perfusion gives a clear advantage over deep hypothermic circulatory arrest alone. Retrograde cerebral perfusion appears to be of benefit only if the risk of embolic stroke
is high, such as in the presence of abundant atherosclerotic debris in the lumen of the aortic arch [36].
It is at present unclear whether cerebral ischemic
tolerance can be extended by pharmacologic adjuncts.
On the basis of animal experiments, barbiturates, corticosteroids, and even lidocaine have been proposed for
this purpose. There is evidence that the reduction of excitation (e.g., by barbiturates) does indeed reduce neuronal oxygen requirement and prolongs the safe duration of cerebral ischemia [37]. It is unclear, however,
whether this effect is also present when the patient has
been anesthetized with other narcotics. Corticosteroids
have been used by several groups without clear clinical
evidence of their effect [38, 39]. Recent data suggest
that steroids would probably have to be administered
several hours before the operation to limit potential cerebral damage [39]. The insufflation of CO
used increasingly in order to minimize air embolism
[40]. The effect has not been clearly proven in prospective studies, but its use leads to a remarkable reduction
of intracardiac bubbles, as documented by transesophageal echocardiography.
For partial arch replacement, the anticipated arrest
time in our hands is almost always less than 20 min; in
this situation we employ hypothermic arrest with a nasopharyngeal temperature of 19±21 8C. In most patients
with degenerative aneurysm who require total arch replacement, an arrest time of less than 30 min will be
necessary, and again hypothermic circulatory arrest
with a nasopharyngeal temperature of 16±18 8C is used.
If unforeseen problems are encountered during dissection of the arch already under conditions of arrest, a
Dacron graft is anastomosed in end-to-end fashion to
the origins of the supraaortic branches (Fig. 10.11).
Antegrade perfusion of the arch vessels can then be resumed either via the axillary artery or by direct cannulation of the graft itself. This will then give sufficient
time for most of the arch repair procedure to be completed without the pressure of cerebral ischemic time.
We utilize retrograde perfusion only if marked atheromas are present in the lumen of the arch in order to
minimize the risk of embolism.
has been
2
10.7 Operative Technique
10.7.1 Incision
The choice of incision primarily depends on the exact
procedure planned, taking into consideration exposure,
morbidity of the incision itself, and the options to minimize neurologic complications. As a rule, a median
sternotomy provides excellent exposure for any procedure involving the proximal or total arch. A left posterolateral thoracotomy in the fourth or fifth intercostal
space provides excellent exposure for a distal arch procedure, especially if additional surgery is necessary on
the descending aorta. It also allows total arch replacement to the level of the distal ascending aorta. A bilateral thoracotomy gives easy access for any procedure on
the thoracic aorta [41] except for more complex operations on the aortic root.
The morbidity of the incision is primarily related to
the degree of respiratory impairment. The median sternotomy leads to minimal impairment; a lateral thoracotomy will reduce postoperative FEV1 by 20±30%. This
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119
ab
Fig. 10.4.
cending aorta. The patient had become symptomatic with hemoptysis and had been referred on an emergency basis. The
apex of the left hemithorax is filled by the aneurysm, the increased antero-posterior diameter in
of significant obstructive lung disease. Aortic replacement
True aneurysm of the aortic arch and proximal des-
c underlines the presence
through a left thoracotomy would be associated with an increased risk of embolism during retrograde perfusion. The diameter of the distal aorta is acceptable at the level of the left
pulmonary artery and can thus be reached from a median sternotomy as part of total arch replacement
10.7.2 Cannulation
The place of arterial cannulation has become an important aspect of aortic arch surgery irrespective of the
type of cerebral protection to be used. Traditionally,
femoral arterial cannulation was the standard in most
aortic procedures. In the past 10±15 years it has been
realized that this could contribute to an increased incidence of neurological complications, possibly due to
embolization of chronic thrombus or atherosclerotic
debris from the descending aorta during perfusion with
retrograde flow [42, 43]. Cannulation of the proximal
aorta ± either in a normal segment or direct cannula-
Fig. 10.5. Congenital anomalies may pose difficulties for surgi-
cal exposure, as in this patient with distal arch aneurysm,
right-sided descending aorta, and an aberrant left subclavian
artery. A bilateral thoracotomy is probably the best approach
for these anatomical variant
tion of the aneurysm ± has repeatedly been shown to
be associated with decreased risk of stroke. Most recently, cannulation of the right axillary artery either directly or via a short vascular graft anastomosed to the
artery has become an alternative, and is not only used
in acute dissection, but also in the presence of arch ancan lead to dyspnea, atelectasis, hypoxemia, and prolonged mechanical ventilation and intensive-care stay. A
bilateral thoracotomy has been used infrequently for
aortic surgery ]41]. In pulmonary surgery it has been
shown to be associated with the highest degree of postoperative pain and pulmonary impairment. The limited
experience in aortic surgery seems to confirm this impression.
eurysm [42, 43].
