Interact CardioVasc Thorac Surg 2007;6:283-287. doi:10.1510/icvts.2006.144428
© 2007 European Association of Cardio-Thoracic Surgery
Institutional report - Vascular thoracic |
Total arch replacement for aneurysm of the aortic arch: factors influencing the distal anastomosis
Mitsuru Asano,
Kenji Okada,
Keitaro Nakagiri,
Hiroshi Tanaka,
Yujiro Kawanishi,
Masamichi Matsumori,
Hiroshi Munakata and
Yutaka Okita*
Department of Cardio-Pulmonary and Vascular Medicine, Division of Cardiovascular, Thoracic, and Pediatric Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
Received 16 September 2006;
received in revised form 26 January 2007;
accepted 29 January 2007
 Presented at the joint 20th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 14th Annual Meeting of the European Society of Thoracic Surgeons, Stockholm, Sweden, September 10–13, 2006.
*Corresponding author. Tel.: +81-78-382-5942; fax: +81-78-382-5959.
E-mail address: yokita{at}med.kobe-u.ac.jp (Y. Okita).
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Abstract
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Total arch replacement (TAR) for aneurysm of the aortic arch through the midsternotomy has several advantages over left thoracotomy. The purpose of this study was to identify the factors that might have an effect on the distal anastomosis through midsternotomy. From October 1999 to August 2005, 125 patients underwent TAR for aneurysm of the aortic arch through midsternotomy. Ninety-four patients with antegrade cerebral perfusion were selected. Distal anastomosis was performed under circulatory arrest (CA) of the lower body. Preoperatively, the diameter of aneurysm, the depth of distal end of aneurysm from anterior skin surface and the anteroposterior diameter of body trunk were measured. Postoperatively, the distance from the carina to the distal anastomosis was measured. There were six early deaths (6.4%). Duration of CA was 37±7.6 min. Diameter of the aneurysm was 60.6±13.2 mm and the depth of the distal end of aneurysm was 139±20.6 mm. There was no correlation between CA time and these factors. The anteroposterior diameter of body trunk was 200±18.0 mm and has a correlation with CA time. The depth of distal end of aneurysm from anterior skin surface was the only factor that affected duration for distal anastomosis.
Key Words: Total arch replacement; Arch aneurysm; Circulatory arrest; Midsternotomy
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1. Introduction
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Surgical treatment of arch aneurysms has remarkably improved in recent years [1, 2]. Total arch replacement (TAR) for aneurysm of the aortic arch through the midsternotomy has several advantages [1]. However, in TAR, distal anastomosis through midsternotomy is sometimes compromised because of a fragile aortic wall, and narrowed or deep working space. In anecdotes, midsternotomy was used for the aneurysm of arch approximately at the level of tracheal bifurcation and if the aneurysm extended more distal, left thoracotomy was employed [1]. The definitive indications of midsternotomy for arch aneurysm were not reported. The purpose of this study was to identify the factors that might affect on the distal anastomosis when the arch aneurysm was entered from the midsternotomy.
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2. Patients and methods
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2.1. Patients
From October 1999 to August 2005, 130 consecutive patients with non-dissected aneurysm of the aortic arch underwent TAR in our institution. In 125 patients, the aneurysms could be approached through midsternotomy alone. For brain protection, selective antegrade cerebral perfusion (SCP) was used in 94 patients and deep hypothermia circulatory arrest, with retrograde cerebral perfusion in 31 patients. In this study, patients who had SCP were selected. Mean age was 74±6 (57–86) years. Aneurysm shapes were 51 fusiform and 43 saccular.
2.2. Operative techniques
Cardiopulmonary bypass (CPB) was established by using ascending aortic cannulation and bicaval drainage. Both antegrade and retrograde cardioplegia were used to myocardial protection. Aneurysm was opened under deep hypothermic (nasopharyngeal temperature 23 °C) circulatory arrest (CA). SCP for the cerebral protection was started with balloon-tipped catheters which were selectively inserted in all three arteries. The orifice of the descending aorta, which was distal to the aneurysm, was transected from inside of the aneurysm without touching the left vagal nerve and the left recurrent nerve. Aggressive dissection and division of the esophageal branches, bronchial arteries, and upper intercostal arteries facilitated adequate mobilisation of the descending aorta. A quadrifurcated Dacron graft was used and distal anastomosis was performed with 4-0 polypropylene suture with reinforcement of a Teflon felt strip. Rewarming was started after the distal anastomosis. In patients without intra- or extra-cranial vascular lesions, the ascending aorta to graft anastomosis was achieved and the coronary arteries were reperfused. Finally, individual anastomosis of the left subclavian artery, the left common carotid artery, and the brachiocephalic artery to the graft branches were performed with 5-0 polypropylene suture. For patients who had cranial vascular obstructive lesion, reconstruction of arch vessels was performed prior to rewarming and to the proximal anastomosis (Fig. 1).
