Catherine F. Castner

Outcomes after thoracoabdominal aortic aneurysm repair with hypothermic circulatory arrest

OBJECTIVE Recent advances in endovascular surgery have put into question the role of open operative treatment of thoracoabdominal aortic aneurysms. In this context we evaluated our experience with thoracoabdominal aortic aneurysm repair using cardiopulmonary bypass and hypothermic circulatory arrest. METHODS From January 1986 to December 2008, 218 patients (mean age, 63 ± 14 years) underwent thoracoabdominal aortic aneurysm repair with cardiopulmonary bypass and hypothermic circulatory arrest. The degree of repair was as follows: Crawford extent I, 57 (26%) patients; Crawford extent II, 91 (41%) patients; and Crawford extent III, 70 (32%) patients. Degenerative aneurysms were present in 160 (73%) patients. Eighteen (8%) patients underwent emergency operations. RESULTS The mean durations of cardiopulmonary bypass and hypothermic circulatory arrest were 160 ± 44 and 31 ± 12 minutes, respectively. Stroke occurred in 8 (3.7%) patients, and spinal cord ischemic injury occurred in 10 (4.6%) patients (8 with paraplegia and 2 with paraparesis). Temporary dialysis for new-onset renal failure was required in 3.6% of hospital survivors. Thirty-day and 1-year mortality rates were 7.3% and 24.5%, respectively. After emergency operations, the 30-day mortality rate was 33.3% compared with 5.0% after elective operations (P = .001). Five- and 10-year survivals were 55% and 23%, respectively. Twenty-five patients required reoperation on the graft or contiguous aorta at a mean of 5 ± 3 years after the initial procedure. Five- and 10-year rates of freedom from reoperation were 87% and 60%, respectively. CONCLUSIONS Cardiopulmonary bypass with hypothermic circulatory arrest can be safely used for thoracoabdominal aortic aneurysm repair, providing excellent protection against end-organ injury. Early mortality and morbidity rates do not exceed those reported for endovascular repair, with particularly favorable outcomes among patients undergoing elective operations.

One-Stage Repair of Extensive Chronic Aortic Dissection Using the Arch-First Technique and Bilateral Anterior Thoracotomy

BACKGROUND We evaluated a one-stage technique for extensive replacement of the thoracic aorta in patients with chronic aortic dissection. METHODS Fifty-one patients with chronic expanding thoracic aortic dissections (48 type A, 3 type B with proximal extension) were treated with a single procedure using a bilateral anterior thoracotomy, hypothermic circulatory arrest, and reperfusion of the arch vessels first to minimize brain ischemia. Forty-six patients had previous operations: for acute type A aortic dissection (n = 36), aortic valve disease (n = 6), or coronary artery disease (n = 4). The ascending aorta and entire arch were replaced in all patients combined with varying lengths of the descending aorta. RESULTS Hospital mortality was 3.9% (2 patients). Five patients (10%) required reoperation for bleeding. Two patients were discharged on ventilatory support and 2 on dialysis. No patient sustained a stroke, and paraplegia developed in one. The 5- and 7-year survival rates were 79% and 68%. Freedom from reoperation on the thoracic or abdominal aorta was 92% at 5 and 7 years postoperatively. Serial tomograms have documented substantial enlargement of the residual dissected aorta in only 2 patients (reoperated). CONCLUSIONS The technique is a safe and suitable alternative to the two-stage (elephant trunk technique) and hybrid procedures for treatment of chronic dissection with aneurysm of the thoracic aorta. It eliminates the risk of rupture in the interval between staged procedures and the risks associated with a second thoracic aortic procedure, and is associated with a low rate of reoperation on the remaining aorta.

Outcomes After Total Aortic Arch Replacement With Right Axillary Artery Cannulation and a Presewn Multibranched Graft

BACKGROUND Several techniques are available for aortic arch replacement. We evaluated our experience with total aortic arch replacement using a presewn multibranched graft and right axillary artery cannulation for brain perfusion. METHODS Between 2002 and 2010, 88 patients (mean age, 61.5±14.6 years) underwent total aortic arch replacement by midline sternotomy (27 patients) or bilateral anterior thoracotomy (61 patients). During a brief period of deep hypothermic circulatory arrest (DHCA) (mean duration, 11.0±7.8 minutes), the brachiocephalic arteries were detached from the aorta and clamped. Cerebral perfusion through the right axillary artery was then initiated while the arteries were sequentially attached to the branches of the presewn graft (mean duration: 40.4±9.8 minutes). The ascending aorta and entire arch were replaced in all patients, combined with varying lengths of the descending aorta. RESULTS The 30-day mortality rate was 5.7%. Stroke occurred in 3.4%, spinal cord ischemic injury in 3.4% (1 paraplegia, 2 paraparesis), and new-onset renal failure requiring dialysis in 3.4% of patients. The 5-year survival rate was 70.7%±5.5%. All graft branches remained patent during imaging follow-up (mean duration, 2.6±2.2 years). Six patients required reoperation on the graft or contiguous aorta after the initial repair, but no reoperations were required on the aortic arch or its branches. The 5-year rate of freedom from reoperation was 90.4%±4.0%. CONCLUSIONS The use of a presewn multibranched graft and hypothermic brain perfusion through the right axillary artery is a safe method for replacement of the aortic arch, resulting in a low incidence of neurologic complications and favorable durability and patency.

