Methods and Results of the Brain and Visceral Organs Protection During the Correction of the Ascending Aorta and Aortic Arch Aneurysm or Isolated Aortic Arch Aneurism

DOI: https://doi.org/10.30702/ujcvs/21.4203/k014075-081/089.12
Keywords: arch aneurysm, aortic dissection, deep hypothermia, retrograde cerebral perfusion

Abstract

The ascending aorta and aortic arch aneurysm surgical correction is the most difficult problem of cardiovascular surgery due to the necessity of management of the main disease and adequate protection of the brain and visceral organs.

The aim. To present the methods and results of protection of the central nervous system and visceral organs during the correction of the ascending aorta and aortic arch aneurysm or isolated aortic arch aneurism.

Materials and methods. During 1994–2018, we operated 419 patients with the ascending aorta and aortic arch aneurysm (or isolated aortic arch aneurism).

Diagnosis of aneurysms was based on clinical data, transthoracic and transesophageal echocardiography, computed tomography, X-ray examination, aortography.

All operations were performed under general anesthesia, through the median sternotomy using cardiopulmonary bypass. Valve-sparing technique with aortic valve resuspension/aortic valve plasty and semi-arch/arch replacement was used in 288/9 (68.7%) patients. Bentall operation with semi-arch/arch replacement was used in 86/9 (20.5%) patients. Other operations accounted for 45 (10.7%) patients.

Results. The history of the development of aortic aneurysms treatment options is briefly overviewed in the paper. Diagnostic methods are mentioned, but the main method today is computed tomography. Initial status of the patients was severe. All operations were performed through median sternotomy using cardiopulmonary bypass. The following techniques were used for surgical treatment of aneurysms: 1) valve-sparing technique with aortic valve resuspension/ plasty and semi-arc/arch replacement was used in 288/9 (68.7%) patients. In this group there were 8 Yacoub operations, 6 David operations. In 7 patients, plication of one of the leaflets was performed in case of aortic valve prolapse. 3 patients underwent strengthening of the free edge of the leaflets and 4 patients underwent plasty by the patch in case of leaflet fenestrations; 2) Bentall operation with semi-arch/arch replacement was used in 86/9 (20.5%); 3) others: isolated arch in 15 (3.6%); Wheat operation + arch in 9 (1.0%); aortic arch plasty in 4 (1.0%); Elephant trunk (conventional Elephant trunk) + TEVAR was used in 17 (4.1%) patients. The brain protection was performed differently at each of the two stages in our surgical experience. The best result was achieved at the last stage. The number of postoperative complications decreased from 34.4% to 8.4% and hospital mortality from 17.2% to 5.3%, respectively. Also, a modern endovascular method – hybrid operations Elephant trunk + TEVAR – was used in 17 (4.1%) patients with good immediate result.

Conclusions.

1. At type A aortic dissection (DeBakey type I) the operation of choice is supracoronary ascending aortic replacement with a semi-arch (arch) replacement of the aorta.

2. Accumulation of surgical experience, team training, improvement of methods of protection of the brain and visceral organs allowed to reduce the number of postoperative complications from 34.4% to 8.4% and hospital mortality from 17.2% to 5.3%.