For reasons of simplicity, we cannulate the aorta in
almost all instances. If this is impossible or inadvisable,
such as in reoperations with close proximity between
the aorta and the chest wall, an 8-mm graft is connected to the subclavian/axillary artery and cannulated
directly. The use of a graft minimizes the risk of trauma
to the axillary artery and facilitates decannulation.
We thus use a median sternotomy in most instances
of arch replacement if the distal anastomosis is at the
level of or superior to the left pulmonary artery
(Fig. 10.4). In the remaining patients we prefer the bilateral thoracotomy because of exposure, the possibility
of antegrade perfusion, and facilitated deairing of left
heart and aortic arch (Fig. 10.5).
10.8 Type of Replacement
The type of replacement has been the subject of continuing controversy. After the introduction of the deep
hypothermic circulatory arrest, orthotopic tubular replacement of the aortic arch became the standard, at
cc
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III. Treatment of Thoracic Degenerative Aortic Aneurysms
Fig. 10.6. Schematic drawing of ascending and partial arch re-
placement. The exact level of the distal anastomosis has little
or no impact on morbidity or mortality
least in the hands of most European and American
groups. Partial or complete replacement of the arch was
performed, depending on the pathology of the arch to
be treated. Partial arch replacement consisted of an
open oblique anastomosis to any level of the arch, and
the procedure was termed proximal arch, subtotal arch,
or hemiarch replacement (Fig. 10.6).
Complete replacement implies an end-to-end anastomosis to the descending aorta with implantation of a
patch of aortic wall carrying the origins of the supraaortic branches into the graft (Fig. 10.7). By contrast, several Japanese surgeons have preferred individual connections of the supraaortic vessels to side arms of
a trifurcated aortic graft [27]. The Griepp group [44]
proposed a similar approach with individual anastomoses to the arch vessels in a more individualized fashion.
The evidence produced by the different groups with
heterogenous patient populations is not very clear regarding superiority of one approach over others. It is
quite apparent, however, that partial replacement of the
arch in the form of an open anastomosis carries the
least technical difficulty, is least prone to surgical hemorrhage, and can be performed in the shortest time. In
fact, the time necessary to perform this anastomosis is
more or less identical to the duration of circulatory arrest necessary to install perfusion catheters, if selective
antegrade cerebral perfusion is utilized.
For complete arch replacement, traditional tubular
replacement with patch implantation of the arch vessels
is still the standard. This can be performed within a
period of 25±30 min, thus carrying a minimal risk of
Fig. 10.7. Schematic drawing of total arch replacement with one
anastomosis to the descending aorta and a second connection
for reimplantation of the supraaortic vessels
temporary or permanent neurological dysfunction. If
longer times for repair are anticipated, a modification
used by the New York group appears as the best alternative [10, 34]. In this technique, the origins of the supraaortic vessels are mobilized with a patch of aortic
wall. An oblique anastomosis is created between a
16±18-mm graft and the aortic patch, reqiring approximately 10±15±min of arrest. Antegrade perfusion can
then be resumed via this graft or the axillary artery,
and a second graft (22±26 mm) is anastomosed to the
descending aorta (Fig. 10.11). Both grafts are then connected, either during continuous perfusion via the right
axillary artery or during another brief period of arrest.
The concept of an elephant trunk extension of the
graft into the descending aorta (Figs. 10.8, 10.9) was
developed by Borst et al. [45] in order to facilitate subsequent downstream aortic replacement. For total arch
replacement the graft is invaginated and placed in the
descending aorta. The anastomosis is created between
the fold and the descending aorta. The graft is then unfolded for implantation of the supraaortic vessels.
Saccular aneurysms often occur in the presence of
marked atheroma in the wall of the aortic arch. In order to prevent cerebral embolism, total arch replacement with an anastomosis to aortic wall of reasonable
quality appears as the best solution. Alternatively, separate anastomoses may be created at the level of the individual supraaortic branches, where the degree of
atherosclerosis is usually less pronounced. If the aortic
wall is of reasonable quality, the false aneurysm may
also be treated by implantation of a Dacron patch into
the margins of the intact vascular wall (Fig. 10.10). This
approach requires the shortest arrest time for completion.
