aortic arch surgery: techniques and resultsaz9194.vo.msecnd.net › pdfs › 120401 ›...
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Aortic Arch Surgery:
Techniques and Results
Leonard N. Girardi, M.D.
O. Wayne Isom Professor of Cardiothoracic Surgery
Weill Cornell Medical College
Director, Thoracic Aortic Surgery
New York Presbyterian Hospital
Thoracic Aortic Aneurysms:
Yearly Rupture, Dissection or Death
12
14
16
18
20
% Yearly Rate
0
2
4
6
8
10
12
4.0 - 4.9 5.0 - 5.9 >6.0
Aneurysm Size
% Yearly Rate
Davies, Ann Thor Surg, 2002
Arch Repair
Indications for Surgery
• Diameter greater than 5.5 cm
• Growth greater than 1 cm per year
• Symptomatic aneurysm
• Type A dissection with arch involvement
• Ascending or Descending aneurysm with arch
extension
Arch RepairProfound Hypothermic Circulatory Arrest
15
20Mortality = 12%
CVA = 7%
0
5
10
0 15 30 45 60
minutes of PHCA
% CVA
Cerebral Protection
Prolonged cooling Topical cooling
Cerebral Protection
Barbiturates Speed
Retrograde cerebral perfusion
Aortic Arch Surgery
Retrograde Cerebral Perfusion
Cooling Period
• Pack head in ice
• Minimum of 30 minute
• Cerebral oxymetry
• Bladder temp of 18o C
• Methylhexital (1 gm) prior to circulatory arrest
Retrograde Cerebral Perfusion
• Initiate circulatory arrest, steep Trendelenberg
• Examine anatomy then initiate RCP
• Flows 300 - 500 cc/min• Flows 300 - 500 cc/min
• CVP 20 - 25 mmHg, examine left innominate vein
• Move cannula to one-branch graft for antegrade
perfusion
• Keep RCP on for initial return to CBP
• Maintain gradient of 10o C during warming
Retrograde Cerebral Perfusion
Advantages
• Simplicity and speed
• Maintain cerebral hypothermia•
• Prevention of air and debris emboli
• Flush toxic byproducts of metabolism
• No manipulation of the great vessels
Retrograde Cerebral Perfusion
Disadvantages
• Need for profound hypothermia
• ? Delivery of metabolic substrate• ? Delivery of metabolic substrate
• Effectiveness in cases of prolonged circulatory arrest
Cerebral Protection
Barbiturates ? Speed
Cerebral Protection
Moderate hypothermia
Antegrade cerebral perfusion
Antegrade Cerebral Perfusion
Intraoperative Management
• Degree of cooling varies: 20 C – 25 C
• Clamp innominate, rely on circle of Willis• Clamp innominate, rely on circle of Willis
• Balloon tip catheters into innominate and LCCA
• Flow ~ 10 cc/kg/min
• Maintain MAP ~ 50 mmHg
Antegrade Cerebral Perfusion
Advantages
• Maintain cerebral perfusion during circulatory arrest
• Potential advantage of less hypothermia
• ? Improved cerebral protection for complex or
prolonged arch reconstruction
Antegrade Cerebral Perfusion
Disadvantages
• Complexity and time
• Reliance of intact circle of Willis• Reliance of intact circle of Willis
• Great vessel manipulation, ? Increase embolic events
• Cluttered operative field if choose to use balloon tip
catheters
Arch RepairTechniques
• Hemiarch
• Total Arch• Total Arch
• Total Arch with Elephant Trunk
• Total Arch/Debranching
Aortic Arch Replacement
Primary Procedure N=870
- Hemiarch 497
- Total arch/island 158
- Total arch/elephant trunk 114
- Total arch/debranching 101
Additional Procedures
Asc tube graft 497 Rep IAA 33
CVG/Valve Sp 373 Desc An 47
CABG 207 ASD 29
AoV repair 350 MVR/Rep 91
AVR 147
Surgery of the Aortic Arch
Weill Cornell Medical Center
Complications N = 870
TND 10
CVA 7
Delayed/embolic event 3Delayed/embolic event 3
Tracheostomy 28
Myocardial failure 5
Hemodialysis 14
Reoperation for bleeding 33
Mortality 18
Open Aortic Arch Repair
Author N Year % CVA % Mortality
Czerny 369 2003 5.0 11.5
Safi 218 2004 2.7 8.7Safi 218 2004 2.7 8.7
Kucuker 181 2005 2.2 1.7
Spielvogel 150 2007 4.0 4.6
Sundt 347 2008 8.4 8.9
Leshnower 344 2010 3.6 7.0
Open Arch RepairFreedom From Reoperation
Endovascular
Aortic Arch Repair
Author N Year % CVA % Mortality
Bergeron 25 2006 8.0 8.0
Schumacher 25 2006 4.0 20.0
Czerny 27 2007 0.0 7.4
Melissano 26 2007 7.7 7.7
Weigang 26 2009 3.8 15.4
Holt 26 2010 3.8 3.8
Milewski 27 2010 3.7 11.1
Kulik, Ann Thorac Surg, 2011
Conclusions
• Aortic aneurysms and dissections remain lethal diseases, early diagnosis is critical to survival
• Consistent surgical success can be achieved in high volume centers utilizing a team approach
• RCP and ACP provide excellent cerebral protection, neurologic injury should be minimal
• Hybrid arch repair is appropriate for very high-risk patients
• Open repair remains the gold standard