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Fig. 1. (a) Aneurysm was opened after circulatory arrest. (b) Selective antegrade perfusion (SCP) was started with selective three balloon catheters. The descending aorta was transected from inside of the aneurysm. (c) Using a quadrifurcated graft, distal anastomosis was performed with 4-0 polypropylene suture with Teflon felt reinforcement under deep hypothermic (23) circulatory arrest of the lower body. (d) During rewarming, the ascending aorta was anastomosed, then individual reconstruction of arch vessels to the graft branches was performed.
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2.3. Measurements
Preoperatively, the diameter of aneurysm (Fig. 2), the depth of distal end of aneurysm from anterior skin surface (Fig. 2b) and the anteroposterior diameter of body trunk (Fig. 2c) were measured using computed tomography (CT). During the operation, the aortic wall was subjectively evaluated according to the severity of atherosclerosis in the point of aortic fragility and calcification, and classified into three grades (1: mild, 2: moderate, 3: severe). Postoperatively, distance from the middle point of the tracheal bifurcation to the distal end of the anastomosis was measured by CT (Fig. 3).
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Fig. 2. The diameter of aneurysm (a), the depth of distal end of aneurysm from anterior body surface (b), and the anteroposterior diameter of body trunk (c), was measured by computed tomography.
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Fig. 3. The postoperative distance from tracheal bifurcation to the distal end of the anastomosis by CT.
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2.4. Statistical analysis
All analyses were performed using the Stat view version 4.5 statistical package (Abacus Concepts Inc., Berkeley, CA) and Sigmastat software.
Continuous data are expressed as the mean±standard deviation. Multivariate logistic regression was used to identify independent predictors of prolonged CA and the correlations between CA time and four factors (a d) were analysed. A P-value of 0.05 or less was considered significant.
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3. Results
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The overall in-hospital mortality was 6.4% (6 of 94 patients). No patients required additional skin incision or left pleurotomy. Two patients died due to respiratory dysfunction, two multi-organ failures, one low output syndrome and one sepsis. As the morbidity, 5 patients (5.3%) had respiratory dysfunction, 3 (3.2%) mediastinitis, 3 (3.2%) renal dysfunction, and 3 (3.2%) neurological dysfunction, and 4 (4.3%) hoarseness.
3.1. Preoperative measurements
The mean diameter of aneurysm was 60.6±13.2 mm. The mean distance between distal end of aneurysm and anterior skin level was 139±20.6 mm (Table 1).
3.2. Intra-operative measurement
Duration of lower body CA was 37±7.6 min. The aortic wall score at the distal anastomosis, which was subjectively evaluated by a surgeon (Y.O.), was grade one (normal or trivial) in 24 patients, grade two (moderate) in 25, and grade three (severe) in 36. The mean aortic score was 1.92±0.9. Eighteen patients required a longer CA time (over 40 min). The main reasons for this time consuming was fragile aortic wall; two had aortic injury, one needed concomitant endoarterectomy, and one had adhesion to pleura. In five patients, the surgeon subjectively felt that the distal anastomosis was very deep (Tables 1 and 2).
3.3. Postoperative measurements
The distance from the distal end of the anastomosis to the mid-portion of the tracheal bifurcation was 10.7±7.9 (–10 to 30) mm (Table 1).
3.4. Correlation
The correlation between CA time and the five factors: the diameter of aneurysm (Fig. 4a), the depth of the distal end of aneurysm from anterior skin (Fig. 4b), the anteroposterior diameter of body trunk (Fig. 4c), and the distance between the distal end of the anastomosis and the tracheal bifurcation (Fig. 4d) were analysed. There was no significant correlation between CA time and the diameter of aneurysm, the anteroposterior diameter of body trunk, and the distance from the distal end of the anastomosis to the tracheal bifurcation. However, a weak correlation between the depth of distal end of aneurysm from the anterior skin and with CA time was found (P=0.0085, R2=0.11).
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Fig. 4. The correlation between the CA time and (a) the diameter of aneurysm, (b) the depth of distal end of aneurysm from anterior body skin level, (c) the anteroposterior diameter of body trunk, (d) the distance from tracheal bifurcation to the distal end of the anastomosis.
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The logistic regression for multivariate analysis demonstrated that the depth of distal end of aneurysm from the anterior skin level over 150 mm was the only risk factor (OR: 28.1; CI: 1.73–456.9; P=0.02) for CA time over 40 min (Table 3).
