Aortic Arch Replacement Using a Trifurcated Graft: Simple, Versatile, and Safe

doi:10.1016/j.athoracsur.2005.02.002

The Annals of Thoracic Surgery

Volume 80, Issue 1, July 2005, Pages 90-95

Presented at the Fifty-first Annual Meeting of the Southern Thoracic Surgical Association, Cancun, Mexico, Nov 2–4, 2004.

https://doi.org/10.1016/j.athoracsur.2005.02.002 Get rights and content

Background

Hypothermic selective antegrade cerebral perfusion during aortic arch replacement may prevent adverse neurologic sequelae. It can be provided via balloon-tipped catheters or a branched graft sewn to the brachiocephalic vessels. We report a consecutive series of total arch replacement using a trifurcated graft.

Methods

From September 1999 through October 2004, 109 patients underwent nonemergent total arch replacement using this technique. The graft, placed during a period of hypothermic circulatory arrest, was used for selective cerebral perfusion during the arch reconstruction.

Results

Adverse outcomes were seen in 9 (8.3%) patients: hospital death in 5 (4.6%), and stroke in 5 (4.6%). Transient neurologic dysfunction was noted in 6 (5.5%) patients. Mean duration of hypothermic circulatory arrest was 31.2 ± 6.6 minutes and selective cerebral perfusion was 65.3 ± 20.9 minutes. Reoperation for bleeding was required in 3 (2.8%) patients and prolonged intubation in 15 (13.8%). Median intensive care unit stay was 3 days (interquartile range 2–4; range, 1 to 108) and hospital stay was 9 (interquartile range 8–15; range, 5 to 108).

Conclusions

The trifurcated graft technique results in low rates of perioperative mortality, temporary neurologic dysfunction, and stroke. It may reduce cerebral embolization as it requires no instrumentation of the aortic arch to establish selective cerebral perfusion and, although it mandates hypothermic circulatory arrest to place the graft, this interval is reliably brief enough to fall within accepted safe limits. This strategy leaves no residual arch tissue behind, and allows placement of an elephant trunk proximal to one or more arch vessels if anatomically indicated.

Section snippets

Patient Data Abstraction

From our prospectively compiled database of patients undergoing aortic surgical procedures, we identified 109 consecutive patients (62 male, 47 female) who underwent nonemergent resection of aneurysms of the transverse aortic arch between September 1999 and October 2004, utilizing antegrade cerebral perfusion provided by a trifurcated graft. Clinical and operative details were obtained from the database and the patients’ medical records.

The mean patient age was 63.9 ± 14.4 years (range, 20 to

Intraoperative Findings

All arch reconstructions were completed using a single period of HCA followed by SCP utilizing the trifurcated graft technique. Mean duration of HCA was 31.2 ± 6.6 minutes (range, 17 to 48) at a mean esophageal temperature of 12.8 ± 2.2°C (range, 9.9 to 19.8). Mean duration of SCP was 65.3 ± 20.9 minutes (range, 21 to 113). The duration of cardiopulmonary bypass was 236.2 ± 52.5 minutes (range, 157 to 385).

Adverse Outcome

Adverse outcome was seen in 9 patients (8.3%). There were five hospital deaths (4.6%) and

Comment

Contemporary series [4, 5, 6, 7, 8, 9] of total aortic arch replacements show increasingly impressive results, with low perioperative mortality rates and a low incidence of permanent neurologic injury (see Table 3). Undoubtedly these improvements are multifactorial in etiology. Increasing experience [7, 8], better perioperative patient care, and improved myocardial and cerebral protection have all contributed to improvements in outcome. However, no consensus exists as to the best conduct of

References (28)

C. Hagl et al.
Neurologic outcome after ascending aorta-aortic arch operationseffect of brain protection technique in high-risk patients
J Thorac Cardiovasc Surg
(2001)
D. Spielvogel et al.
Aortic arch replacement using a trifurcated graft and selective cerebral antegrade perfusion
Ann Thorac Surg
(2002)
M. Di Eusanio et al.
Separate grafts or en bloc anastomosis for arch vessels reimplantation to the aortic arch
Ann Thorac Surg
(2004)
Y. Ueda et al.
Retrograde cerebral perfusion for aortic arch surgeryanalysis of risk factors
Ann Thorac Surg
(1999)
T. Kazui et al.
Usefulness of antegrade selective cerebral perfusion during aortic arch operations
Ann Thorac Surg
(2002)
J. Bachet et al.
Antegrade cerebral perfusion with cold blooda 13-year experience
Ann Thorac Surg
(1999)
C.W. Pearce et al.
Aneurysms of aortic arch. Simplified technique for excision and prosthetic replacement
J Thorac Cardiovasc Surg
(1969)
R.B. Griepp et al.
Prosthetic replacement of the aortic arch
J Thorac Cardiovasc Surg
(1975)
M.J. Antunes et al.
Hypothermia and circulatory arrest for surgical resection of aortic arch aneurysms
J Thorac Cardiovasc Surg
(1983)
M.A. Ergin et al.
Hypothermic circulatory arrest in operations of the thoracic aortadeterminants of operative mortality and neurological outcome
J Thorac Cardiovasc Surg
(1994)

