Surgery For Aortic Arch Aneurysm Research Articles

Preoperative renal function affects outcomes of surgery for aortic arch aneurysm in the elderly.

This study aimed to determine the optimal surgical procedure for arch aneurysm in the elderly based on preoperative comorbidities, especially focusing on renal function. The medical records of 374 patients who experienced arch surgery between 2008 and 2019 were reviewed. Among the 374 patients, 92 who underwent total arch replacement (TAR) were assigned to the TAR group and the remaining 152 who underwent debranching thoracic endovascular aortic repair (DTEVAR) were assigned to the DTEVAR group. Chronic kidney disease (CKD) was an independent risk factor of mortality (hazard ratio, 2.85; p = 0.029) in the TAR group but not in the DTEVAR. In the Grade I/II category CKD (estimated glomerular filtration rate (eGFR) > 60mL/min), freedom from all-cause mortality was significantly higher in the TAR group than in the DTEVAR group (p = 0.0155, log-rank). Freedom from all-cause mortality was comparable between the two groups in the Grade IIIa CKD (eGFR, 45-60) (p = 0.584, log-lank), Grade IIIb (eGFR, 30-45) (p = 0.822), and Grade IV/V (eGFR < 30) (p = 0.548). In elderly patients who underwent TAR, CKD was the independent risk factor of the mortality, but not in the patients who underwent debranching TEVAR. Conversion of surgical strategy from TAR to debranching TEVAR in the treatment of aortic arch aneurysms in the elderly with CKD below Grade IIIa is acceptable considering that less-invasiveness. While, in the elderly with Grade I/II CKD, TAR still remains as a primary choice for the arch repair for better mid-term survival.

Total arch replacement with selective antegrade cerebral perfusion and mild hypothermic circulatory arrest.

This article describes the surgical techniques demonstrated in our video, “Total arch replacement (TAR) with selective antegrade cerebral perfusion (SACP) and mild hypothermic circulatory arrest” (Video 1). Video 1 Total arch replacement with selective antegrade cerebral perfusion and mild hypothermic circulatory arrest The aortic arch is the most common location for the development of aortic aneurysms. These aneurysms are often located close to the brachiocephalic vessels, and atheromatous plaque and thrombus are often present both in the aneurysm and in the nearby aorta. In addition, the brachiocephalic branches, especially the left subclavian artery, frequently have atheromatous plaque at the orifices. Despite recent progress in endovascular treatments, mural thrombus and atherosclerotic debris in the aortic arch are frequently problematic. Therefore, endovascular repair cannot be considered as the first-line intervention for arch aneurysm without establishing secure preventive measures against atheroembolism caused by catheterization. The open replacement of the whole aortic arch with brachiocephalic vessel reconstruction using prosthetic grafts remains the gold standard procedure for the management of this condition. Historically, open aortic arch surgery for aortic arch aneurysm has been invasive. We believe that four factors make open arch repair difficult: (I) possible brain injury due to inadequate protection; (II) a deep, narrow operative field in the distal aorta and the left subclavian artery; (III) hemorrhage and transfusion; and (IV) possible myocardial damage due to prolonged ischemia. Therefore, we have used hypothermic circulatory arrest with SACP rather than other brain protective methods, and developed a method to optimize the operative field. Our procedure for arch aneurysm is simple and standardized. We use systemic cooling until 25 to 28 °C at tympanic membrane temperature, followed by SACP with balloon-tipped catheters and myocardial protection by intermittent retrograde blood cardioplegia. Anastomoses are sequentially constructed at the distal arch, the proximal root, the left subclavian artery, the left carotid artery, and the right brachiocephalic artery. Most of these procedures are routinely completed within 3 hours. Patients even over 80 years old can mobilise on the ward and resume oral diet on postoperative day one. Fast-tracked recovery is certainly achieved with this surgical procedure.