Patency and durability of presewn multiple branched graft for thoracoabdominal aortic aneurysm repair.

OBJECTIVE The use of an aortic patch containing the visceral and renal arteries is a well-established technique during thoracoabdominal aortic aneurysm (TAAA) repair. However, the retained aortic tissue may later become aneurysmal. We reviewed our TAAA repair experience using a presewn aortic branched graft to eliminate this risk. METHODS Between March 2003 and December 2008, 52 patients with Crawford extent II and III TAAAs had surgical repair using a presewn aortic branched graft. Postoperative computed tomography (CT) scans with intravenous contrast were available for 41 patients (mean angiographic follow-up 2.3 years). The mean age of these 41 patients was 59 +/- 16 years (range, 22-86), and 21 patients were female (51%). The indications for surgery were degenerative aneurysms in 30 patients (73%), type B dissections in 10 patients (24%), and visceral patch aneurysm in 1 patient (2.4%). Twenty-four patients (59%) underwent repair of a Crawford extent II TAAA and 17 patients (41%) had extent III TAAA repair. RESULTS Patency of the branches to the visceral and renal arteries at 1 and 5 years was 100% and 98%, respectively. Of the 148 graft branches, 2 became occluded and 4 developed stenosis (2 patients). One patient required percutaneous stenting of 3 stenosed branches, and 1 patient died after acute occlusion of 2 branches and stenosis of a third. During the follow-up period that extended to 6.3 years, there were 10 late deaths. Six patients required reoperation on the aortic graft or contiguous aorta, but no reoperations have been required on the visceral abdominal aorta or its branches. CONCLUSION The use of a presewn aortic branched graft is a safe and suitable option for TAAA repair. With midterm follow-up, this technique seems to eliminate the risk of visceral patch aneurysms and results in favorable durability and patency.

Replacement of the descending thoracic aorta: Contemporary outcomes using hypothermic circulatory arrest

OBJECTIVE Recent advances in endovascular repair have put into question the role of open surgery on the descending thoracic aorta. We evaluated our experience with replacement of the descending thoracic aorta using hypothermic circulatory arrest. METHODS From May 1989 to August 2008, 151 patients (mean age 62 +/- 15 years) had descending thoracic aorta replacement using cardiopulmonary bypass and hypothermic circulatory arrest. Concurrent distal aortic arch repair was performed in 71 patients (47%). Seventeen patients (11%) had emergency operation. RESULTS The mean durations of bypass and circulatory arrest were 107 +/- 34 and 32 +/- 9 minutes, respectively. Stroke occurred in 5 patients (3.3%), spinal cord ischemic injury in 2 patients (1.3%; 1 paraplegia, 1 paraparesis), and renal failure requiring dialysis in 2 patients (1.3%). Thirty-day and 6-month mortality rates were 4.0% and 9.9%, respectively. Following emergency operation, the 30-day mortality rate was 17.6% compared with 2.2% after elective surgery (P = .02). Five- and 10-year survival rates were 71% and 45%, respectively. Five patients required reoperation on the graft or contiguous aorta at a mean of 5 +/- 4 years after the initial repair. Five- and 10-year rates of freedom from reoperation were 96% and 92%, respectively. CONCLUSIONS Cardiopulmonary bypass with hypothermic circulatory arrest can be safely used for replacement of the descending thoracic aorta. Although more invasive than endovascular stent grafting, this open surgical technique provides definitive repair, maintenance of left subclavian artery patency, protection against spinal cord injury, and early mortality and morbidity rates that do not exceed those reported for endovascular repair.

Open thoracoabdominal aortic repair for chronic type B dissection

OBJECTIVES Advances in endovascular surgery have brought into question the role of open operative treatment of chronic thoracoabdominal aortic dissection. In this context, we evaluated our experience with open repair of this condition using a single operative technique. METHODS From January 1986 to January 2014, 69 patients with chronic thoracoabdominal aortic dissection underwent open repair using total cardiopulmonary bypass (CPB) and hypothermic circulatory arrest (HCA). The degree of repair was as follows: Crawford extent I, 13 patients (19%), Crawford extent II, 41 patients (59%), and Crawford extent III, 15 patients (22%). Thirty patients (43%) had Marfan or Loeys-Dietz syndrome. Fifty-three patients (77%) had previous operations on the thoracic or abdominal aorta. RESULTS The 30-day mortality rate was 5.8% (4 patients). Stroke occurred in 2 (3%) of 66 operative survivors, and spinal cord ischemic injury in 4 (6%). Temporary dialysis for new-onset renal failure was required in 4.5% of hospital survivors and tracheostomy in 10.6%. Survival after 1, 5, and 10 years was 87%, 65%, and 40%, respectively. Eighteen patients (26%) required a total of 20 subsequent operations on the thoracic or abdominal aorta of whom 15 had Marfan or Loeys-Dietz syndrome. Three of these procedures were for contiguous distal aortic disease and 10 were for patch aneurysms of the intercostal or visceral/renal arteries. CONCLUSIONS Open thoracoabdominal aortic repair for chronic dissection using CPB and HCA can be accomplished with mortality and morbidity rates that are comparable with those reported for endovascular or hybrid techniques. Open repair should remain a viable and primary option for the management of this condition until the long-term effectiveness of alternative methods of treatment is clearly established.