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Fig. 10.10. Schematic drawing of patch repair for saccular aneu-
rysm of the aortic arch. This may be helpful if inflammatory
Fig. 10.8. Schematic drawing of total arch replacement with the
elephant trunk modification. The extension of the graft in the
descending aorta facilitates later distal aortic replacement. The
arterial perfusion cannula can be introduced into a side arm of
the graft as shown in this illustration. Alternatively, it may be
inserted directly into the graft through a stab incision or via
the right axillary artery
changes make dissection of the arch difficult for total arch replacement. There are, however, few data on the long-term durability of this repair
121
Fig. 10.9. Computed tomography of the chest after total arch re-
placement with an elephant trunk. The graft extension can be
seen easily; there is the of beginning thrombosis of the aortic
lumen around the trunk
We commonly perform standard replacement of the
aortic arch with one anastomosis to the descending aorta and a second connection between the graft and a
patch of aortic wall carrying the origins of the supraaortic vessels. With this standardized approach the
circulatory arrest time is less than 30 min in almost all
instances, and our stroke risk has been low. If this is
difficult, such as in acute dissection, we resort to the
two-graft modification with one graft connected in an
oblique fashion to the aortic patch with the brachiocephalic vessels (Fig. 10.11). A second graft is anastomosed to the descending aorta, and the grafts are then
connected.
Fig. 10.11. Schematic drawing of the modified technique for to-
tal arch replacement which limits the necessary time of interruption of cerebral blood flow. In the first step an oblique endto-end anastomosis is created between the aortic button carrying the origins of the head and neck vessels. Antegrade perfusion of the head can then be resumed through the right axillary artery (as shown) or by direct cannulation of the graft. A
second graft is then anastomosed to the descending aorta, and
the grafts are connected. This technique not only limits the
duration of cerebral ischemia, but also facilitates surgical hemostasis at the distal anastomosis to the descending aorta
10.9 Results
Hospital mortality mainly depends on the urgency of
the operation, age, and the presence and degree of
atherosclerosis. Elective arch replacement is possible
with a mortality rate of 2±6%. In patients over the age
of 80 years, mortality may be as high as 8±15%. In
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III. Treatment of Thoracic Degenerative Aortic Aneurysms
emergency situations, the presence or absence of shock
prior to the operation appears to be the primary determinant of survival.
In our own 9-year experience consisting of approximately 800 thoracic aortic operations for aneurysm or
dissection, 524 were performed on patients with degenerative aneurysm of the proximal aorta. Of these, 217
patients underwent elective arch replacement. Hospital
mortality has been low despite the need for concomitant mitral and coronary artery bypass surgery. For
elective ascending aortic replacement, early mortality
was 4.6% (14/307), compared with 2.0% for partial arch
replacement (3/148) and 5.8% (4/69) for total arch replacement. Thus, mortality was not increased by the
addition of arch replacement with circulatory arrest
compared with replacement of the ascending aorta only.
The published incidence of stroke varies considerably between series and ranges from 2 to 8% [15, 16,
19, 20, 25±32]. The incidence of stroke in our experience is identical between ascending aortic and arch replacement (2.1 vs. 2.0%). The incidence of temporary
neurologic dysfunction seems to depend on similar factors and patient age [19]. In our series the risk of developing temporary neurologic dysfunction including confusion was higher after arch repair with circulatory arrest (8.3 vs. 12.1%). By multivariate analysis, the presence of peripheral vascular disease was the only risk
factor for stroke. Age and indicators of generalized
atherosclerosis were significant risk factors for the development of temporary neurologic dysfunction. There
was no relationship between hypothermic circulatory
arrest and temporary neurologic dysfunction. Persistent
dysfunction of the left recurrent laryngeal nerve was
seen in three patients after total arch replacement, and
this incidence of 4% is lower than that seen with descending aortic and arch replacement through the left
chest.
10.10 Conclusions
Replacement of the aortic arch for degenerative aneurysms is a standardized procedure which can be performed with a low risk. Both operative technique and
cerebral discussion are still the subject of controversial
discussion. In many patients standard arch replacement
using hypothermic arrest yields excellent results. Technical modifications should be kept in mind to be able
to apply an individualized approach to patient and aortic pathology in difficult situations.
References
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