A Method to Prevent Cerebral Embolism during Surgery for Aortic Arch Aneurysm Complicated by Severe Atherosclerotic Changes

A Method to Prevent Cerebral Embolism during Surgery for Aortic Arch Aneurysm Complicated by Severe Atherosclerotic Changes

"Hybrid" Approach for the Treatment of Aortic Arch Aneurysm

High mortality and morbidity rates are associated with the conventional surgery for aortic arch aneurysm because of cardiopulmonary bypass and deep hypothermic circulatory arrest. In this report, we describe a "hybrid" treatment for aortic arch aneurysm that combines the surgical debranching procedure and the stenting technique. A surgical bypass graft is created from the ascending aorta to every main branch of the aortic arch. Subsequently, an endovascular stent graft is deployed retrogradely through the femoral artery with the aid of digital subtraction angiography. The patient was discharged on postoperative day 7. A computed tomography scan was routinely performed at 1 week postoperatively to confirm the good patency of all grafts and the stent. The feasibility and the benefit of the hybrid treatment for aortic arch aneurysm are confirmed.

Vocal cord paralysis after aortic arch surgery: Predictors and clinical outcome

This study is retrospective cohort study of data on vocal cord paralysis after aortic arch surgery collected during 14 years at a general hospital. We investigated factors in the development of vocal cord paralysis after aortic arch surgery and the effect of vocal cord paralysis on clinical course and outcome. We reviewed data for 182 patients who underwent aortic arch surgery for aortic arch aneurysm and aortic dissection between 1989 and 2003, of whom 58 patients had proximal aortic repair, 62 had distal arch repair, and 62 had total arch repair. We assessed factors associated with the development of vocal cord paralysis and examined in detail the clinical outcome of patients with vocal cord paralysis. Postoperative vocal cord paralysis occurred in 40 patients. Multiple logistic regression analysis revealed the following risk factors with odds ratios (OR) for vocal cord paralysis: extension of procedures into distal arch (OR, 17.0), chronic dilatation of the aorta at the left subclavian artery (OR, 9.14), and total arch repair (OR, 4.24). Adoption of open-style stent-grafts reduced the incidence of vocal cord paralysis (OR, 0.031). The postoperative occurrence of vocal cord paralysis itself emerges as an independent predictor of pulmonary complications (OR, 4.12) and leads to a longer duration of hospital stay. The risk of vocal cord paralysis after aortic arch surgery depends on surgical factors, such as aneurysmal involvement of the distal arch, or the application of newer, less invasive surgical procedures. Vocal cord paralysis after aortic arch surgery itself, under aggressive postoperative respiratory management, did not increase aspiration pneumonia but was associated with postoperative complications leading to higher hospital mortality and prolonged hospitalization.

Medium-term results after surgery for aortic arch aneurysm with hypothermic cerebral perfusion

We have used two techniques of hypothermic cerebral perfusion (CP) for the surgical treatment of aortic arch aneurysm in the last 10 years. Between March 1985 and December 1993, 83 patients underwent surgery for aortic arch aneurysm. Fifty-one cases had aortic dissection (AD) in the transverse arch and/or its branches, and 32 cases showed true aneurysm (TA) of the aortic arch. In those 83 patients, 37 cases received antegrade CP and 46 cases underwent retrograde CP. Surgical results were compared among the groups by Kaplan-Meier actuarial method and Cox-Mantel statistical analysis. The early mortality after surgery for aortic arch aneurysm was 11.8% in the AD group and 21.9% in the TA group. The early mortality was 21.6% with antegrade CP and 10.9% with retrograde CP. The 6-year actuarial survival rate was 71.7% in the TA group and 67.1% in the AD group. In the AD group, the 3-year survival rate was 93.9% with retrograde CP and 61.1% with antegrade CP (P < 0.005). In the TA group, the 3-year survival rate was similar for antegrade CP (73.3%) and retrograde CP (69.2%). These results suggest that current surgical results of aortic arch aneurysm with hypothermic CP are acceptable and the retrograde CP technique might be recommended, especially for surgery of aortic arch aneurysm with AD.