M.P. Ehrlich et al.

Predictors of adverse outcome and transient neurological dysfunction after ascending aorta/hemiarch replacement

Ann Thorac Surg

(2000)

M.P. Ehrlich et al.

Retrograde cerebral perfusion provides negligible flow through brain capillaries in the pig

J Thorac Cardiovasc Surg

(2001)

L.F. Duebener et al.

Direct visualization of minimal cerebral capillary flow during retrograde cerebral perfusionan intravital fluorescence microscopy study in pigs

Ann Thorac Surg

(2003)

J.L. de Brux et al.

Retrograde cerebral perfusionanatomic study of the distribution of blood to the brain

Ann Thoracic Surg

(1995)

Cited by (71)

Thoracic Aortic Aneurysm Resection
2021, Cohen's Comprehensive Thoracic Anesthesia
In the United States, thoracic aortic aneurysms affect more than 15,000 people every year, and millions of Americans live with undiagnosed thoracic aortic aneurysms. The management of patients with thoracic aortic aneurysms must involve detailed and clear communication between cardiologists, surgeons, and anesthesiologists. The repairs of thoracic aortic aneurysms are delicate surgeries that require cardiopulmonary bypass, hypothermic circulatory arrest, one-lung ventilation, and other complex techniques and procedures. This chapter presents a surgical case requiring the resection of a thoracic aortic aneurysm in the context of a teenage male with Marfan syndrome. A brief history of thoracic aortic aneurysms is presented, as well as an extensive case management section in which the primary concerns of the surgical procedure are detailed. Surgical considerations are discussed by organ system, as well as important discussions pertaining to proper blood pressure and temperature monitoring, transesophageal echocardiography, intraoperative ventilation settings with one-lung ventilation, and postoperative ventilatory considerations. Subsequently, alternative methods as well as the risks and benefits of the procedure are discussed. The chapter concludes with a presentation of the most up-to-date literature, including information on central nervous system protection and monitoring, a discussion regarding the location of arterial cannulation, and a novel system of classification for acute aortic dissections.
Aortic arch aneurysms. Epidemiology, clinical scenario and diagnosis. Surgical indications. Open surgery
2015, Cirugia Cardiovascular
El arco aórtico es un segmento fundamental de la aorta. Se describe la enfermedad quirúrgica que afecta al mismo, así como la epidemiología y la historia natural de los aneurismas torácicos, que son la condición que más frecuentemente lo afectan. Se revisan las manifestaciones clínicas de estos y las técnicas empleadas para su diagnóstico. Finalmente, se expone una panorámica de las indicaciones quirúrgicas y las técnicas de cirugía abierta empleadas.
Aortic arch is a fundamental segment of the aorta. Surgical pathology, epidemiology and natural history of thoracic aneurysms are described. Clinical manifestations and diagnostic are reviewed. Finally, an overview of surgical indications and most frequently open surgery used techniques is offered.
Reprint of: Reoperations on the total aortic arch in 119 patients: Short- and mid-term outcomes, focusing on composite adverse outcomes and survival analysis
2015, Journal of Thoracic and Cardiovascular Surgery
To determine the preoperative and perioperative risk factors that significantly predict adverse outcomes after total arch replacement in patients with previous proximal aortic surgery and to analyze patient survival.
We performed univariate analysis and logistic regression on data extracted from a prospectively maintained database for 119 patients who had undergone total arch operations during a 7.5-year period. All patients had undergone previous proximal aortic surgery. The adverse outcome was defined as a single composite endpoint comprising operative mortality, permanent neurologic deficit, and renal failure necessitating permanent hemodialysis.
The incidence of the composite endpoint was 13.5% (16 of 119 patients). The univariate predictors were preoperative pulmonary disease (P = .010), cardiac ischemia time (P = .032), and cardiopulmonary bypass (CPB) time (P = .073). On multivariate analysis, the following were predictors of the composite endpoint: preoperative pulmonary disease (P = .036), CPB time (P = .039), concomitant coronary artery bypass (P = .0057), previous aortic valve replacement (P = .027), and previous thoracoabdominal aortic aneurysm surgery (P = .057). Multivariate analysis showed that the CPB time predicted mortality (P = .0044), and previous thoracoabdominal aortic aneurysm surgery predicted stroke (P = .034). The overall survival was 85.3% during a median follow-up of 4.76 years (95% confidence interval, 4.2-5.1).