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4. Discussion
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The surgical treatment for arch aneurysms has remarkably improved in recent years, and operative mortality was reported as low as 0.8–5.3% [1, 2]. The most common approach for aortic arch down to distal arch aneurysm is through midsternotomy [1–3]. This approach has several advantages in cerebral, cardiac, pulmonary and recurrent nerve protection, which reduces postoperative respiratory dysfunction and wound pain caused by left thoracotomy [1, 4]. Benefits of the midsternotomy are feasible access for ascending aortic cannulation and establishment of an ordinary cardiopulmonary system, combined surgery such as aortic valve or coronary surgery, more appropriate brain protection using SCP [3, 5] and myocardial protection, and less impairment of respiratory function than left thoracotomy. The posterolateral left thoracotomy approach provides some advantages such as wider exposure of the distal part of the aortic arch, however, a femoro-femoral bypass was normally required, which might produce cerebral embolism caused by a result of retrograde perfusion [6]. In addition, manipulation of the left lung sometimes causes serious bronchial bleeding, particularly in the setting of deep hypothermia, and may lead to pulmonary complications. Also from the left thoracotomy, isolation of the left vagal nerve is mandatory to make an anastomosis. There have been several alternatives for the exposure of the distal aortic arch besides the posterolateral left thoracotomy; L-shape incision approach (a combination of a left anterior thoracotomy and upper half midsternotomy), midsternotomy with left anterolateral thoracotomy and anteroaxillary thoracotomy [7–9]. However, no study which accumulated a significant number of patients was reported. Procedures regarding the distal anastomosis in TAR would be the most difficult part during the operation. Severely diseased aorta of distal arch and deep anastomotic site within a narrow working-space, particularly in larger male patients, makes this procedure more technically demanding [1, 2]. Minatoya et al. applied ‘a stepwise technique’ to facilitate the distal anastomosis, such as suturing a separate graft first as a short elephant trunk then making a graft to graft anastomosis [2]. Regarding the extension of the thoracic aneurysm for surgical anastomosis, Ogino et al. reported that for aneurysms from the aortic root to the end of the aortic arch, the median approach is feasible and that from the end of the ascending aorta to the mid-portion of the descending aorta the anterolateral approach is preferable, and from the proximal descending aorta to the distal part of the descending aorta, the posterolateral approach should be employed [1]. Our aim in this study was to identify the factors that might affect the distal anastomosis of TAR when the aneurysm was entered from the mid line. The diameter of aneurysm indicates the area of working-space and the depth of distal end of aneurysm from anterior skin surface shows depth of working-space. The anteroposterior diameter of body trunk shows the body size. We speculated that the depth of anastomosis, the room for working-space and the characters of aortic wall might affect the quality of distal anastomosis. However, our data demonstrate that only the depth of distal end of aneurysm, which was analogue to the depth of anastomosis from the midsternotomy, was proven to be a risk factor for a longer CA time. The distal anastomosis could be safely performed at the level of 10 mm distal to the tracheal bifurcation regardless of the diameter and the shape of the aneurysm, the antero-posterior diameter of body trunk, and aortic wall quality. Although there was a tendency that a fragile aortic wall required longer CA time >40 min.
In conclusion, the aneurysm of the aortic arch was safely accessible from the midsternotomy down to the level of tracheal bifurcation. We could reach a portion 1 cm lower from tracheal bifurcation without being affected by working space, shape of aneurysms and the quality of aortic wall. Only the depth of distal anastomosis from anterior body surface is the risk factor for a longer CA time.
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Conference discussion
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Dr. D.C. Miller (Stanford, California, USA): Please tell us the weight, number of kilograms, and body surface area, BSA in meters squared, for your patients.
Dr. Okita: Our patients are quite small compared to Caucasian people. Our average body weight is around 50 and 60, and including a 30 kg 80-year-old lady. So quite small.
Dr. E. Buffolo (Sao Paulo, Brazil): The cases presented by Dr. Okita's group represent, in our opinion, a good application of the hybrid approach. In this case, what would we do? It will be a median sternotomy. And if the patient has normal, or almost normal, ascending aorta, we would apply a stent in the aortic arch and do anastomotic deviation to the arch vessels. This is a very simple procedure, does not need extracorporeal circulation or even deep hypothermia and circulatory arrest. It's simple vascular surgery. Since the last patients, I do not remember cases that I operate the aortic arch with extracorporeal circulation. I think that these cases are good indications to the hybrid approach.
Dr. Miller: I'll be polite and not ask you about the long-term durability of this hybrid approach; but you've made a very provocative and even inflammatory point. Furthermore, for the patients' sake we do not want the vascular surgeons to be doing these kind of hybrid arch operations without us.
Dr. Okita, can you respond to Dr. Buffolo's suggestion that we do these cases without the pump and without circulatory arrest?
Dr. Okita: I'm sorry we cannot show the videos. But if you go, in some patients, the arch is very dirty; and we don't want to embolize with an endovascular graft.
Our data shows that our circulatory arrest time is around 40 min. That means very stable and very encouraging results. So we don't want to do endovascular surgery like that.
Dr. Miller: I would love to do total arch replacements in 40 kilo patients. The exposure would be like an inguinal hernia repair for us compared to the huge and obese American patients we operate on all too commonly.
Dr. Okita: I don't agree.
Dr. Miller doesn't know how small our patient is. And the 30 kg, 80-year-old lady is very fragile. It's very difficult conditions.
Dr. Miller: I would take that patient any day over a 130 kg, 2.5 square meter 'gringo' in North America or lumberjack in northern Europe.
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References
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- Minatoya K, Ogino H, Matsuda H, Sasaki H, Yagihara T, Kitamura S. Surgical management of distal arch aneurysm: another approach with improved results. Ann Thorac Surg 2006; 81:1353–1357.[Abstract/Free Full Text]
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Abstract
1. Introduction