Branch graft patency after open repair of thoracoabdominal aortic aneurysms.

Objectives: The long‐term function of branch grafts to the visceral and renal arteries during open thoracoabdominal aortic aneurysm repair is unknown. We assessed the patency of single and multiple branch grafts with postoperative imaging studies in patients followed for up to 13 years. Methods: A total of 99 of 130 patients undergoing open thoracoabdominal aortic aneurysm repair who received a total of 298 branch grafts to the celiac, superior mesenteric, and renal arteries were evaluated with serial imaging studies at 6‐ to 12‐month intervals. The mean duration of angiographic follow‐up was 40.4 months and extended to 159 months. Thirty‐three patients receiving 74 grafts were followed for more than 5 years, and 7 patents receiving 22 grafts were followed for more than 10 years. Eighty‐four grafts were grafted to the celiac artery, 73 grafts were grafted to the superior mesenteric artery, 71 grafts were grafted to the left renal artery, and 70 grafts were grafted to the right renal artery. Results: Nine graft occlusions occurred in 6 patients. One of these patients died of intestinal ischemia after occlusion of the celiac and superior mesenteric artery grafts, and 1 patient developed occlusion of both renal artery grafts and remains on dialysis. Five graft occlusions in the other 4 patients were asymptomatic, and no interventions were required. One additional patient developed significant stenosis of the celiac, superior mesenteric, and right renal arteries and underwent successful percutaneous angioplasty. No other patient required intervention. Freedom from occlusion of the 298 grafts at 1, 5, and 10 years is 98%, 97%, and 93%, respectively. Conclusions: This represents the largest series of patients with branch grafts for open thoracoabdominal aortic aneurysm repair with extended angiographic follow‐up. The favorable long‐term graft patency rates represent a benchmark against which methods for establishing flow to the visceral and renal arteries using alternative techniques can be compared.

Clinical outcomes and rates of aortic growth and reoperation after 1-stage repair of extensive chronic thoracic aortic dissection

Objective: The study objective was to analyze clinical outcomes, distal segmental aortic growth, and aortic reoperation rates after 1‐stage open repair of extensive chronic thoracic aortic dissection via bilateral anterior thoracotomy. Methods: Eighty patients underwent extensive 1‐stage repair of chronic aortic dissection that included the ascending aorta, the entire aortic arch, and the varying lengths of the descending thoracic aorta. One half or more of the descending thoracic aorta was replaced in 62 (78%) of the 80 patients. Hospital mortality was 2.5% (2 patients). Stroke occurred in 1 patient (1.2%), spinal cord ischemic injury occurred in 1 patient (1.2%), and renal failure requiring long‐term dialysis occurred in 2 patients (2.5%). Sixty‐five of the 78 hospital survivors (83%) had serial imaging studies suitable for calculation of growth rates of the remaining dissected thoracic and abdominal aorta. Forty‐seven patients were followed for more than 5 years, and 21 patients were followed for more than 10 years. Results: The mean annual growth rate for the distal contiguous aorta was 1.7 mm/y. Forty aortas increased in diameter, 16 aortas remained unchanged, and 9 aortas decreased in diameter. Five patients required reoperation on the contiguous thoracic or abdominal aorta 8, 27, 34, 51, and 174 months postoperatively for progressive enlargement. Actuarial freedom from reoperation on the contiguous aorta at 5 and 10 years was 95.4% and 93%, respectively. Actuarial freedom from any aortic reoperation at 5 and 10 years was 89.2% and 84.4%, respectively. Actuarial survival for the entire cohort at 5 and 10 years was 76.4% and 52.6%, respectively, and survival free of any aortic operation was 68.6% and 43.9%, respectively. No patient whose cause of death was known died of aortic rupture. Conclusions: Our extended experience with the 1‐stage open procedure confirms its safety and durability for treatment of chronic aortic dissection with enlargement confined to the thoracic aorta. The procedure is associated with low operative risk and a low incidence of reoperation on the contiguous aorta. It represents a suitable alternative to the 2‐stage, frozen elephant trunk, and hybrid procedures that are also used to treat this condition.