Aortic arch reoperations, although technically demanding, can produce acceptable results. Preoperative pulmonary disease, CPB time, and concomitant coronary artery bypass predicted an adverse outcome. The CPB time predicted mortality, and previous thoracoabdominal aortic surgery predicted stroke.
Reoperations on the total aortic arch in 119 patients: Short- and mid-term outcomes, focusing on composite adverse outcomes and survival analysis
2014, Journal of Thoracic and Cardiovascular Surgery
To determine the preoperative and perioperative risk factors that significantly predict adverse outcomes after total arch replacement in patients with previous proximal aortic surgery and to analyze patient survival.
We performed univariate analysis and logistic regression on data extracted from a prospectively maintained database for 119 patients who had undergone total arch operations during a 7.5-year period. All patients had undergone previous proximal aortic surgery. The adverse outcome was defined as a single composite endpoint comprising operative mortality, permanent neurologic deficit, and renal failure necessitating permanent hemodialysis.
The incidence of the composite endpoint was 13.5% (16 of 119 patients). The univariate predictors were preoperative pulmonary disease (P = .010), cardiac ischemia time (P = .032), and cardiopulmonary bypass (CPB) time (P = .073). On multivariate analysis, the following were predictors of the composite endpoint: preoperative pulmonary disease (P = .036), CPB time (P = .039), concomitant coronary artery bypass (P = .0057), previous aortic valve replacement (P = .027), and previous thoracoabdominal aortic aneurysm surgery (P = .057). Multivariate analysis showed that the CPB time predicted mortality (P = .0044), and previous thoracoabdominal aortic aneurysm surgery predicted stroke (P = .034). The overall survival was 85.3% during a median follow-up of 4.76 years (95% confidence interval, 4.2-5.1).
Aortic arch reoperations, although technically demanding, can produce acceptable results. Preoperative pulmonary disease, CPB time, and concomitant coronary artery bypass predicted an adverse outcome. The CPB time predicted mortality, and previous thoracoabdominal aortic surgery predicted stroke.
Visceral and spinal cord protection during thoracoabdominal aortic aneurysm repair: Clinical and laboratory update
2013, Journal of Thoracic and Cardiovascular Surgery
Total arch replacement in patients with aortic dissection with an isolated left vertebral artery
2013, Annals of Thoracic Surgery
The presence of an isolated left vertebral artery requires changes in the aortic arch reconstruction techniques and cerebral protection methods in patients with total arch replacement. The best method for surgical repair of the isolated left vertebral artery is controversial. We retrospectively reviewed our experience of total arch replacement in patients with aortic dissection with this vessel anomaly.
Between August 2003 and December 2008, 21 patients with aortic dissection (type A dissection, n = 20; type B dissection, n = 1) with an isolated left vertebral artery underwent total arch replacement under hypothermic cardiopulmonary bypass combined with selective cerebral perfusion. Concomitant stented elephant trunk was implanted in 20 patients.
There was no in-hospital death. Injury to the spinal cord occurred in 2 patients with chronic dissection using stented elephant trunk implantation. One had weakness in the left lower extremity, and the other patient had paraparesis: both recovered during the follow-up period. One patient experienced transient neurologic deficit, and acute renal failure was observed in 1 patient: both recovered completely before hospital discharge.
Acceptable results were obtained in patients with aortic dissection with an isolated left vertebral artery. Although there was no clear evidence that the spinal cord injury was related to the isolated left vertebral artery using stented elephant trunk implantation, the isolated left vertebral artery was constructed as soon as possible in patients with this vessel anomaly.

View all citing articles on Scopus

View full text

Original articleCardiovascularAortic Arch Replacement Using a Trifurcated Graft: Simple, Versatile, and Safe

Background

Methods

Results

Conclusions

Section snippets

Patient Data Abstraction

Intraoperative Findings

Adverse Outcome

Comment

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thoracic Surg

Original article
Cardiovascular
Aortic Arch Replacement Using a Trifurcated Graft: Simple, Versatile, and Safe