Surgical Approaches to Nondissecting Atherosclerotic Aneurysms of the Distal Aortic Arch or Proximal Descending Aorta Using Deep Hypothermic Circulatory Arrest with Retrograde Cerebral Perfusion: Midsternotomy and Left Lateral Thoracotomy

Abstract

Surgical results in patients with nondissecting atherosclerotic aneurysms of the distal aortic arch or proximal descending aorta were investigated in relation to two approaches to the aneurysm: midstemotomy or posterolateral left thoracotomy. From May 1993 to April 1998 a total of 118 patients with nondissecting aneurysms of the distal arch underwent surgery. Patients were divided into two groups: 73 patients with midstemotomy (group A) and 45 with posterolateral left thoracotomy (group B). The mean ages were 70.4 ± 5.9 years in group A and 68.5 ± 9.0 years in group B. Indications for midstemotomy were severe atherosclerosis of the proximal arch in 30 patients, aneurysms involved the proximal arch in 15, ruptured aneurysm in 8, chronic obstructive pulmonary disease in 7, coronary artery bypass grafting of the right coronary artery in 5, redo after left thoracotomy in 5, severe aortic regurgitation in 3, carotid surgery in 2, and the presence of an aberrant right subclavian artery in 2. Indications for left thoracotomy were coexistent aneurysms of the descending aorta in 26 patients, normal proximal arch in 16, redo after midstemotomy in 2, and ruptured aneurysm in 1. A technique using deep hypothermic circulatory arrest with retrograde cerebral perfusion was used in all patients. In group A, 65 patients had total arch replacement, 3 distal arch replacement, 1 distal arch and descending aorta replacement, and 5 patch repair. In group B, 2 patients had total arch replacement, 16 replacement of the distal arch, 23 distal arch and descending aorta replacement, and 4 patch repair. There were eight hospital deaths in group A compared with three in group B. One patient in group A had a stroke, as did 5 in group B (P = 0.019). Transient brain dysfunction was found in 23 patients of group A and in 14 of group B. There was no difference in operating time or bypass time, but circulatory arrest and cardiac ischemic times were longer in group A. Postoperative wake-up times, mechanical ventilation times, intensive care unit stays, and postoperative hospital stays were similar. Although surgical approaches for nondissecting aneurysms of the distal aortic arch or proximal descending aorta should be chosen depending on the individual, total arch replacement through a midsternotomy is recommended whenever feasible because of the lower incidence of postoperative stroke compared with left thoracotomy.