Replacement of the Descending Aorta: Recent Outcomes of Open Surgery Performed with Partial Cardiopulmonary Bypass

Abstract

Conclusion: Descending thoracic aortic replacement performed with partial cardiopulmonary bypass (CPB) has compatible risks to that associated with thoracic endovascular aneurysm repair (TEVAR). Summary: Endovascular treatment of descending thoracic aortic aneurysms (TAA) has drastically changed the treatment of this disease. Results are generally favorable, and endovascular treatment can be used even in high-risk patients not considered candidates for open surgery. The authors note that there are several strategies for open treatment of descending TAA. These include a single-clamp technique, distal perfusion with left heart bypass, hypothermic circulatory arrest, and partial CPB. Their technique uses partial CPB with hypothermic circulatory arrest when there is no room for a distal aortic cross-clamp. They compared their results of open distal thoracic aortic repair using partial CPB with literature results for TEVAR. There were 113 patients (75 men) with a mean age of 68 ± 12 years who underwent graft placement for descending TAA not associated with dissection; of these, 16 (14.2%) were emergencies. Operations were performed through a left thoracotomy with partial CPB and segmental clamping of the aorta. The authors also used magnetic resonance angiography preoperatively in elective cases to detect the artery of Adamkiewicz. Intraoperative motor evoked potentials were measured. The early mortality rate was 5.3%, with a 1% mortality rate in elective cases and 31.3% in emergencies. Spinal cord dysfunction was 2.7% overall, 1% in elective cases, and 12.5% in emergency cases. Stroke rates were 7.6% overall, 4.1% in elective cases, and 25% in emergency cases. Respiratory failure rates were 9.7% overall, 9.2% in elective cases, and 12.5% in emergency cases. During follow-up, no patient underwent reoperation secondary to problems with the original open repair. Overall survival estimates using Kaplan-Meier techniques were 92.3% at 3 years, 90.6% at 5 years, and 70.2% at 10 years. Comment: At first glance, one questions the relevance of this article. Although certainly the results presented are excellent, no one can argue that there is a huge difference between a thoracotomy and a small incision in the groin. Therefore, although the results the authors presented may be compatible with those reported for endovascular repair of TAA, morbidity is not. However, not everyone who has a TAA can have an endovascular repair. In cases where there are short or wide proximal or distal landing zones, severe neck angulation, or tortuous or stenotic access arteries, an open TAA repair can certainly be justified based on the results presented here and by others (Ann Thorac Surg 2004;77:1298-303; Ann Thorac Surg 2001;72:481-6).