References

  1. Coselli JS, LeMaire SA, editors. Aortic arch surgery: Principles, strategies and outcomes. 1st ed. Hoboken: Wiley Blackwell; 2008.
  2. Conway BD, Stamou SC, Kouchoukos NT, Lobdell KW, Khabbaz KR, Murphy E, et al. Improved clinical outcomes and survival following repair of acute type A aortic dissection in the current era. Interactive Cardiovascular and Thorac Surg. 2014 Dec;19(6):971-7. https://doi.org/10.1093/icvts/ ivu268
  3. Czerny M. Re: Proximal aortic repair versus extensive aortic repair in the treatment of acute type A aortic dissection: a meta-analysis. Europ J Cardio-Thorac Surgery. 2016 May;49(5):1402. https://doi.org/10.1093/ejcts/ezv354
  4. Qu JZ, Kao LW, Smith JE, Kuo A, Xue A, Iyer MH, et al. Brain Protection in Aortic Arch Surgery: An Evolving Field. J Cardiothorac Vasc Anesth. 2021 Apr;35(4):1176-1188. https://doi.org/10.1053/j.jvca.2020.11.035. Epub 2020 Nov 21.
  5. Sultan I, Bianco V, Patel HJ, Arnaoutakis GJ, Di Eusanio M, Chen EP, et al. Surgery for type A aortic dissection in patients with cerebral malperfusion: results from the international registry of acute aortic dissection. J Thorac Cardiovasc Surg. 2019 Nov 14:S0022-5223(19)32762-X. https://doi.org/10.1016/j.jtcvs.2019.11.003. Epub ahead of print. PMID: 31959445.
  6. Ohtsubo S, Itoh T, Takarabe K, Rikitake K, Furukawa K, Suda H, et al. Surgical results of hemiarch replacement for acute type A dissection. Ann Thorac Surg. 2002 Nov;74(5):S1853-6. https://doi.org/10.1016/s0003-4975(02)04133-4
  7. Perreas K, Samanidis G, Dimitriou S, Kalogris P, Balanika M, Antzaka C, et al. Outcomes after ascending aorta and proximal aortic arch repair using deep hypothermic circulatory arrest with retrograde cerebral perfusion: analysis of 207 patients. Interactive Cardiovascular and Thorac Surg. 2012 Sep;15(3):456-61. https://doi.org/10.1093/icvts/ivs252
  8. Rylski B, Beyersdorf F, Kari FA, Schlosser J, Blanke P, Siepe M. Acute type A aortic dissection extending beyond ascending aorta: limited or extensive distal repair. J Thorac Cardiovascular Surgery. 2014 Sep;148(3):949-54. https://doi.org/10.1016/j.jtcvs.2014.05.051
  9. Safi HJ, Letsou GV, Iliopoulos DC, Subramaniam MH, Miller CC 3rd, Hassoun H, et al. Impact of retrograde cerebral perfusion on ascending aortic and arch aneurysm repair. Ann Thorac Surg. 1997 Jun;63(6):1601-7. https://doi.org/10.1016/s0003-4975(97)00296-8
  10. Svensson LG, Crawford CC, Stanley E. Cardiovascular and Vascular Disease of the Aorta. 1st ed. Philadelphia: Saunders; 1997.
  11. Abe T, Yamamoto H, Miyata H, Motomura N, Tokuda Y, Tanemoto K, et al. Patient trends and outcomes of surgery for type A acute aortic dissection in Japan: an analysis of more than 10 000 patients from the Japan Cardiovascular Surgery Database. Eur J Cardiothorac Surg. 2020 Apr 1;57(4):660-667. https://doi.org/10.1093/ejcts/ezz323
  12. Urbanski PP, Lenos A, Irimie V, Bougioukakis P, Zacher M, Diegeler A. Acute aortic dissection involving the root: operative and long-term outcome after curative proximal repair. Interactive Cardiovascular and Thorac Surg. 2016 May;22(5):620-6. https://doi.org/10.1093/icvts/ivw002
  13. Yan Y, Xu L, Zhang H, Xu ZY, Ding XY, Wang SW, et al. Proximal aortic repair versus extensive aortic repair in the treatment of acute type A aortic dissection: a meta-analysis. Eur J Cardiothorac Surg. 2016 May;49(5):1392-401. https://doi.org/10.1093/ejcts/ezv351
  14. Okita Y. Current surgical results of acute type A aortic dissection in Japan. Ann Cardiothorac Surg. 2016 Jul;5(4):368-76. https://doi.org/10.21037/acs.2016.06.02
  15. Sun L, Qi R, Zhu J, Liu Y, Zheng J. Total arch replacement combined with stented elephant trunk implantation: a new “standard” therapy for type A dissection involving repair of the aortic arch? Circulation. 2011 Mar 8;123(9):971-8. https://doi.org/10.1161/CIRCULATIONAHA.110.015081
  16. Poon SS, Theologou T, Harrington D, Kuduvalli M, Oo A, Field M. Hemiarch versus total aortic arch replacement in acute type A dissection: a systematic review and me-ta-analysis. Ann Cardiothorac Surg. 2016;5(3):156-73. https://doi.org/10.21037/acs.2016.05.06
Published
2021-03-16
How to Cite
Kravchenko, V. I., Kravchenko, I. M., Zhekov, I. I., Lybavka, V. D., & Lazoryshynets, V. V. (2021). Methods and Results of the Brain and Visceral Organs Protection During the Correction of the Ascending Aorta and Aortic Arch Aneurysm or Isolated Aortic Arch Aneurism. Ukrainian Journal of Cardiovascular Surgery, (1 (42), 75-81. https://doi.org/10.30702/ujcvs/21.4203/k014075-081/089.12
Issue
Ukrainian Journal of Cardiovascular Surgery No 1 (42) 2021
Section
PATHOLOGY OF AORTA

Most read articles by the same author(s)